Burn or freeze

Can I have some opinions on what is better,to freeze the pulmonary vein with the cryo balloon or to burn it with rf?
I know that the best and most experience ep is the best person to do the job but saying the people are top of the game.
Thanks spencer

Can you rephrase your last sentence, I am confused by it. Shannon is the one who knows most, but from what I gather from talking with my EP's, one of which has done many Cryo's, is that Cyro is better, unless maybe you have an Elite Ablationist like Natale. RF burns are more precise, vs Cryo are broader. Also they tell me Cryo is less traumatic to the tissue.

Hi Spenser,

Cryo is mostly used to speed up the PVI process, and/or by those EPs who are not confident in their RF ablation skills. The vast majority of elite level ablationist use RF for good reason! It is far more flexible and allows the operator to seamlesslly move from the PVI ( pulmonary vein isolation ) phase for which Cryo is specifically and solely designed to address, to being able to ablate Non-PV triggers anywhere in the left and right atrial they are found, which is a HUGE advantage for more experienced ablation EPs allowing them to avoid having to switch out Cryo catheters and insert RF through sheaths into the LA as you really want to minimize transfer of sheaths/catethers too and from the RA and LA to avoid possibly micro air bubbles etc that can cause emboli issues.

As such the vast majority of Cryo users are those who limit their ablation work to only doing PVI and then they get out after confirming at least acute electrical block across the Cryo lesions for each isolated PV. This kind of ablation is likely to have a decent chance for success only in a fair percentage of earlier stage and more basic paroxysmal (PAF) cases... You know the kind where AFIB may have been active for from less than 1 yr to 3 yrs and with not much progression in terms of episode duration and frequency.

The more advanced the case of AFIB from more aggressive and frequent episodes of PAF to for sure persistent and LSPAF (long standing persistent AF) the more you approach 100% odds of having multiple Non-PV triggers ready to spoil any Cryo of standard RF PVI only ablation that does not even look for any real time detected Non PV triggers at all! Alas, roughly 85% of AFIB ablations are PVI-only as thstvis the limit most EP fellowship training programs teach. Tecsiuation is gradually improving with more EPs stretching their wings to be able to better help a wider array of AFIB patients with ablation.

A highly skilled RF EP will almost never use Cryo except for parts of some specific procedures like pediatric SVT ablation in the right atria where in small children hearts the distance from the key anatomical circuit that must be ablated to stop a common form of SVT (supra-ventricular tachycardia) is so close to the AV node that a focal Cryo catether is often used to allow gradually freezing so that the EP can confirm he/she has partly frozen the right area while NOT freezing the AV node and thus making the child pacemaker dependent for life. When, with Cryo, they can confirm their partial lesion is avoiding the AV node before delivering the final and permanent deep freeze to insure permanent ablation of that SVT circuit while confirming sparing of the AV node.

Great RF ablationists are fully capable of just as consistent, and even more durable PV isolation compared with Cryo ... both can work okay for their intended purpose, but Cryo is targeting a PVI-only for the most part. Not surprisingly therefore, it is the underexperiecd operators where RF ablation, which takes a good deal longer to master, will underscore an advantage for using Cryo especially so for less experienced operators.

But the real solution and smart approach to choosing an ablationist is do Not choose the technology and then try to find an EP who will use it on you. That is not a wise approach! Make your target finding the most experienced and consistently successful ablation EP you can possibly arrange for your self, while being fully willing to travel for 5 days if needed, as it so often is, for you to access a real maestro level ablationist. And then let them do their job of choosing the very best tools for your ablation. Do not try to force an EP's hand in using some whiz-bang sounding technology that may sound like the 'bee's knees' to us lay folks. That is the surest way to get into trouble I know of in this field.

Pick the doctor, not the tech .... this is your best chance to insure the right decision maker is making all the tools and technology choices for your ablation. Some excellent EPs might decide to use Cryo for the PVI part of any ablation and then do the switcheroo over to RF catheters for the rest of a more extended ablation including Non-PV trigger real time EP sleuthing, detection and ablation, simply to save time for the PVI phase.

That alone is another incentive for regular limited PVI-only ablationists to choose Cryo since as the quicker procedure it can allow them to add up 1 to 2 more PVI-only ablation cases a day and can thus up their billable events higher as well as serve more patients.

Finally, more EPs are starting to learn to use Dr Natale's 'Gliding Catheter' RF technique which confers even better continuous line creation than a fixed diameter round Cryo balloon. And this gliding catheter technique is a notable improvement over trying to create a contiguous linear line via using the standard ubiquitous 'dot by dot' traditional RF ablation method used by literally 95% of all current EPs using RF ablation. The gliding catheter method also provides a continuously variable trajectory of these truly continuous lines around the PVs and across and around most other variable and even undulating atrial tissue target areas while allowing the EP to adjust contact force and power across variably thick areas of the LA and RA. And this, unlike a fixed Cryo ballon that only creates a continuous lesion via several partial circle arcs needed around each vein to make for a contnous encirclement of an entire PV osmium and all of these lesions are typically more proximal to the PV itself and thus these Cryo PVI lesions tend not to be as distal around the outer antral region surrounding each PV. A more antral approach as in PVAI (PV Antral Isolation versus a Segmental or Ostial PVI) the later of which reduces greatly the risk of PV stenosis .. especially relative to RF Ostial PVI.

Anyway, you get the message ... choose the most experienced operator and as of circ 2017, by making a wise and discriminating choice in your ablation EP you will almost invariably wind up with a highly skilled RF operator in any event.

Shannon



Edited 1 time(s). Last edit at 06/25/2017 06:00PM by Shannon.

Thanks for the response it makes good sense.

Cryo doesn't always work if the anatomy of your veins is a certain way. I was scheduled to do a cryo ablation but before my ablation, my EP ordered a CT scan of the pulmonary veins to see if a Cryo ablation was appropriate. It turned out the anatomy of my veins was not compatible with a cryo. It's a good thing because my veins were hard to isolate and the surgery took over 5 hours. If they had done a cryo, I would most likely need another ablation. Talk to your EP about a CT-scan before moving forward.

I've read a lot of material from those who have used RF and Cryo-. RF seems to have about a 70% success rate while Cryo- is around 90%.

I had crying done on the 14th August 2017 and my heart has not missed a beat since,I now don’t drink alcohol or caffeine out of choice and take magnesium and potassium supplements other than that I’m back to normal again after 10 months out of rythem. I run less but still most days and just enjoy life to the full. No medication since November last year..