https://repub.eur.nl/pub/104203/REPUB_104203-OA.pdf

2017 HRS / EHRA / ECAS / APHRS / SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation

Since publication of the last American Heart Association (AHA) scientific statement on this topic in 1998,1 device technology, advances in interventional techniques, and an innovative spirit have opened the field of congenital heart therapeutic catheterization. Unfortunately, studies testing the safety and efficacy of catheterization and transcatheter therapy are rare in the field because of the difficulty in identifying a control population, the relatively small number of pediatric patients with congenital heart disease (CHD), and the broad spectrum of clinical expression. This has resulted in the almost exclusive “off-label” use of transcatheter devices, initially developed for management of adult diseases, for the treatment of CHD.

The objective of the present writing group, which included representatives of the AHA and endorsements from the Society for Cardiovascular Angiography and Interventions and the American Academy of Pediatrics, was not only to provide the reader with an inventory of diagnostic catheterization and interventional treatment options but also to critically review the literature and formulate relative recommendations that are based on key opinion leader expertise and level of evidence. The writing group was charged with the task of performing an assessment of the evidence and giving a classification of recommendations and a level of evidence to each recommendation. The American College of Cardiology/AHA classification system was used, as follows:

### Classification of Recommendations

Indications for Cardiac Catheterization and Intervention in Pediatric Cardiac Disease A Scientific Statement From the American Heart Association

Ablation procedures for atrial fibrillation are being performed with increasing frequency. One of the most serious complications is the development of pulmonary vein stenosis, which occurs in 1% to 3% of current series. The presentation of pulmonary vein stenosis varies widely. The majority of patients are symptomatic although specific referral bias patterns can affect this. Symptoms may include dyspnea or hemoptysis or may be consistent with bronchitis. These symptoms are affected by the number of stenotic veins as well as the severity of the stenosis. The more severe the stenosis and the greater number of stenosed veins result in more symptoms. Because of the variability in symptoms, clinicians must have heightened sensitivity to the presence of the condition. Diagnostic tests of value include magnetic resonance angiography and computed tomography. Although echocardiography has been used, it does not usually provide adequate assessment. Progression of stenosis is unpredictable and may be rapid. The specific anatomy of the stenosis varies widely and affects management. Because of the presence of antral fusion of the origin of the left superior and left inferior pulmonary vein, a stenosis involving 1 or the other can impinge and affect outcome. In this setting, bifurcation techniques familiar to interventional cardiology are very helpful. Controversy currently exists about the optimal treatment approach. The use of balloons and larger stents (approximately 10 mm) results in more optimal results than just balloon angioplasty alone; however, even with stent implantation, recurrent restenosis may occur in 30% to 50% of patients. Follow-up of these patients typically involves computed tomography imaging to document restenosis. If significant restenosis is identified, it should be treated promptly because of the potential for progression to total occlusion.

Pulmonary Vein Stenosis Complicating Ablation for Atrial Fibrillation: Clinical Spectrum and Interventional Considerations

Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up.

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation

Aims Although the generation of linear lesions by ablation improves success rates in patients with persistent atrial fibrillation (AF), the procedure has been considered unsuitable for cryoablation balloon catheter technologies. We developed a technique for linear ablations, using second-generation cryoballoon technology.

Methods and results This was a single-arm, prospective study in 76 patients with persistent AF treated consecutively at our centre. Cryoablation was performed using a 28 mm second-generation cryoballoon. The first cryoenergy application was performed in close proximity to the position during isolation of the left superior pulmonary vein (PV). Sequential overlapping freezes were applied along the left atrial (LA) roof by slight clockwise rotation of the sheath in combination with slight retraction of the sheath and incremental advancement of the cryoballoon, until reaching the original position for right superior PV isolation. The acute endpoint was the creation of a roofline, defined as complete conduction block across the LA roof >120 ms and ascending activation across the posterior LA wall. Acute success in roofline generation was achieved in 88% of patients, applying on average five (median 4–6) freezes with nadir temperature of −40°C (−36 to −44°C). In five patients, conduction block could not be achieved. No phrenic nerve injuries occurred during roofline generation.

Conclusion Generation of linear roofline lesions is possible with the second-generation cryoballoon. The technique can be used in combination with PV isolation to treat persistent AF with good acute success rates, short procedure times, and acceptable safety concerns. If validated by further studies, the method would be an appealing alternative to radiofrequency ablation techniques.

Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation.

Introduction: Pulmonary vein stenosis (PVS) is a potential complication of pulmonary vein isolation (PVI) using radiofrequency energy. The aim of our study was the evaluation of the severity and long-term outcome of primary angioplasty and angioplasty with pulmonary vein stenting for PVS.



Methods and Results: Twelve patients with 15 PVS (greater than 70% stenosis) were prospectively evaluated. Primary dilation of the stenosis was performed because of clinical symptoms (10 patients) and/or the lung perfusion scans showed a significant perfusion defect (11 patients). Magnetic resonance imaging and lung perfusion scans performed before, directly after, during 3-month, and 6-month follow-up. In the stenting group additional multislice CT-scans directly after, during 6-month, and 12-month follow-up were performed.



Within 2 months after primary balloon angioplasty, the PV size parameters were significantly reduced (P < 0.001) with recurrence of PVS in 11 of 15 PVs (73%). Pulmonary vein stenting in 8 patients and 11 PVs resulted in no vein stenosis during 12-month follow-up. Normalization of lung perfusion was noted in 8 of 12 patients. We observed 2 patients with hemoptysis during PV dilation, as severe complications with potential life-threatening character.



Conclusion: PVS stenting seems to be superior to balloon angioplasty and effective at least over a period of 12 months in treating acquired PVS after pulmonary vein isolation.

Percutaneous Pulmonary Vein Stenting for the Treatment of Severe Stenosis After Pulmonary Vein Isolation

Background:We analyzed the procedural experience cryoballoon ablation (CBA) of atrial fibrillation (AF) gained over 8 years in a high-volume centre to understand the influence of the learning curve on feasibility, safety and clinical outcome.Methods and Results:In 424 patients (62% male) with drug-refractory AF, CBA was performed between 2005 and 2012. The analyzed period was divided into 8 calendar years. The endpoint of the study was arrhythmia recurrence after the 3-month blanking period in the 1-year follow-up since the index procedure, in the absence of anti-arrhythmic drugs class I and III. A combined AF type, Left Atrium size, Renal insufficiency, MEtabolic syndrome, cardiomyopathy (ALARMEc) risk score was calculated for each patient. The overall 1-year success rate of a single CBA was 73%. Continuous increase in 1-year success rate was observed with successive years of the study. The gradual improvement in outcome was related to gradual fall in ALARMEc risk score in successive patients. A continuous decrease in fluoroscopy and procedure time was observed in each subsequent year.Conclusions:CBA, followed by the proper selection of patients, facilitates a satisfactory outcome, especially in patients at an early stage of PV-trigger-dependent AF. Still, as with each new technology, it requires completion of a learning curve. (Circ J 2014; 78: 1612–1618)

Harald Greis

Papers

Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation.

Percutaneous Pulmonary Vein Stenting for the Treatment of Severe Stenosis After Pulmonary Vein Isolation

Learning curve in cryoballoon ablation of atrial fibrillation: eight-year experience.