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Iatrogenic Atrial Septal Defect After Cryoballoon Pulmonary Vein Isolation SHINSUKE MIYAZAKI, M.D., JIN IWASAWA, M.D., AKIO KUROI, M.D., and YOSHITO IESAKA, M.D. From the Tsuchiura Kyodo Hospital, Ibaraki, Japan

atrial fibrillation, atrial septal defect, catheter ablation, cryoablation, cryoballoon A 73-year-old man with paroxysmal atrial fibrillation (AF) was referred to our center for catheter ablation using cryoballoon. He had hypertension, no structural heart disease, and normal anatomy on pre-procedural cardiac computed tomography (CT). A single transseptal puncture was performed using a radiofrequency needle (Baylis Medical, Montreal, QC, Canada) and 8-Fr long sheath (SL0, SJM, Minneapolis, MN, USA) because patent foramen ovale was not observed. The transseptal sheath was exchanged over a guidewire for a 15-Fr steerable sheath (Flexcath Advance, Medtronic, Minneapolis, MN, USA). All pulmonary veins were successfully isolated using exclusively 28-mm second-generation balloon (Arctic Front Advance, Medtronic). Repeat 320-row multidetector cardiac CT (Aquilion one, Toshiba, Otawara, Japan), which was obtained 8 months after the procedure, did not show any pulmonary vein stenosis; however, left to right interatrial shunt was captured on the CT image (Fig. 1). The patient was free from any atrial tachyarrhythmias after the procedure, and any adverse event was not observed during the follow-up period. Pulmonary vein isolation using cryoballoon is an accepted and effective therapy for paroxysmal AF. The cryoballoon is maneuvered in the left atrium through a large diameter 15F

J Cardiovasc Electrophysiol, Vol. 26, p. 1021, September 2015. Disclosures: None. Address for correspondence: Shinsuke Miyazaki, Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300–0053, Japan. Fax: 81-29-826-2411; E-mail: [email protected] doi: 10.1111/jce.12676

Figure 1. Left to right shunt (red arrows) was observed on the image (A: transverse plane, B: coronal plane) of 320-row multidetector CT that was obtained 8 months after cryoballoon pulmonary vein isolation. LA = left atrium; RA = right atrium; LAA = LA appendage; Ao = descending aorta. For a high quality, full color version of this figure, please see Journal of Cardiovascular Electrophysiology’s website: www.wileyonlinelibrary.com/journal/jce

sheath. The reported prevalence of iatrogenic atrial septal defect (ASD) was 20–30% on transesophageal echocardiography at 6–12 months after the cryoballoon procedure, and only left to right shunt was reported. In the present case, iatrogenic left to right shunt was identified incidentally on the follow-up cardiac CT. High-speed and wide-coverage multidetector CT scanners have the advantage of decreased cardiac motion and artifact, and improved the image quality. The occurrence of paradoxical embolism is unlikely because shunt is oriented left to right; however, the clinical significance of persistent iatrogenic ASD remains unclear. Although no adverse clinical events were reported up to now in patients with persistence of iatrogenic ASD, further effort should be taken to reduce the diameter of the steerable sheeth of cryoballoon.

Iatrogenic Atrial Septal Defect After Cryoballoon Pulmonary Vein Isolation.

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