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Laser Balloon: New endoscopic catheter ablation in atrial fibrillation 

Laser catheter ablation is a new method of treatment for atrial fibrillation, which was first established in south Germany in the Isar Heart Center. It allows the examiner (cardiologist) a direct, endoscopic view of the confluence of the pulmonary veins. This is a new innovative approach in the treatment of atrial fibrillation. Preliminary data and our very positive experience demonstrate that this method has the potential for a potentially higher primary success rate. Due to the direct view, the need for X-rays can be considerably reduced, and, for example, computer-generated tomography can be dispensed with prior to the procedure.

The treatment of cardiac arrhythmia is one of the focus areas at Isar Heart Center. Dr. Turgut Brodherr, one of the leading experts in the world, is leading the Heart Rhythm Center Munich. 

The Isar Heart Center is one of the 3 Clinics in Germany performing the most Laser ablations in atrial fibrillation in Germany.


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Vorhofflimmern: CT unterstützt Darstellung der Veneneingänge bei Lungenvenenablation
The goal of any atrial fibrillation treatment (atrial fibrillation ablation) is the electrical isolation of the entry points of the four pulmonary veins from the tissues of the left atrium (pulmonary vein isolation: the areas colored red in the image). 
Often the cause of atrial fibrillation is found in the tissue behind these entry points. There, electrical impulses are generate that then result in an irregular beating of the heart. 
The intent of the ablation is to eliminate these pulses and also to hinder their transfer to the atria. The goal of the various electrophysiological approaches to treatment is to produce small areas of scar tissue between the pulmonary veins and the actual atrial tissue. These scar tissues then constitute an insurmountable barrier for the disturbing impulses. For a successful treatment, it is important that no gaps remain between the scar zones because only a cohesive scar curve ensures long-term electrical disconnection of the pulmonary veins.


Laserkatheterablation: Alternative Behandlungsmethode bei Vorhofflimmern

During a ablation therapy using conventional catheter techniques, the surgeon has no direct view of the confluence of the pulmonary veins. The X-ray fluoroscopic, computer-based navigation process, in which previously recorded CT images are fused together with images from X-ray equipment, along with the measurement of electrical pulses, is used during sclerotherapy as a guide. 
In most conventional treatment processes, the tissue has to be treated step by step which is tedious and complicated. The documentation of already sclerotized areas is usually done indirectly by a computer-assisted method (see navigation method). The difficulty is that the whole treatment must be performed through a long sheath entering through a vein in the area of the groin. (Illustration. Fa. Cardiofocus)

Laser-Ballon: Neue Technik zur Therapie des Vorhofflimmerns

The laser balloon catheter consists of the catheter shaft and the balloon itself. An endoscope has been incorporated into the catheter shaft. This endoscope allows the examiner to see through the balloon. Since blood would limit vision in the left atrium, the balloon is advanced into the pulmonary vein entranceway, and, with a slight amount of pressure in the direction of the pulmonary vein, the blood is expelled from the pulmonary vein entrance. Thereby, through the balloon, the examiner has a clear view of the pulmonary vein entrance. A light source allows the examiner to determine the subsequent destination of the laser beam and in advance simulate the subsequent treatment. The actual treatment with the laser is then also performed with visual assistance (endoscopic atrial fibrillation ablation). (Illustration. Fa. Cardiofocus)


As in a conventional method of treatment, the success of treatment is assessed with a so-called mapping catheter. Laser treatment of atrial fibrillation using a balloon catheter is a new therapeutic approach. The visual control of the intra-cardiac endoscope promises a “seamless” ablation sequence, as it is possible with the standard procedure using a radio frequency ablation catheter.The first available data supports this supposition. Whether there is a more favorable recidivism of atrial fibrillation by laser ablation than by using other methods, will have to be shown through future studies.
Laser Ablation: Ballonkatheter ermöglicht neues Behandlungsverfahren bei Vorhofflimmern
Video: A view through the endoscope to the pulmonary vein entrance. You can see clearly through the balloon as the pulsating blood is retained. Thus, the laser can be optimally positioned and the therapeutic laser emission can be released without blood limiting the precision between laser optics and pulmonary vein tissue.
The possible complication risks of ablation therapy, such as the occurrence of pericardial effusion, an intra-procedural stroke or an injury of surrounding structures such as a nerve (e.g. the phrenic nerve) also exist in the laser ablation. The complication of a pulmonary vein stenosis - as described in all other methods of ablation - has not yet occurred in the laser therapy. 
The direct view of the pulmonary veins is probably the most important benefit of this procedure. The examiner has the possibility to have optical control of the laser process (pictured here). The balloon catheter assures the intervention takes place without blood around the pulmonary vein entrance: "This is the big advantage of this method," says Prof. Lewalter of IHC. "Previous applications with lasers on the heart were less successful because blood flow could lead to an uncontrolled cooling of the area being sclerotized, so that the chances of ablation success were relatively poor. But since it can be performed without blood flow, this eliminates the cooling effect: The areas of ablation can be accurately set and thus it is possible to achieve good primary success."
The laser procedure is a new therapeutic method and extensive clinical studies, especially in consideration of the long-term, have yet to be done. In an initial clinical study with 200 patients ("Pulmonary Vein Isolation Using the Visually-Guided Laser Balloon: The First 200-patient, multi-center Clinical Experience") 99% of all pulmonary vein isolations by means of laser ablation catheters were initially successful. Of these patients, after six months, after a single ablation procedure 65 % had not developed a resumption of atrial fibrillation. Furthermore, it was found that there was a low rate of complications, even in regard to an absence of strokes, pulmonary vein stenosis and atrial-esophageal fistula. 
Along with other leading international cardiological centers, the Isar Heart Center is beginning to collect comprehensive clinical data on the intra-atrial laser application to present at upcoming scientific conferences.