Pulmonary vein isolation using an occluding cryoballoon for circumferential ablation: feasibility, complications, and short-term outcome.

AIMS: To assess safety, feasibility and short term outcome of pulmonary vein (PV) isolation in paroxysmal atrial fibrillation (AF) with a cryoballoon. METHODS: We consecutively treated 57 patients with a double lumen 23 or 28 mm cryoballoon. The acute results, complications and follow-up over the first three months were analysed, using a comprehensive and intensive follow-up period. RESULTS: During 57 procedures, 185 of 220 targeted PV's were successfully isolated using the cryoballoon (84%) (balloon group, 33 patients). In 33 veins (15%) an additional segmental isolation (hybrid group, 24 patients) was necessary with a standard cryocatheter to achieve isolation. The average procedure times were respectively 211 +/- 108 and 261 +/- 83 minutes (NS), the average fluoroscopy times 52 +/- 36 and 66 +/- 33 minutes (NS). The number of balloon applications did not differ between both groups: respectively a median 9 (4-18) and 10 (5-17) (NS). We observed four phrenic nerve paralysis after ablation of the right superior PV: two resolved immediately after cessation of the cryoenergy, one recovered after 3 months, one persisted up to 6 months. A daily transtelephonic rhythm recording showed a significant drop in mean AF burden from 24% to 10%, 8% and 5% during the three consecutive months of follow-up (p < 0.01 versus baseline). No differences were observed between the treatment groups. 34 patients (60%) were completely free from AF after a single procedure. CONCLUSIONS: Balloon cryoablation of the pulmonary veins with additional segmental isolation if necessary, is a good approach for patients presenting with paroxysmal AF, showing a significant reduction in AF burden after a single procedure. The major complication seems to be phrenic nerve paralysis after ablation of the right superior PV, but this is potentially reversible over several months.

Long-term follow-up of patients with refractory heart failure and myocardial ischemia treated with cardiac resynchronization therapy.

Studies in patients without coronary artery disease have shown the restoration of glucose metabolism by cardiac resynchronization therapy (CRT) without changes in myocardial perfusion. We report on the long-term outcome of CRT in 24 patients with severe heart failure (HF) and advanced coronary artery disease not amenable for revascularization. All patients had documented myocardial ischemia on stress (99)Tc-sestamibi single-photon emission computed tomography, and all underwent successful implantations of CRT systems. The mean left ventricular ejection fraction was 21%+/- 4%, 19 patients (79%) had anginal complaints and 20 (83%) had diffuse three-vessel disease. During a follow-up of 13 +/- 0.7 months, two patients died suddenly and one died of progressive HF. Among survivors, functional capacity decreased from New York Heart Association class 3.2 +/- 1.4 to 2.1 +/- 1.0 (P < 0.01), and the Minnesota questionnaire quality-of-life scores decreased from 43 +/- 15 to 28 +/- 13 (P < 0.01). Despite an increase from 264 +/- 104 to 385 +/- 121 m in distance walked in 6 minutes (P < 0.01), the number of anginal attacks/week remained unchanged (4.7 +/- 0.7 to 4.5 +/- 0.6). Patients with advanced HF, stable angina, and documented myocardial ischemia may undergo safe and successful implantations of CRT systems.

Repetitive intraoperative dislocation during transvenous left ventricular lead implantation: usefulness of the retained guidewire technique.

Dislocation of the transvenous left ventricular lead has been reported in a substantial number of patients selected for cardiac resynchronization therapy. We describe a novel technique using a retained guidewire in patients with repetitive intraoperative dislocation to stabilize the lead in its final position. Pacing and sensing parameters between patients in whom the retained guidewire technique was used (n = 6) were not significantly different as compared to the group of patients (n = 67) without this technique during a 6-month follow-up. No dislocations were observed in the group of patients with the retained guidewire technique and fluoroscopic evaluation did not reveal (minor) dislocation. This technique might be considered for patients with repetitive intraoperative left ventricular lead dislocation.

The effect of maze operations on atrial volume.

BACKGROUND: Unmodified maze III operations show long-term eradication of atrial fibrillation (AF) in more than 85% of patients with or without structural heart disease. The effect of this procedure on atrial volumes is not known. METHODS: Two patient populations were studied: (1) patients undergoing unmodified maze III operations combined with surgical structural heart disease, mostly mitral valve operations (group A; n = 32); and (2) patients with only AF selected for unmodified maze III operations (group B; n = 32). In groups A and B, transthoracic Doppler echocardiographic studies were prospectively made preoperatively, and at 3 and 12 months postoperatively. Left and right atrial dimensions and volumes and atrial contractions were determined and compared with base line patient characteristics and 12 months arrhythmia outcomes. RESULTS: One year postoperatively all patients were alive. In groups A and B, 92% were free of AF and other atrial arrhythmias. A significant reduction of left atrial volume at 1 year postoperatively was apparent in group A, whereas the left atrial volume did not change significantly in group B. The reduction observed in group A was not related to postoperative age, type or duration of AF, or late atrial arrhythmia outcome. In both groups the right atrial volume remained unchanged at 12 months postoperatively. CONCLUSIONS: The unmodified maze III operation does not affect atrial volume in patients without structural heart disease. In patients with structural heart disease, the mitral valve operation contributes to the reduction of left atrial volume and dimension by improving the hemodynamic condition.