https://doi.org/10.1007/s00392-024-02526-y
1Agaplesion Diakonieklinikum Rotenburg gGmbH Klinik für Kardiologie Rotenburg (Wümme), Deutschland; 2Agaplesion Diakonieklinikum Rotenburg gGmbH Kardiologie und Geriatrie Rotenburg (Wümme), Deutschland; 3Agaplesion Diakonieklinikum Rotenburg gGmbH Medizinische Klinik I Rotenburg (Wümme), Deutschland
Background:
Pulmonary vene isolation (PVI) is the standard invasive electrophysiologic therapy for atrial fibrillation (AF). This elective procedure has a safety profile with appr. 7% complications including up to 1% pericardial effusion independently from the ablation technique. Since pericardial effusion or pericardial tamponade is a lifethreatening complication and should be reduced to the minimum we present data using atrial transseptal puncture (TP) with transesophageal ultrasound (US) guidance.
Methods and Results:
We present a single center retrospective observational study from 2021-2023.
302 patients (59%male, 41% female, mean age 68 (44-81 years)) were included with paroxysmal (67%), persistent and permanent (33%) AF. All patients had oral anticoagulation (96% NOAK; 4% Marcumar). NOAK was omitted the morning before PVI and continued in the evening after the procedure. Marcumar was continued and the procedure was performed up to INR 2,5.
Patients clinical characteristics: Arterial hypertension 63%, pulmonary hypertension 12%, HFrEF 7%, Diabetes mellitus 6%, coronary artery disease 11%, chronic renal failure 7%, history of stroke 4%, CHA2DS2VASc Score 0 and 1 38%; 2 21%; 3 9%; >3 22%, prior heart surgery 5%.
All patients undergoing de-novo PVI (69%) or re-do PVI (31%) were consecutively recruited. De-novo PVI were performed with cryoballoon ablation techique (63%) and re-do-PVI with radiofrequency ablation. Each TP was guided by transesophageal ultrasound echocardiography (TEE) and TP was only performed with clear needle tenting and correct needle positioning. Due to atrial septal conditions (atrial septal aneurysma, rigid tissue) 4 (1,3%) patients had atrial balloon dilatations. 23 (7,6%) patients showed atrial septal aneurysms.
Patients undergoing re-do PVI had a double TP. All patients had a transthoracic echocardiography shortly after the procedure and the following day. The left atrial appendage was screened for thrombus.
Procedure time was 61(±14)min for cryoballoon and 83(±25) for radiofrequency ablation. The mean cryoballoon temperature was 47±11°C. Radiofrequency ablation was lesion size index and contact force guided. The femoral venous puncture site was compressed with a cutaneous Z- suture.
Neither tamponades nor pericardial effusion occured in all patients. No blood transfusion was needed. No clinically apparent ischemic cerebral event was observed.
Conclusions:
Ultrasound-guided atrial transseptal punctures should be recommended in PVI procedures to avoid peri-procedural pericardial effusion complications.