Isolation of the superior vena cava by ultra‐low temperature cryoablation

• DOI: 10.1002/joa3.13010
• Publication Date: 2024-03-01T03:25:12Z
• Authors: Khalid Bin Waleed; Zaki Akhtar; Lisa WM Leung; Mark M. Gallagher
• Keywords: Cryoablation; Isolation; Cryosurgery

A patient with shocks from his ICD related to AF underwent redo ablation. The only identifiable target was the superior vena cava. This isolated using ultra-low cryotherapy, eliminating episodes of AF. 53-year-old man non-ischemic dilated cardiomyopathy (ejection fraction 35%), received recurrent dual-chamber implantable cardioverter-defibrillator (ICD) because atrial fibrillation (AF), 7 years after an extensive radiofrequency ablation including pulmonary veins (PVs) isolation, left roof, endocardial coronary sinus, mitral and cavotricuspid isthmus as well complex fractionated electrograms at base appendage septum. Redo performed temperature cryoablation (ULTC) Adagio catheter (Adagio Medical, Inc)1 which we were evaluating, supported by a three-dimensional electroanatomic mapping (CARTO, Biosense Webster) (Figure 1A,B). PVs found be isolated, all lines previous procedure blocked, no sustained arrhythmia inducible. Mapping right atrium (RA) showed electrical potentials 1C) extending 3 cm into cava (SVC). After placing deflectable high in SVC stimulate phrenic nerve, positioned RA-SVC junction pre-shaped 20 mm J-tip stylet creating loop SVC. With stimulation abdominal palpation monitor nerve function 1A), UTLC applied, giving clear isolation without loss response 1D). Nine applications 30 s each used, slight rotation application, reaching nadir between −115 −125°C. first 5 delayed potentials; complete then achieved persisted for more than min. At 12 months ablation, is not receiving antiarrhythmic drugs has detected any since procedure, or problem leads change burden pacing. In addition PVs, vein Marshall, have been identified sites responsible initiation.2, Ablation around endangers sinus node; use energy also risks venous stenosis.4 We took precautions when treating veins. Sinus node concern availability sensing pacing patient's ICD. efficacy cryotherapy demonstrated cryoballoon therapy2, 3, but previously ULTC. To best our knowledge, present case Isolation required several deliveries perhaps part inexperience technique. No occurred there are data on safety otherwise administration close leads. other poorly quantified make it difficult recommend widespread use. Compared cryoballoon, ULTC advantage shorter delivery time (recommended 30–60 compared 180–240 Arctic Front), unlike does obstruct during therapy. potential that used can passed within cryo catheter, whereas therapy inferior region must lie balloon surface format avoids dilemma potentially impeding myocardium source taking risk additional jugular subclavian access approach above. Mark Gallagher research funding Webster acted consultant Adagio, Webster, Cook Medical. Authors declare conflict interests this article. Ethics committee approval applicable report. consented publication