Discussion
We present the first reported case of the use of a novel integrated dilator and needle system (AcQCross™️ Qx) in combination with a 15F steerable sheath (Medtronic FlexCathTM) to perform a cryoballoon procedure, without the need of sheath exchange. So far, a few experiences with the AcQCross™️ Qx system have been published1,6,7, which documented safety and improved procedural efficacy, as the time needed for TSP was significantly lower in AcQCross Qx groups as compared to traditional TSP approach. The main novelty of our approach consists in TSP monitoring. While Rizzi et al.1 and Yap et al.6,7 performed TSP respectively under transesophageal echocardiography monitoring the former and intracardiac imaging the latter, we chose to safely perform TSP with AcQCross™️ Qx system under fluoroscopy monitoring. The connection to a pressure line by using an Y connector allowed us to confirm the position of the needle by checking LA pressure after its protrusion and after that we could safely advance the guidewire into left superior pulmonary vein. This double check of LA pressure and fluoroscopically correct guidewire position before advancing the 15 F steerable sheath provides safety and reduces the need of cardiac imaging during the procedure. Eventually, AcQcross™️ Qx seems to be a promising novel TSP system, which has the potential to reduce the need of x-rays, the risk of air embolism due to sheath exchanges, and the complexity of TSP preserving safety by using echocardiographic monitoring or the double check suggested in this paper. Also young electrophysiologists and EP fellows may benefit from this new technology, as lowering complexity of this procedure could lead to a steeper learning curve. Further clinical studies need to be done to verify safety and feasibility outcomes and to finally assess the effective relevance of this new technology.