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The Value of Catheter-Based Cryoablation for the Management of Cardiac Arrhythmias

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The Value of Catheter-Based Cryoablation for the Management of Cardiac Arrhythmias The value of catheter-based cryoablation for the management of cardiac arrhythmias Citation for published version (APA): Manusama, R. J. (2012). The value of catheter-based cryoablation for the management of cardiac arrhythmias. Datawyse / Universitaire Pers Maastricht. https://doi.org/10.26481/dis.20120316rm Document status and date: Published: 01/01/2012 DOI: 10.26481/dis.20120316rm Document Version: Publisher's PDF, also known as Version of record Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. 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If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license above, please follow below link for the End User Agreement: www.umlib.nl/taverne-license Take down policy If you believe that this document breaches copyright please contact us at: [email protected] providing details and we will investigate your claim. Download date: 28 Sep. 2021 The value of catheter-based cryoablation for the management of cardiac arrhythmias © Copyright Randy Manusama, Maastricht 2012 ISBN 978 94 6159 127 2 Production: Datawyse | Universitaire Pers Maastricht The value of catheter-based cryoablation for the management of cardiac arrhythmias PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit Maastricht, op gezag van de Rector Magnificus, Prof. mr. G.P.M.F. Mols, volgens het besluit van het College van Decanen, in het openbaar te verdedigen, op vrijdag 16 maart 2012 om 10:00 uur door Randolph John Manusama UMP UNIVERSITAIRE PERS MAASTRICHT Promotor Prof. Dr. H.J.G.M Crijns Co-promotor Dr. C.C.M.M. Timmermans Beoordelingscommissie Prof. Dr. M. Allessie (voorzitter) Prof. Dr. A.P.M. Gorgels Prof. Dr. R.N.W. Hauer, Universitair Medisch Centrum Utrecht Prof. Dr. M.J. Schalij, Leids Universitair Medisch Centrum Prof. Dr. H.J.J. Wellens This study was performed in the Maastricht University Medical Center, the Netherlands and sup- ported bij a grant from ZonMw. Financial support by ‘Stichting hartsvrienden RESCAR Maastricht and Maastricht University Medical Center for the publication of this thesis is gratefully acknowl- edged. Nil Volentibus Arduum (niets is onmogelijk voor hen die willen) Contents Introduction 9 Chapter I Developments in cryoablation 17 Chapter II Catheter-based cryoablation permanently cures patients 29 with common atrial flutter Chapter III Single cryothermia applications of less than 5 minutes 41 produce permanent cavotricuspid isthmus block in humans Chapter IV Typical atrial flutter can effectively be treated using single 53 one-minute of cryoablation: results from a repeat electrophysiological study Chapter V Comparison of 6.5-mm, 10-mm and 15-mm cryoablation 67 catheter-tip for the treatment of common atrial flutter Chapter VI Long-term follow-up after cryothermic ostial pulmonary 79 vein isolation in patient with paroxysmal atrial fibrillation Chapter VII Catheter-based cryoablation of post-infarction and 93 idiopathic ventricular tachycardia: initial experience in a selected population Chapter VIII General discussion and future perspective 107 Summary 125 Samenvatting 129 Dankwoord 135 Curriculum vitae 137 Publications 139 Introduction Arrhythmia treatment has been a challenge for many decades. The effectiveness of quinine and related alkaloids (as used in anti-malarial concoctions) in sup- pressing atrial arrhythmias was noted in the 1800s, but it was not until Wenckebach personally observed (in 1914) and described the use of the isomer of quinine, quinidine.1 This was the first of several drugs that offered anti- arrhythmic therapy with a (temporary) relief of symptoms, but on the other hand obliged life-long commitment and the risk of life-threatening side effects.2, 3 With the advent of an invasive therapy to treat arrhythmias a permanent cure was at hand. The first surgical attempt of permanent ablation was performed in 1968 when a right free-wall accessory pathway was successfully divided in a 31- year-old fisherman.4 Many were to follow, extending surgical techniques to in- clude His-bundle interruption for AV-nodal reentry tachycardia5, left atrial isola- tion for atrial tachycardia6 and endocardial ventriculotomy7 to treat drug- refractory ischemic ventricular tachycardia. The first clinical experience with catheter ablation in the early 1980s was related to a high-energy DC shock and illustrated its potential as a closed-chest procedure.8, 9 However, due to a rela- tively high morbidity and low efficacy,10 this modality lost interest. By creating a localized area of extreme heat through an unmodulated sine-wave AC at fre- quencies of 500 to 1,000 kHz., radiofrequency catheter ablation has shown to be highly effective in a variety of arrhythmias,11-15 offering a better safety profile compared to its predecessor. In the following years radiofrequency energy had become the principal energy source in catheter ablation, expelling most rhythm disorders from the operating room. However, serious side effects may occur16-18 and encouraged some operators to investigate alternative energy sources. Cryothermia, i.e. the ability to induce tissue necrosis through intense freez- ing, has shown to be an effective and versatile tool. From the early sixties, its unique feature to cause tissue injury while preserving its architecture became clear. While most evidence was gathered from in vitro studies directed at cryo- preservation and from experimental and clinical work on frostbite,19-21 it pro- vided the basic features of cryosurgery i.e. rapid freezing, slow thawing, and a repetition of the freeze-thaw cycle that still remain valid to date.22-24 Following the technical developments in instrumentation, its usefulness expanded to serve cardiac surgery in arrhythmia treatment. As it matured into a meaningful clini- cal application, previous insights were reevaluated to proclaim its cardioprotec- tive properties and to ensure maximum tissue injury at the lowest expense of energy delivery and complications. Early experiences in transthoracic surgery demonstrated its potential in arrhythmia management as lesions were homoge- 9 INTRODUCTION neous,25, 26 non-arrhythmogenic25 and well circumscribed.26, 27 Ongoing bio- medical engineering resulted in the development of catheter-based cryoabla- tion. Several authors using percutaneous cryoablation confirmed that cryother- mia is a safe energy source, because of the preservation of tissue architecture,26, 28 the low thrombogenicity29, 30 and the ability to permit total recovery of previ- ously affected tissue at suboptimal (-21°C) temperatures (cold-mapping).31, 32 In the first study performed in patients, percutaneous cryoablation, directed at the AV-node of 12 patients with drug-refractory atrial fibrillation was found to be both feasible and safe.33 To ensure procedural success and a high long-term efficacy, applications lasted for 5 minutes and were repeated per site, mainly to overcome the warming effect of the circulating blood surrounding the catheter- tip. To provide a freezing regimen with a shorter ablation duration more studies involving other arrhythmias were necessary. Lesion formation during cryoabla- tion has proven to be a complex process, involving multiple factors of variable importance that limit the ability to predict the amount of tissue loss based on a single parameter. Cooper et al. already emphasized in 1970 the complexity of cryoablation in his analytical prediction of the temperature field emanating from cryosurgical cannula.34 During the steady state of a cryodelivery more than a dozen parameters like heat of the (un)frozen tissue, blood flow, thermal con- ductivity of the (un)frozen tissue, probe radius and application time, were in- volved in a complex equation to ultimately define the lesion size. Although this theoretical background lacked any clinical verification, it actually gave a nice overview of the many factors thought to participate in cryo-injury. The use of an ablation catheter instead of a surgical probe even added more variables to this equation since other factors i.e. superfusate flow, tip pressure and catheter ori- entation may play a role in lesion formation. Aim of this thesis Early data showed the feasibility and safety of catheter-based cryoablation in a small group of patients.33 In previous studies from cryosurgery,26, 35 a relatively long application
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