Thromboembolic Risks of the Procedural Process in Second-Generation Cryoballoon Ablation Procedures: Analysis From Real-Time Transcranial Doppler Monitoring

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Atrial fibrillation ablation is associated with substantial risks of silent cerebral events (SCEs) or silent cerebral lesions. We investigated which procedural processes during cryoballoon procedures carried a risk.

Methods and Results

Forty paroxysmal atrial fibrillation patients underwent pulmonary vein isolation using second-generation cryoballoons with single 28-mm balloon 3-minute freeze techniques. Microembolic signals (MESs) were monitored by transcranial Doppler throughout all procedures. Brain magnetic resonance imaging was obtained pre- and post-procedure in 34 patients (85.0%). Of 158 pulmonary veins, 152 (96.2%) were isolated using cryoablation, and 6 required touch-up radiofrequency ablation. A mean of 5.0±1.2 cryoballoon applications was applied, and the left atrial dwell time was 76.7±22.4 minutes. The total MES counts/procedures were 522 (426–626). Left atrial access and Flexcath sheath insertion generated 25 (11–44) and 34 (24–53) MESs. Using radiofrequency ablation for transseptal access increased the MES count during transseptal punctures. During cryoapplications, MES counts were greatest during first applications (117 [81–157]), especially after balloon stretch/deflations (43 [21–81]). Pre– and post–pulmonary vein potential mapping with Lasso catheters generated 57 (21–88) and 61 (36–88) MESs. Reinsertion of once withdrawn cryoballoons and subsequent applications produced 205 (156–310) MESs. Touch-up ablation generated 32 (19–62) MESs, whereas electric cardioversion generated no MESs. SCEs and silent cerebral lesions were detected in 11 (32.3%) and 4 (11.7%) patients, respectively. The patients with SCEs were older than those without; however, there were no significant factors associated with SCEs.


A significant number of MESs and SCE/silent cerebral lesion occurrences were observed during second-generation cryoballoon ablation procedures. MESs were recorded during a variety of steps throughout the procedure; however, the majority occurred during phases with a high probability of gaseous emboli.

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