The Effect of Open-Irrigated Radiofrequency Catheter Ablation of Atrial Fibrillation on Left Atrial Pressure and B-Type Natriuretic Peptide JENS SEILER, M.D., PH.D., DANIEL STEVEN, M.D., KURT C. ROBERTS-THOMSON, M.B.B.S., PH.D., KEIICHI INADA, M.D., USHA B. TEDROW, M.D., GREGORY F. MICHAUD, M.D., and WILLIAM G. STEVENSON, M.D. From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
Background: Open-irrigated radiofrequency catheter ablation (oiRFA) of atrial fibrillation (AF) imposes a volume load and risk of pulmonary edema. We sought to assess the effect of volume administration during ablation on left atrial (LA) pressure and B-type natriuretic peptide (BNP). Methods: LA pressure was measured via transseptal sheath at the beginning and end of 44 LA ablation procedures in 42 patients. BNP plasma levels were measured before and after 10 procedures. Results: A median of 3,255 (interquartile range [IQR], 2,014)-mL saline was administered during the procedure. During LA ablation, the median fluid balance was +1,438 (IQR, 1,109) mL and LA pressure increased by median 3.7 (IQR, 5.9) mm Hg (P < 0.001). LA pressure did not change in the 19 procedures with furosemide administration (median P = −0.3 [IQR, 7.1] mm Hg, P = 0.334). The correlation of LA pressure and fluid balance was weak (rs = 0.383, P = 0.021). BNP decreased in all four procedures starting in AF or atrial tachycardia and then converting to sinus rhythm (P = 0.068), and increased in all six procedures starting and finishing in sinus rhythm (P = 0.028). After ablation, symptomatic volume overload responding to diuresis occurred in three patients. Conclusions: A substantial intravascular volume load during oiRFA can be absorbed with little change in LA pressure, such that LA pressure is not a reliable indicator of the fluid balance. Subsequent redistribution of the volume load imposes a risk after the procedure. Conversion to sinus rhythm may improve ability to acutely accommodate the volume load. (PACE 2014; 37:616–623) atrial fibrillation, radiofrequency catheter ablation, open irrigation, left atrial pressure, B-type natriuretic peptide
Jens Seiler has received a research grant from St. Jude Medical (Switzerland). The spouse of Jens Seiler is an employee of Boston Scientific and a former employee of St. Jude Medical. Daniel Steven has received a research grant from Biosense Webster. Kurt Roberts-Thomson is the recipient of a Postgraduate Research Scholarship from the National Health and Medical Research Council of Australia (NHMRC grant ID 489417) and the Astra-Zeneca Fellowship in Medical Research from the Royal Australian College of Physicians. Usha Tedrow has received research grants from Biosense Webster and Boston Scientific, and speaking honoraria from Boston Scientific, Medtronic, and St. Jude Medical. Gregory Michaud has received consultancy fees from St. Jude Medical and Biosense Webster and speaking honoraria from St. Jude Medical, Boston Scientific, and Medtronic. There is no conflict of interest. Address for reprints: Jens Seiler, M.D., PH.D., Cardiovascular Division, University Hospital, Freiburgstrasse, CH-3010 Bern, Switzerland. Fax: 41-31-632-1414, e-mail: [email protected] Received May 2, 2013; revised October 14, 2013; accepted October 20, 2013. doi: 10.1111/pace.12329
Introduction Catheter ablation of atrial fibrillation (AF) is commonly performed by applying extensive lesions encircling the pulmonary vein regions.1,2 Ablation with open irrigation catheters is common, but imposes a volume load as irrigation rates, commonly 17–30 mL/min, are often employed. Cases of heart failure and pulmonary edema after ablation have been reported.3,4 Volume administration, decreased left atrial (LA) compliance, conversion of atrial rhythm during or after the procedure, and an effect of ablation on the neuroendocrine function of the atria are possible mechanisms.3,5 B-type natriuretic peptide (BNP) is produced and released in the ventricles and the atria in response to volume overload and AF, respectively.6–8 Plasma BNP levels change rapidly in response to cardiac filling pressure, and an acute decrease of the BNP level was shown in patients after direct-current cardioversion of AF and catheter ablation of nonparoxysmal AF.9–11 The effect of atrial ablation on LA filling pressures has not been systematically evaluated.
©2013 Wiley Periodicals, Inc. 616
May 2014
PACE, Vol. 37
OPEN-IRRIGATED ATRIAL FIBRILLATION ABLATION EFFECTS
In this study, we sought to investigate changes in LA pressure during open-irrigated radiofrequency catheter ablation (oiRFA) for AF and periprocedural plasma BNP levels, and to relate these changes to the volume load and rhythm change.
Methods Patients Unselected patients undergoing LA oiRFA for AF, or atrial tachycardia (AT) secondary to a previous AF ablation between May 2008 and April 2009 were analyzed. Written informed consent for ablation was provided by all patients, and procedures were performed according to protocols approved by the Brigham and Women’s Hospital Human Subject Protection Committee.
Mapping and Ablation Procedure Procedures were performed under conscious sedation, with the exception of one procedure under general anesthesia. One or two transseptal vascular sheaths were inserted via the right femoral vein into the LA and perfused using heparinized saline at a rate of 20–50 mL/h. Heparin was administered to maintain an activated clotting time of >350 seconds throughout the procedure. Mapping and ablation were performed using a 7.5-F or 7-F, 3.5-mm-tip quadripolar open-irrigated catheter (NaviStarTM ThermoCoolTM or CelsiusTM ThermoCoolTM , Biosense Webster, Diamond Bar, CA, USA). A 7-F, 20-pole circumferential diagnostic catheter was used for assessment of pulmonary vein activation and isolation.12 Radiofrequency energy was delivered using a Stockert 70 generator (Stockert GmbH, Freiburg, Germany) in a powercontrolled mode at 20–40 W at an irrigation rate of 17–30 mL/min with the goal of achieving a catheter tip temperature of
Background: Open-irrigated radiofrequency catheter ablation (oiRFA) of atrial fibrillation (AF) imposes a volume load and risk of pulmonary edema. We sought to assess the effect of volume administration during ablation on left atrial (LA) pressure and B-type natriuretic peptide (BNP). Methods: LA pressure was measured via transseptal sheath at the beginning and end of 44 LA ablation procedures in 42 patients. BNP plasma levels were measured before and after 10 procedures. Results: A median of 3,255 (interquartile range [IQR], 2,014)-mL saline was administered during the procedure. During LA ablation, the median fluid balance was +1,438 (IQR, 1,109) mL and LA pressure increased by median 3.7 (IQR, 5.9) mm Hg (P < 0.001). LA pressure did not change in the 19 procedures with furosemide administration (median P = −0.3 [IQR, 7.1] mm Hg, P = 0.334). The correlation of LA pressure and fluid balance was weak (rs = 0.383, P = 0.021). BNP decreased in all four procedures starting in AF or atrial tachycardia and then converting to sinus rhythm (P = 0.068), and increased in all six procedures starting and finishing in sinus rhythm (P = 0.028). After ablation, symptomatic volume overload responding to diuresis occurred in three patients. Conclusions: A substantial intravascular volume load during oiRFA can be absorbed with little change in LA pressure, such that LA pressure is not a reliable indicator of the fluid balance. Subsequent redistribution of the volume load imposes a risk after the procedure. Conversion to sinus rhythm may improve ability to acutely accommodate the volume load. (PACE 2014; 37:616–623) atrial fibrillation, radiofrequency catheter ablation, open irrigation, left atrial pressure, B-type natriuretic peptide
Jens Seiler has received a research grant from St. Jude Medical (Switzerland). The spouse of Jens Seiler is an employee of Boston Scientific and a former employee of St. Jude Medical. Daniel Steven has received a research grant from Biosense Webster. Kurt Roberts-Thomson is the recipient of a Postgraduate Research Scholarship from the National Health and Medical Research Council of Australia (NHMRC grant ID 489417) and the Astra-Zeneca Fellowship in Medical Research from the Royal Australian College of Physicians. Usha Tedrow has received research grants from Biosense Webster and Boston Scientific, and speaking honoraria from Boston Scientific, Medtronic, and St. Jude Medical. Gregory Michaud has received consultancy fees from St. Jude Medical and Biosense Webster and speaking honoraria from St. Jude Medical, Boston Scientific, and Medtronic. There is no conflict of interest. Address for reprints: Jens Seiler, M.D., PH.D., Cardiovascular Division, University Hospital, Freiburgstrasse, CH-3010 Bern, Switzerland. Fax: 41-31-632-1414, e-mail: [email protected] Received May 2, 2013; revised October 14, 2013; accepted October 20, 2013. doi: 10.1111/pace.12329
Introduction Catheter ablation of atrial fibrillation (AF) is commonly performed by applying extensive lesions encircling the pulmonary vein regions.1,2 Ablation with open irrigation catheters is common, but imposes a volume load as irrigation rates, commonly 17–30 mL/min, are often employed. Cases of heart failure and pulmonary edema after ablation have been reported.3,4 Volume administration, decreased left atrial (LA) compliance, conversion of atrial rhythm during or after the procedure, and an effect of ablation on the neuroendocrine function of the atria are possible mechanisms.3,5 B-type natriuretic peptide (BNP) is produced and released in the ventricles and the atria in response to volume overload and AF, respectively.6–8 Plasma BNP levels change rapidly in response to cardiac filling pressure, and an acute decrease of the BNP level was shown in patients after direct-current cardioversion of AF and catheter ablation of nonparoxysmal AF.9–11 The effect of atrial ablation on LA filling pressures has not been systematically evaluated.
©2013 Wiley Periodicals, Inc. 616
May 2014
PACE, Vol. 37
OPEN-IRRIGATED ATRIAL FIBRILLATION ABLATION EFFECTS
In this study, we sought to investigate changes in LA pressure during open-irrigated radiofrequency catheter ablation (oiRFA) for AF and periprocedural plasma BNP levels, and to relate these changes to the volume load and rhythm change.
Methods Patients Unselected patients undergoing LA oiRFA for AF, or atrial tachycardia (AT) secondary to a previous AF ablation between May 2008 and April 2009 were analyzed. Written informed consent for ablation was provided by all patients, and procedures were performed according to protocols approved by the Brigham and Women’s Hospital Human Subject Protection Committee.
Mapping and Ablation Procedure Procedures were performed under conscious sedation, with the exception of one procedure under general anesthesia. One or two transseptal vascular sheaths were inserted via the right femoral vein into the LA and perfused using heparinized saline at a rate of 20–50 mL/h. Heparin was administered to maintain an activated clotting time of >350 seconds throughout the procedure. Mapping and ablation were performed using a 7.5-F or 7-F, 3.5-mm-tip quadripolar open-irrigated catheter (NaviStarTM ThermoCoolTM or CelsiusTM ThermoCoolTM , Biosense Webster, Diamond Bar, CA, USA). A 7-F, 20-pole circumferential diagnostic catheter was used for assessment of pulmonary vein activation and isolation.12 Radiofrequency energy was delivered using a Stockert 70 generator (Stockert GmbH, Freiburg, Germany) in a powercontrolled mode at 20–40 W at an irrigation rate of 17–30 mL/min with the goal of achieving a catheter tip temperature of
