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Deep brain stimulation (DBS) is a well-established therapy for drug-refractory Parkinson's disease. As 100–200 Hz signals from DBS are transmitted from the generator implanted subcutaneously in the anterior chest wall, there is a risk of central nervous system damage by radiofrequency energy or cardioversion. A 76-year-old female with a DBS was admitted for catheter ablation because of palpitation and syncope by paroxysmal atrial fibrillation. There may have been a risk of central nervous system damage and DBS electrode malfunction by radiofrequency energy and defibrillation shocks. In addition, cardioversion by an external defibrillator had the possibility to cause brain injury in patients with DBS. Therefore, pulmonary vein isolation by cryoballoon and cardioversion using an intracardiac defibrillation catheter were performed. Despite continued application of DBS during the procedure, no complications occurred. This is the first case report of cryoballoon ablation accompanied with intracardiac defibrillation under continued DBS. Cryoballoon ablation may be an alternative atrial fibrillation ablation method to radiofrequency catheter ablation for patients with DBS. Additionally, intracardiac defibrillation may reduce the risk of central nervous system damage and DBS malfunction.
Learning objective
Deep brain stimulation (DBS) is a well-established therapy for Parkinson's disease. In patients with DBS, there is a risk of central nervous system damage by radiofrequency energy or cardioversion by an external defibrillator. Cryoballoon ablation may be an alternative atrial fibrillation ablation method to radiofrequency catheter ablation for patients with continued DBS. In addition, intracardiac defibrillation may reduce the risk of central nervous system damage and DBS malfunction.
]. In cryoballoon ablation, pressurized nitrous oxide is delivered to the balloon with its temperature inside the balloon being able to reach −80 °C. Tissue changes due to freezing only occur immediately in the surrounding myocardium, and cryothermal energy may have less risk of damage than radiofrequency energy [
]. Therefore, cryoballoon ablation could be an alternative catheter ablation method to radiofrequency catheter ablation for patients with continued DBS.
Additionally, intracardiac defibrillation catheter is often used in AF ablation. Because cardioversion can be performed by positioning electrodes between the right atrium and the coronary sinus [
], the risk of damage to the CNS and DBS may be reduced.
However, to our knowledge, there are no reports about the use of cryoballoon ablation or intracardiac defibrillation for AF in patients with DBS. Here, we report the first case of cryoballoon ablation and cardioversion using intracardiac defibrillation catheter for AF with DBS.
Case report
A 76-year-old female was referred to our hospital because of palpitation and syncope. A deep brain stimulator (Activa RC, Medtronic, Inc., Minneapolis MN, USA) was implanted to treat her Parkinson's disease. Paroxysmal atrial fibrillation was detected on electrocardiography (Fig. 1A ), and syncope occurred after conversion to sinus rhythm. Other causes of syncope, such as epilepsy and orthostatic hypotension, were ruled out. Therefore, bradycardia–tachycardia syndrome was suspected to be the cause of syncope. The patient had been taking edoxaban 30 mg/day before the procedure. After confirming that there was no thrombus in the left atrial appendage by contrast-enhanced computed tomography and intracardiac echocardiography during the procedure, we performed catheter ablation for AF. Because her tremor seemed too severe to enable stillness during the procedure without DBS, DBS was continued during the procedure.
(A) Body surface 12‑lead electrocardiogram. Artifacts by DBS were noted on the electrograms.
(B) Intracardiac electrograms during right superior PV isolation. Artifacts by DBS were noted on the intracardiac electrograms of the electrode in the SVC. Although high-pass and low-pass signal filters were set to be 30 and 250 Hz, respectively, PV potential (arrow) could be detected. Artifact in the center of the figure was pacing spike from electrode in the SVC.
CMAP, compound motor action potential; CS, coronary sinus; DBS, deep brain stimulation; HRAd, HRAp, distal and proximal electrodes in the high right atrium; LRA, low right atrium; PV, pulmonary vein; SVC, superior vena cava.
The procedure was performed under intravenous conscious sedation with hydroxyzine and fentanyl. Electrophysiological studies and catheter ablation were performed using a 3-D mapping system (Ensite NavX ™, Abbott, Abbott Park, IL, USA) and a cryoballoon catheter (POLARx™, Boston Scientific, Boston MA, USA). As the cardiac rhythm at the beginning of the procedure was AF, electrical cardioversion was needed. An intracardiac defibrillation catheter (BeeAT™, Japan Lifeline, Tokyo, Japan) was inserted into the coronary sinus to minimize the risk of CNS damage and DBS malfunction by cardioversion. Fluoroscopic images taken during the procedure are shown in Fig. 2. Although high-pass and low-pass signal filters were set to be 30 and 250 Hz, respectively, pulmonary vein potential could be detected on electrograms (Fig. 1B). Pulmonary vein isolation by cryoballoon was successful. After pulmonary vein isolation, cardioversion using an intracardiac defibrillation catheter was performed one time at 10 J. Finally, the disappearance of pulmonary vein potential was confirmed during sinus rhythm. The procedure time was 72 min. The function and impedance of the DBS did not change between pre- and post-procedure. No peri-procedural complications occurred, and the patient was discharged two days after the procedure. She maintained sinus rhythm and syncope disappeared during 6 months of follow-up after the procedure.
Fig. 2Fluoroscopic images taken during the procedure. The deep brain stimulation generator was implanted subcutaneously in the left anterior chest wall.
We report the first case of cryoballoon ablation and cardioversion using intracardiac defibrillation catheter for AF with DBS. Cryoballoon ablation and intracardiac defibrillation were performed without complications including CNS damage.
High-frequency continuous electrical stimulation to the brain can improve symptoms of neurological disease [
]. More than 30,000 DBS surgeries were performed between 2002 and 2011 in the USA, and DBS has become a standard of care for treatment-refractory neurological disorders [
]. This report suggested that keeping a distance between the ablation catheter and generator might reduce the risks of heating and DBS electrode malfunction [
]. However, unlike catheter ablation for atrioventricular nodal reentrant tachycardia, ablation sites in AF ablation are typically the pulmonary vein and left atrium. If the generator is implanted in the left anterior chest wall, the distance between the ablation catheter and the generator can be quite short. Additionally, ablation lesions of AF ablation are generally larger than those of atrioventricular nodal reentrant tachycardia. Therefore, there is still a risk of CNS damage by radiofrequency energy, and there have been no reports about radiofrequency ablation for AF in patients with DBS.
In terms of cryothermal energy, catheter ablation for atrioventricular nodal reentrant tachycardia using a linear ablation catheter with a 8.6-mm tip was previously reported in patients with DBS [
]. Although cryoballoon ablation was noninferior to radiofrequency catheter ablation for the treatment of patients with drug-refractory paroxysmal AF with respect to efficacy and safety [
], to our knowledge, there have been no reports on cryoballoon ablation for AF in patients with DBS. In the present study, we hesitated to use antiarrhythmic drugs for rhythm control therapy because bradycardia–tachycardia syndrome was suspected to be the cause of presyncope. Therefore, we chose cryoballoon ablation as a rhythm control therapy without antiarrhythmic drugs and treated AF without complications. Cryoballoon ablation may be an alternative AF ablation method to radiofrequency catheter ablation for patients with DBS.
A previous case report showed that cardioversion by an external defibrillator has the capability to cause brain lesions in patients with DBS [
]. In that case, DBS was implanted at the right anterior chest wall, and the paddles of external defibrillator were placed to the right of the sternum and the left anterior axillary line. Although DBS was not interposed between the paddles of external defibrillator, brain lesions occurred. Therefore, changing the position of the paddles cannot completely prevent interference of DBS [
]. However, we needed to perform cardioversion because the cardiac rhythm at the beginning of the procedure was AF; therefore, an intracardiac defibrillation catheter was used in this case. Because low-energy shocks can be performed by positioning electrodes between the right atrium and the coronary sinus [
]. Although high-pass and low-pass signal filters were set to be 30 and 250 Hz, respectively, pulmonary vein potential could be detected in our case. One possible explanation for this might be that bipolar potentials of intracardiac electrograms were not greatly affected by DBS because the distance between each electrode was short and the electrodes were far away from the generator.
This is the first case report of cryoballoon ablation and cardioversion using intracardiac defibrillation catheter with DBS. Cryoballoon ablation can be an alternative AF ablation method to radiofrequency catheter ablation in patients with DBS. Additionally, intracardiac defibrillation can reduce the risk of CNS damage and DBS malfunction.
Patient permission/consent statement
Informed consent was obtained from the patient for publication of this case report.
Declaration of competing interest
Masaharu Masuda received lecturer's fees from Johnson and Johnson and Medtronic.
Acknowledgments
None.
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