Novel three‐dimensional imaging approach for cryoballoon navigation and confirmation of pulmonary vein occlusion

• Published in: Pacing and clinical electrophysiology Vol. 43; no. 3; pp. 269 - 277
• Main Authors: Kowalewski, Christopher A. B., Rodrigo, Miguel, Brodt, Chad, Haddad, Francois, Wang, Paul J., Narayan, Sanjiv M.
• Format: Journal Article
• Language: English
• Published: United States Wiley Subscription Services, Inc 01-03-2020
• Subjects: ablation; Aged; Apposition; atrial fibrillation; Atrial Fibrillation - diagnostic imaging; Atrial Fibrillation - surgery; Atrium; Cardiac arrhythmia; Catheters; Computed tomography; cryoballoon; Cryosurgery - instrumentation; Cryosurgery - methods; Feasibility Studies; Female; Fibrillation; Fluoroscopy; Humans; Imaging, Three-Dimensional; Male; Occlusion; Phantoms, Imaging; Phlebography; Pulmonary Veins - surgery; PVI; Radiography, Interventional - methods; Tomography, X-Ray Computed - methods; PVI; atrial fibrillation; ablation; cryoballoon
• ISSN: 0147-8389; 1540-8159; 1540-8159
• DOI: 10.1111/pace.13858

Background
Cryoballoon apposition is crucial for durable pulmonary vein isolation (PVI) in atrial fibrillation, yet the balloon is difficult to visualize by conventional mapping systems, and pulmonary venography may miss small or out‐of‐plane leaks. We report a novel imaging system that offers real‐time 3D navigation of the cryoballoon within atrial anatomy that may circumvent these issues.
Methods and results
A novel overlay guidance system (OGS) registers already‐acquired segmented atrial cardiac tomography (CT) with fluoroscopy, enabling real‐time visualization of the cryoballoon within tomographic left atrial imaging during PVI. Phantom experiments in a patient‐specific 3D printed left atrium showed feasibility for confirming PV apposition and leaks. We applied OGS prospectively to 68 PVs during PVI in 17 patients. The cryoballoon was successfully reconstructed in all cases, and its apposition was compared to concurrent PV venography. The OGS uncovered leaks undetected by venography in nine veins (eight cases), which enabled repositioning, confirming apposition in remaining 68 veins. Concordance of OGS to venography was 83.8% (χ2, P < .01)
Conclusions
We report a new system for real‐time imaging of cryoballoon catheters to ensure PV apposition within the tomography of the left atrium. While providing high concordance with other imaging modalities for confirming balloon apposition or leak, the system also identified leaks missed by venography. Future studies should determine if this tool can provide a new reference for cryoballoon positioning.