Bronchial Injury After Atrial Fibrillation Ablation Using the Second-Generation Cryoballoon
2018; Lippincott Williams & Wilkins; Volume: 11; Issue: 3 Linguagem: Inglês
10.1161/circep.117.005925
ISSN1941-3149
AutoresBarbara Bellmann, Ralf‐Harto Hübner, Tina Lin, Matthias Paland, Florian Steiner, Phillip Krause, Verena Tscholl, Patrick Nagel, Matthias Rose, Norbert Suttorp, Ulf Landmesser, Andreas Rillig,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 11, No. 3Bronchial Injury After Atrial Fibrillation Ablation Using the Second-Generation Cryoballoon Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessLetterPDF/EPUBBronchial Injury After Atrial Fibrillation Ablation Using the Second-Generation Cryoballoon Barbara Bellmann, MD, Ralf-Harto Hübner, MD, Tina Lin, MBBS, BMedSci, Matthias Paland, MD, Florian Steiner, MD, Phillip Krause, MD, Verena Tscholl, MD, Patrick Nagel, MD, Mattias Roser, MD, Norbert Suttorp, MD, Ulf Landmesser, MD and Andreas Rillig, MD Barbara BellmannBarbara Bellmann From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Ralf-Harto HübnerRalf-Harto Hübner From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Tina LinTina Lin From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Matthias PalandMatthias Paland From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Florian SteinerFlorian Steiner From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Phillip KrausePhillip Krause From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Verena TschollVerena Tscholl From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Patrick NagelPatrick Nagel From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Mattias RoserMattias Roser From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Norbert SuttorpNorbert Suttorp From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). , Ulf LandmesserUlf Landmesser From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). and Andreas RilligAndreas Rillig From the Department of Cardiology (B.B., V.T., P.N., M.R., U.L., A.R.) and Department of Pneumology (R.-H.H., M.P., F.S., P.K., N.S.), Charité–Universitätsmedizin Berlin, University Hospital Berlin, Germany; and Heartcare Victoria, Melbourne, Australia (T.L.). Originally published16 Mar 2018https://doi.org/10.1161/CIRCEP.117.005925Circulation: Arrhythmia and Electrophysiology. 2018;11:e005925Cryoballon ablation of atrial fibrillation may be associated with bronchial damage, but the factors causing this are poorly characterized.1–5Eleven consecutive patients were included in this prospective, single-center pilot study (German Clinical Trials Register No. DRKS00011273). All patients experienced paroxysmal (n=9; 82%) or persistent atrial fibrillation and were treated with the second-generation 28 mm cryoballon (Medtronic, Inc, Minneapolis, MN). The day after cryoballon ablation, a bronchoscopy was performed to assess for bronchial injury (BI) in all patients. In addition, body plethysmography was conducted before and after the procedure. The evaluations of the bronchoscopies were performed in a blinded fashion by 2 independent pulmonologists (R.-H.H., M.P.). This study conforms to the guiding principles of the Declaration of Helsinki of 2014 and was approved by the local ethics committee (EA/111/16).In all 11 patients (6 women; mean age, 66±8.8 years), pulmonary vein isolation (PVI) of all pulmonary veins (PVs) was successfully performed. Preexisting diseases were coronary artery disease (9.1%) and arterial hypertension (55%). The mean left atrial diameter was 50.4±7.2 mm. Five patients (45%) were under anticoagulation with apixaban and 6 (55%) with rivaroxaban. The mean CHA2DS2-Vasc Score was 1.9±1.1. The procedure was performed under deep sedation using propofol, midazolam, and fentanyl. All patients were breathing spontaneously. After transseptal puncture, anatomic localization of the PVs was identified with intravenous contrast injection under fluoroscopy. The Achieve catheter (Medtronic, Inc, Minneapolis, MN) was used to record the electrograms of the PVs and to confirm PVI. Before starting cryoballon ablation, occlusion of the PV was confirmed by intravenous contrast injection under fluoroscopy. During cryoapplication at the septal PVs, continuous stimulation of the right phrenic nerve was performed. Esophageal temperature was measured with an esophageal temperature probe (CS-1000; CIRCA-Scientific, Englewood, CO).In 2 patients, a left common PV ostium was identified. The mean procedure time was 104.2±17.9 minutes, and the mean fluoroscopy time was 20.8±6.4 minutes. To achieve complete PVI, a mean of 2.2±1.3 freezes at the left superior PV (LSPV), 1.3±0.4 freezes at the left inferior PV, 1.1±0.3 freezes at the right superior PV, and 1 freeze at the right inferior PV were applied. In the patients with a left common PV ostium, 3.5±0.7 freezes were necessary to achieve PVI. The minimal temperatures were as follows: LSPV: −45±4.5°C, left inferior PV: −45.9±2.9°C, left common PV ostium: −46.3±9.0°C, right superior PV: −48.7±7.2°C, right inferior PV: −45.7±7.8°C. The mean duration of each freeze was LSPV: 183±13 seconds, left inferior PV: 177±11 seconds, left common PV ostium: 180±8 seconds, right superior PV: 177±4.5 seconds, right inferior PV: 183±21 seconds. The data on the duration and temperature of each freeze for each patient is presented in Table I in the Data Supplement.All patients underwent bronchoscopy in the morning on the day after cryoballon ablation. In 1 of 11 (9%) asymptomatic patients, an erythematous lesion (diameter, ≈1.5 cm) with hemorrhagic erosions within the left main bronchus (LMB) near to the left upper lobe was identified via bronchoscopy the next day (patient No. 4; Figure). The mean distance between the LSPV and the LMB in the overall population was 6.4±2.7 mm. The distance between the LSPV and the LMB was measured during angiography in the anteroposterior position using the PACS measurement tool (Siemens Healthineers, Munich, Germany) when the balloon was fully inflated and contrast agent was injected (Figure). No patient received a CT scan. In the patient with BI, the distance between the LSPV and LMB was 2.1 mm, and coughing was experienced during the thawing phase after cryoapplication at the LSPV. Coughing was not documented in any other patient during or directly after cryoapplication at the LSPV. Body plethysmography before and after ablation demonstrated no significant differences in vital capacity (3.9±1.2 versus 3.7±1.0 L; P=0.39) and FEV1 (expiratory 1-second capacity; 1.4±0.6 versus 1.4±0.6 L; P=0.5). No major complications occurred during cryoballon ablation or bronchoscopy. All patients were discharged home on the second day.Download figureDownload PowerPointFigure. Fluoroscopy and bronchoscopy from the patient with the bronchial injury. A, The anatomicproximity of the left superior pulmonary vein to the left main bronchus (marked with the asterisk) in the patient with the bronchial injury (anterioposterior). Diagnostic catheters are positioned in the coronary sinus (CS) and in the right ventricle (RV). An esophageal temperature probe (ESO) was placed in the esophagus. B, An erythematous lesion with hemorrhagic erosions (diameter, ≈1.5 cm) anteromedial in the left main bronchus near to the left upper lobe as detected during bronchoscopy the day after cryoballoon ablation in patient No. 4. The lesion is marked with a black arrow. CB indicates cryoballoon.This is the first study that demonstrates BI detected via bronchoscopy the day after PVI using the second-generation cryoballon in humans. The LSPV was in closer proximity to the LMB in the patient with BI (2.1 mm) as compared with patients without BI. It appears feasible that the close proximity between the LSPV and LMB could result in a higher likelihood of BI. This observation is in line with the findings of Verma et al.4 In their study, patients with ice formation within the bronchus during ablation had a closer proximity between LMB and LSPV. In our study the minimal temperature in the patient with BI was −41°C during cryoballon ablation at the LSPV with a maximum duration of 180 seconds of the 2 freezes at the LSPV. It is noteworthy that the patient with BI experienced coughing during the thawing phase after ablation of the LSPV. This may suggest that coughing during cryoapplication or during the thawing phase might be a predictor for BI. The clinical long-term consequences of BI remain unknown yet. However, the results of pulmonary function before and after cryoballon ablation did not differ significantly. The implications of our findings are of major importance for planning larger studies to enhance safety of cryoballon ablation in the future.DisclosuresDr Rillig received travel grants from Biosense, Hansen Medical, Medtronic, and St. Jude Medical and lecture fees from St. Jude Medical, Medtronic, and Boehringer Ingelheim and participated at the Boston Scientific electrophysiology (EP) fellowship. Dr Bellmann participated at the Boston Scientific EP fellowship. T. Lin received a clinical fellowship from EHRA; travel grants from Biosense Webster, St. Jude Medical, Bayer, and Topera, Inc; and Speakers honoraria from Servier and Boehringer. Dr Tscholl received travel grants from Biotronik, Biosense Webster, St. Jude Medical, and a sponsored EP and Devices fellowship from Biotronik. Dr Nagel received travel grants, lecture fees, or compensations for Advisory Board activities from Biotronik, Boehringer-Ingelheim, and ZOLL and participated at the Boston Scientific EP fellowship. Dr Roser received travel grants, lecture fees, or compensations for Advisory Board activities from Bayer Healthcare, Berlin Chemie, Biotronik, Boston Scientific, Medtronic, Pfizer, Sanofi, St. Jude Medical, and ZOLL CMS. Dr Landmesser has received advisory board honoraria from St Jude Medical.Footnotes*Drs Bellmann and Hübner contributed equally to this work.The Data Supplement is available at http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.117.005925/-/DC1.Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org.Correspondence to: Andreas Rillig, MD, Department of Cardiology, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Hindenburgdamm 30, 12200 Berlin, Germany. E-mail [email protected]References1. Luik A, Radzewitz A, Kieser M, Walter M, Bramlage P, Hörmann P, Schmidt K, Horn N, Brinkmeier-Theofanopoulou M, Kunzmann K, Riexinger T, Schymik G, Merkel M, Schmitt C. Cryoballoon versus open irrigated radiofrequency ablation in patients with paroxysmal atrial fibrillation: the prospective, randomized, controlled, noninferiority FreezeAF study.Circulation. 2015; 132:1311–1319. doi: 10.1161/CIRCULATIONAHA.115.016871.LinkGoogle Scholar2. Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Natale A, Packer D, Skanes A, Ambrogi F, Biganzoli E. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation.Circ Arrhythm Electrophysiol. 2010; 3:32–38. doi: 10.1161/CIRCEP.109.859116.LinkGoogle Scholar3. Aryana A, Bowers MR, Hayatdavoudi SM, Zhang Y, Afify A, D'Avila A, O'Neill PG. Impact of pulmonary vein cryoballoon ablation on bronchial injury.J Cardiovasc Electrophysiol. 2016; 27:861–867. doi: 10.1111/jce.12983.CrossrefMedlineGoogle Scholar4. van Opstal JM, Timmermans C, Blaauw Y, Pison L. Bronchial erosion and hemoptysis after pulmonary vein isolation by cryoballoon ablation.Heart Rhythm. 2011; 8:1459. doi: 10.1016/j.hrthm.2010.06.024.CrossrefMedlineGoogle Scholar5. Verma N, Gillespie CT, Argento AC, Tomson T, Dandamudi S, Piña P, Ringwala S, Lin AC, Chicos AB, Kim S, Arora R, Passman RS, Knight BP. Bronchial effects of cryoballoon ablation for atrial fibrillation.Heart Rhythm. 2017; 14:12–16. doi: 10.1016/j.hrthm.2016.10.012.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Vogler J, Fink T, Sohns C, Sommer P, Pott A, Dahme T, Rottner L, Sciacca V, Sieren M, Jacob F, Barkhausen J, Sano M, Eitel C, Metzner A, Ouyang F, Kuck K, Tilz R and Heeger C (2020) Acute Hemoptysis Following Cryoballoon Pulmonary Vein Isolation, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2020.02.003, 6:7, (773-782), Online publication date: 1-Jul-2020. Heeger C, Bellmann B, Fink T, Bohnen J, Wissner E, Wohlmuth P, Rottner L, Sohns C, Tilz R, Mathew S, Reissmann B, Lemeš C, Maurer T, Lüker J, Sultan A, Plenge T, Goldmann B, Ouyang F, Kuck K, Metzner I, Metzner A, Steven D and Rillig A (2019) Efficacy and safety of cryoballoon ablation in the elderly: A multicenter study, International Journal of Cardiology, 10.1016/j.ijcard.2018.09.090, 278, (108-113), Online publication date: 1-Mar-2019. March 2018Vol 11, Issue 3 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.117.005925PMID: 29874170 Originally publishedMarch 16, 2018 Keywordsatrial fibrillationhumanscryosurgerybronchoscopycoronary artery diseasePDF download Advertisement SubjectsArrhythmiasAtrial FibrillationElectrophysiology
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