Rate of acquired pulmonary vein stenosis after ablation of atrial fibrillation referred to electroanatomical mapping systems: Does it matter?
Abstract
Background: Thermal injury during radiofrequency ablation (RFA) of atrial fibrillation (AF) can lead to pulmonary vein stenosis (PVS). It is currently unclear if routine screening for PVS by imaging (echocardiography, computed tomography) is clinically meaningful and if there is a correlation between PVS and the electroanatomical mapping system (EAMS) used for the ablation procedure. It was therefore investigated in the current single center experience.
Methods: All patients from January 2004 to December 2016 with the diagnosis of PVS after interventional ablation of AF by radiofrequency were retrospectively analyzed. From 2004 to 2007, transesophageal echocardiography was routinely performed as screening for RFA-acquired PVS (group A). Since 2008, diagnostics were only initiated in cases of clinical symptoms suggestive for PVS (group B).
Results: The overall PVS rate after interventional RFA for AF of the documented institution is 0.72% (70/9754). The incidence was not influenced by screening: group A had a 0.74% PVS rate and group B a 0.72% rate (NS). Referred to as the EAMS, there were significant differences: 20/4229 (0.5%) using CARTO®, 48/4510 (1.1%) using EnSite®, 1/853 (0.1%) using MediGuide®, and 1/162 (0.6%) using Rhythmia®. Since 2009, no significant difference between technologies was found.
Conclusions: The present analysis of 9754 procedures revealed 70 cases of PVS. The incidence of PVS
is not related to screening but to the application of different EAMS. Possible explanations are technological backgrounds (magnetic vs. electrical), learning curves, operator experience, and work-flow differences. Furthermore, incorporation of new technologies seems to be associated with higher incidences of PVS before workflows are optimized.
Keywords: pulmonary vein stenosisradiofrequency ablationatrial fibrillationelectroanatomical mapping system
References
- Cappato R, Calkins H, Chen SA, et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. 2005; 111(9): 1100–1105.
- McWilliams E, Giles J, Furniss S. Pulmonary vein stenosis may still occur after ablation. Europace. 2010; 12(8): 1097.
- Fender EA, Widmer RJ, Holmes DR, et al. Severe pulmonary vein stenosis resulting from ablation for atrial fibrillation: presentation, management, and clinical outcomes. Circulation. 2016; 134(23): 1812–1821.
- Teunissen C, Velthuis BK, Hassink RJ, et al. Incidence of pulmonary vein stenosis after radiofrequency catheter ablation of atrial fibrillation. JACC Clin Electrophysiol. 2017; 3(6): 589–598.
- Holmes DR, Monahan KH, Packer D. Pulmonary vein stenosis complicating ablation for atrial fibrillation: clinical spectrum and interventional considerations. JACC Cardiovasc Interv. 2009; 2(4): 267–276.
- Prieto LR, Schoenhagen P, Arruda MJ, et al. Comparison of stent versus balloon angioplasty for pulmonary vein stenosis complicating pulmonary vein isolation. J Cardiovasc Electrophysiol. 2008; 19(7): 673–678.
- De Potter TJR, Schmidt B, Chun KR, et al. Drug-eluting stents for the treatment of pulmonary vein stenosis after atrial fibrillation ablation. Europace. 2011; 13(1): 57–61.
- Schoene K, Arya A, Jahnke C, et al. Acquired pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation: single-center experience in catheter interventional treatment. JACC Cardiovasc Interv. 2018; 11(16): 1626–1632.
- Schoene K, Sommer P, Arya A, et al. Complex cases of acquired pulmonary vein stenosis after radiofrequency ablation: is surgical repair an option? EP Europace. 2018.
- Earley MJ, Showkathali R, Alzetani M, et al. Radiofrequency ablation of arrhythmias guided by non-fluoroscopic catheter location: a prospective randomized trial. Eur Heart J. 2006; 27(10): 1223–1229.
- Sra J, Krum D, Hare J, et al. Feasibility and validation of registration of three-dimensional left atrial models derived from computed tomography with a noncontact cardiac mapping system. Heart Rhythm. 2005; 2(1): 55–63.
- Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary. EP Europace. 2017; 20(1): 157–208.
- Rolf S, Kircher S, Arya A, et al. Tailored atrial substrate modification based on low-voltage areas in catheter ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2014; 7(5): 825–833.
- Gepstein L, Hayam G, Ben-Haim SA. A novel method for nonfluoroscopic catheter-based electroanatomical mapping of the heart. In vitro and in vivo accuracy results. Circulation. 1997; 95(6): 1611–1622.
- Wittkampf FH, Wever EF, Derksen R, et al. LocaLisa: new technique for real-time 3-dimensional localization of regular intracardiac electrodes. Circulation. 1999; 99(10): 1312–1317.
- Fenici R, Brisinda D. From 3D to 4D imaging: is that useful for interventional cardiac electrophysiology? Conf Proc IEEE Eng Med Biol Soc. 2007; 2007: 5996–5999.
- Nakagawa H, Ikeda A, Sharma T, et al. Rapid high resolution electroanatomical mapping: evaluation of a new system in a canine atrial linear lesion model. Circ Arrhythm Electrophysiol. 2012; 5(2): 417–424.
- Rostamian A, Narayan SM, Thomson L, et al. The incidence, diagnosis, and management of pulmonary vein stenosis as a complication of atrial fibrillation ablation. J Interv Card Electrophysiol. 2014; 40(1): 63–74.
- Bourier F, Fahrig R, Wang P, et al. Accuracy assessment of catheter guidance technology in electrophysiology procedures: a comparison of a new 3D-based fluoroscopy navigation system to current electroanatomic mapping systems. J Cardiovasc Electrophysiol. 2014; 25(1): 74–83.
- Finlay MC, Hunter RJ, Baker V, et al. A randomised comparison of Cartomerge vs. NavX fusion in the catheter ablation of atrial fibrillation: the CAVERN Trial. J Interv Card Electrophysiol. 2012; 33(2): 161–169.
- Sommer P, Rolf S, Piorkowski C, et al. Nonfluoroscopic catheter visualization in atrial fibrillation ablation: experience from 375 consecutive procedures. Circ Arrhythm Electrophysiol. 2014; 7(5): 869–874.
- Bourier F, Reents T, Ammar-Busch S, et al. Sensor-Based Electromagnetic Navigation (Mediguide®): How Accurate Is It? A Phantom Model Study. J Cardiovasc Electrophysiol. 2015; 26(10): 1140–1145.
- Dong J, Dickfeld T, Dalal D, et al. Initial experience in the use of integrated electroanatomic mapping with three-dimensional MR/CT images to guide catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2006; 17(5): 459–466.
- Schneider C, Ernst S, Malisius R, et al. Transesophageal echocardiography: a screening method for pulmonary vein stenosis after catheter ablation of atrial fibrillation. Eur J Echocardiogr. 2006; 7(6): 447–456.
- Stavrakis S, Madden GW, Stoner JA, et al. Transesophageal echocardiography for the diagnosis of pulmonary vein stenosis after catheter ablation of atrial fibrillation: a systematic review. Echocardiography. 2010; 27(9): 1141–1146.
