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Ezzeddine FM, Asirvatham SJ, Nguyen DT. Pulsed Field Ablation: A Comprehensive Update. J Clin Med 2024; 13:5191. [PMID: 39274404 PMCID: PMC11396515 DOI: 10.3390/jcm13175191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/28/2024] [Accepted: 08/28/2024] [Indexed: 09/16/2024] Open
Abstract
One of the recent advancements in the field of cardiac electrophysiology is pulsed field ablation (PFA). PFA is a novel energy modality that does not rely on thermal processes to achieve ablation which, in turn, results in limited collateral damage to surrounding structures. In this review, we discuss the mechanisms, safety, efficacy, and clinical applications of PFA for the management of atrial and ventricular arrhythmias. We also summarize the published pre-clinical and clinical studies regarding this new technology.
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Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
- Department of Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
- Department of Clinical Anatomy, Mayo Clinic, Rochester, MN 55905, USA
| | - Duy T Nguyen
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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2
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Squara F, Supple G, Liuba I, Wasiak M, Zado E, Desjardins B, Marchlinski FE. Value of high-output pace-mapping of the right phrenic nerve for enabling safe radiofrequency ablation of atrial fibrillation: insights from three-dimensional computed tomography segmentation. Europace 2024; 26:euae207. [PMID: 39082747 PMCID: PMC11321358 DOI: 10.1093/europace/euae207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/02/2024] [Indexed: 08/15/2024] Open
Abstract
AIMS Right phrenic nerve (RPN) injury is a disabling but uncommon complication of atrial fibrillation (AF) radiofrequency ablation. Pace-mapping is widely used to infer RPN's course, for limiting the risk of palsy by avoiding ablation at capture sites. However, information is lacking regarding the distance between the endocardial sites of capture and the actual anatomic RPN location. We aimed at determining the distance between endocardial sites of capture and anatomic CT location of the RPN, depending on the capture threshold. METHODS AND RESULTS In consecutive patients undergoing AF radiofrequency ablation, we defined the course of the RPN on the electroanatomical map with high-output pacing at up to 50 mA/2 ms, and assessed RPN capture threshold (RPN-t). The true anatomic course of the RPN was delineated and segmented using CT scan, then merged with the electroanatomical map. The distance between pacing sites and the RPN was assessed. In 45 patients, 1033 pacing sites were analysed. Distances from pacing sites to RPN ranged from 7.5 ± 3.0 mm (min 1) when RPN-t was ≤10 mA to 19.2 ± 6.5 mm (min 9.4) in cases of non-capture at 50 mA. A distance to the phrenic nerve > 10 mm was predicted by RPN-t with a ROC curve area of 0.846 [0.821-0.870] (P < 0.001), with Se = 80.8% and Sp = 77.5% if RPN-t > 20 mA, Se = 68.0% and Sp = 91.6% if RPN-t > 30 mA, and Se = 42.4% and Sp = 97.6% if non-capture at 50 mA. CONCLUSION These data emphasize the utility of high-output pace-mapping of the RPN. Non-capture at 50 mA/2 ms demonstrated very high specificity for predicting a distance to the RPN > 10 mm, ensuring safe radiofrequency delivery.
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Affiliation(s)
- Fabien Squara
- Department of Cardiology, Pasteur University Hospital, 30 avenue de la Voie Romaine, 06000 Nice, France
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Gregory Supple
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Ioan Liuba
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Michal Wasiak
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Erica Zado
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Benoit Desjardins
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Francis E Marchlinski
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Reddy VY, Mansour M, Calkins H, d'Avila A, Chinitz L, Woods C, Gupta SK, Kim J, Eldadah ZA, Pickett RA, Winterfield J, Su WW, Waks JW, Schneider CW, Richards E, Albrecht EM, Sutton BS, Gerstenfeld EP. Pulsed Field vs Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation: Recurrent Atrial Arrhythmia Burden. J Am Coll Cardiol 2024; 84:61-74. [PMID: 38864538 DOI: 10.1016/j.jacc.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The ADVENT randomized trial revealed no significant difference in 1-year freedom from atrial arrhythmias (AA) between thermal (radiofrequency/cryoballoon) and pulsed field ablation (PFA). However, recent studies indicate that the postablation AA burden is a better predictor of clinical outcomes than the dichotomous endpoint of 30-second AA recurrence. OBJECTIVES The goal of this study was to determine: 1) the impact of postablation AA burden on outcomes; and 2) the effect of ablation modality on AA burden. METHODS In ADVENT, symptomatic drug-refractory patients with paroxysmal atrial fibrillation underwent PFA or thermal ablation. Postablation transtelephonic electrocardiogram monitor recordings were collected weekly or for symptoms, and 72-hour Holters were at 6 and 12 months. AA burden was calculated from percentage AA on Holters and transtelephonic electrocardiogram monitors. Quality-of-life assessments were at baseline and 12 months. RESULTS From 593 randomized patients (299 PFA, 294 thermal), using aggregate PFA/thermal data, an AA burden exceeding 0.1% was associated with a significantly reduced quality of life and an increase in clinical interventions: redo ablation, cardioversion, and hospitalization. There were more patients with residual AA burden <0.1% with PFA than thermal ablation (OR: 1.5; 95% CI: 1.0-2.3; P = 0.04). Evaluation of outcomes by baseline demographics revealed that patients with prior failed class I/III antiarrhythmic drugs had less residual AA burden after PFA compared to thermal ablation (OR: 2.5; 95% CI: 1.4-4.3; P = 0.002); patients receiving only class II/IV antiarrhythmic drugs pre-ablation had no difference in AA burden between ablation groups. CONCLUSIONS Compared with thermal ablation, PFA more often resulted in an AA burden less than the clinically significant threshold of 0.1% burden. (The FARAPULSE ADVENT PIVOTAL Trial PFA System vs SOC Ablation for Paroxysmal Atrial Fibrillation [ADVENT]; NCT04612244).
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Affiliation(s)
- Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, New York, USA.
| | - Moussa Mansour
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hugh Calkins
- Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Andre d'Avila
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Larry Chinitz
- NYU Langone Health, Heart Rhythm Center, New York, New York, USA
| | - Christopher Woods
- Sutter California Pacific Medical Center, San Francisco, California, USA
| | - Sanjaya K Gupta
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - Jamie Kim
- Catholic Medical Center, Manchester, New Hampshire, USA
| | | | | | | | - Wilber W Su
- Banner University Medical Center, Phoenix, Arizona, USA
| | - Jonathan W Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Wang Z, Tang M, Reddy VY, Chu H, Liu X, Xue Y, Wang J, Xu J, Liu S, Xu W, Zhang Z, Han B, Hong L, Yang B, Ding M, Liang M. Efficacy and safety of a novel hexaspline pulsed field ablation system in patients with paroxysmal atrial fibrillation: the PLEASE-AF study. Europace 2024; 26:euae174. [PMID: 38912887 PMCID: PMC11223653 DOI: 10.1093/europace/euae174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/10/2024] [Indexed: 06/25/2024] Open
Abstract
AIMS Pulsed field ablation (PFA) is an emerging non-thermal ablative modality demonstrating considerable promise for catheter ablation of atrial fibrillation (AF). However, these PFA trials have almost universally included only Caucasian populations, with little data on its effect on other races/ethnicities. The PLEASE-AF trial sought to study the 12-month efficacy and the safety of a multi-electrode hexaspline PFA catheter in treating a predominantly Asian/Chinese population of patients with drug-refractory paroxysmal AF. METHODS AND RESULTS Patients underwent pulmonary vein (PV) isolation (PVI) by delivering different pulse intensities at the PV ostium (1800 V) and atrium (2000 V). Acute success was defined as no PV potentials and entrance/exit conduction block of all PVs after a 20-min waiting period. Follow-up at 3, 6, and 12 months included 12-lead electrocardiogram and 24-h Holter examinations. The primary efficacy endpoint was 12-month freedom from any atrial arrhythmias lasting at least 30 s. The cohort included 143 patients from 12 hospitals treated by 28 operators: age 60.2 ± 10.0 years, 65.7% male, Asian/Chinese 100%, and left atrial diameter 36.6 ± 4.9 mm. All PVs (565/565, 100%) were successfully isolated. The total procedure, catheter dwell, total PFA application, and total fluoroscopy times were 123.5 ± 38.8 min, 63.0 ± 30.7 min, 169.7 ± 34.6 s, and 27.3 ± 10.1 min, respectively. The primary endpoint was observed in 124 of 143 patients (86.7%). One patient (0.7%) developed a small pericardial effusion 1-month post-procedure, not requiring intervention. CONCLUSION The novel hexaspline PFA catheter demonstrated universal acute PVI with an excellent safety profile and promising 12-month freedom from recurrent atrial arrhythmias in an Asian/Chinese population with paroxysmal AF. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05114954.
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Affiliation(s)
- Zulu Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Wenhua Road No. 83, Shenhe District, 110016 Shenyang, China
| | - Min Tang
- Department of Cardiology, Fuwai Hospital of Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Vivek Y Reddy
- Department of Cardiology, Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, NY, USA
| | - Huimin Chu
- Arrhythmia Center, Ningbo First Hospital, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Xingpeng Liu
- Department of Cardiology, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yumei Xue
- Department of Cardiology, Guangdong Provincial People’s Hospital, Guangzhou, China
| | - Jingfeng Wang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Xu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Shaowen Liu
- Department of Cardiology, Shanghai First People’s Hospital, Shanghai, China
| | - Wei Xu
- Department of Cardiology, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, China
| | - Zhihui Zhang
- Department of Cardiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Lang Hong
- Department of Cardiology, Jiangxi Provincial People’s Hospital, Nanchang, China
| | - Bing Yang
- Department of Cardiology, Shanghai East Hospital, Shanghai, China
| | - Mingying Ding
- Department of Cardiology, General Hospital of Northern Theater Command, Wenhua Road No. 83, Shenhe District, 110016 Shenyang, China
| | - Ming Liang
- Department of Cardiology, General Hospital of Northern Theater Command, Wenhua Road No. 83, Shenhe District, 110016 Shenyang, China
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5
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Badertscher P, Knecht S, Rosso R, Krisai P, Spreen D, Katic J, Du Fay de Lavallaz J, Sticherling C, Kühne M. How to perform pulmonary vein isolation using a pentaspline pulsed field ablation system for treatment of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)02832-7. [PMID: 38964447 DOI: 10.1016/j.hrthm.2024.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 06/25/2024] [Accepted: 06/25/2024] [Indexed: 07/06/2024]
Affiliation(s)
- Patrick Badertscher
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Sven Knecht
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Raphael Rosso
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Philipp Krisai
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - David Spreen
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Josip Katic
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; Clinic for Heart and Cardiovascular Diseases, University Hospital Split, Split, Croatia
| | - Jeanne Du Fay de Lavallaz
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Christian Sticherling
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Michael Kühne
- Department of Cardiology, University Hospital Basel, Basel, Switzerland.
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6
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Ekanem E, Neuzil P, Reichlin T, Kautzner J, van der Voort P, Jais P, Chierchia GB, Bulava A, Blaauw Y, Skala T, Fiala M, Duytschaever M, Szeplaki G, Schmidt B, Massoullie G, Neven K, Thomas O, Vijgen J, Gandjbakhch E, Scherr D, Johannessen A, Keane D, Boveda S, Maury P, García-Bolao I, Anic A, Hansen PS, Raczka F, Lepillier A, Guyomar Y, Gupta D, Van Opstal J, Defaye P, Sticherling C, Sommer P, Kucera P, Osca J, Tabrizi F, Roux A, Gramlich M, Bianchi S, Adragão P, Solimene F, Tondo C, Russo AD, Schreieck J, Luik A, Rana O, Frommeyer G, Anselme F, Kreis I, Rosso R, Metzner A, Geller L, Baldinger SH, Ferrero A, Willems S, Goette A, Mellor G, Mathew S, Szumowski L, Tilz R, Iacopino S, Jacobsen PK, George A, Osmancik P, Spitzer S, Balasubramaniam R, Parwani AS, Deneke T, Glowniak A, Rossillo A, Pürerfellner H, Duncker D, Reil P, Arentz T, Steven D, Olalla JJ, de Jong JSSG, Wakili R, Abbey S, Timo G, Asso A, Wong T, Pierre B, Ewertsen NC, Bergau L, Lozano-Granero C, Rivero M, Breitenstein A, Inkovaara J, Fareh S, Latcu DG, Linz D, Müller P, Ramos-Maqueda J, Beiert T, Themistoclakis S, Meininghaus DG, Stix G, Tzeis S, Baran J, Almroth H, Munoz DR, de Sousa J, Efremidis M, Balsam P, Petru J, Küffer T, Peichl P, Dekker L, Della Rocca DG, Moravec O, Funasako M, Knecht S, Jauvert G, Chun J, Eschalier R, Füting A, Zhao A, Koopman P, Laredo M, Manninger M, Hansen J, O'Hare D, Rollin A, Jurisic Z, Fink T, Chaumont C, Rillig A, Gunawerdene M, Martin C, Kirstein B, Nentwich K, Lehrmann H, Sultan A, Bohnen J, Turagam MK, Reddy VY. Safety of pulsed field ablation in more than 17,000 patients with atrial fibrillation in the MANIFEST-17K study. Nat Med 2024; 30:2020-2029. [PMID: 38977913 PMCID: PMC11271404 DOI: 10.1038/s41591-024-03114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/04/2024] [Indexed: 07/10/2024]
Abstract
Pulsed field ablation (PFA) is an emerging technology for the treatment of atrial fibrillation (AF), for which pre-clinical and early-stage clinical data are suggestive of some degree of preferentiality to myocardial tissue ablation without damage to adjacent structures. Here in the MANIFEST-17K study we assessed the safety of PFA by studying the post-approval use of this treatment modality. Of the 116 centers performing post-approval PFA with a pentaspline catheter, data were received from 106 centers (91.4% participation) regarding 17,642 patients undergoing PFA (mean age 64, 34.7% female, 57.8% paroxysmal AF and 35.2% persistent AF). No esophageal complications, pulmonary vein stenosis or persistent phrenic palsy was reported (transient palsy was reported in 0.06% of patients; 11 of 17,642). Major complications, reported for ~1% of patients (173 of 17,642), were pericardial tamponade (0.36%; 63 of 17,642) and vascular events (0.30%; 53 of 17,642). Stroke was rare (0.12%; 22 of 17,642) and death was even rarer (0.03%; 5 of 17,642). Unexpected complications of PFA were coronary arterial spasm in 0.14% of patients (25 of 17,642) and hemolysis-related acute renal failure necessitating hemodialysis in 0.03% of patients (5 of 17,642). Taken together, these data indicate that PFA demonstrates a favorable safety profile by avoiding much of the collateral damage seen with conventional thermal ablation. PFA has the potential to be transformative for the management of patients with AF.
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Affiliation(s)
- Emmanuel Ekanem
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Winchester Cardiology and Vascular Medicine, Winchester Medical Center Valley Health, Winchester, VA, USA
| | | | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Pierre Jais
- IHU LIRYC, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Alan Bulava
- Ceske Budejovice Hospital and Faculty of Health and Social Sciences, University of South Bohemia in Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Yuri Blaauw
- Universitair Medish Groningen, Groningen, the Netherlands
| | - Tomas Skala
- University Hospital Olomouc, Olomouc, Czech Republic
| | | | | | - Gabor Szeplaki
- Atrial Fibrillation Institute, Mater Private Hospital, Dublin, Ireland
- Cardiovascular Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | | | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | | | | | - Estelle Gandjbakhch
- Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Institute of Cardiology, ICAN Institute for Cardiometabolism and Nutrition, Paris, France
| | | | | | | | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- University of Brussels VUB, Jette Brussels, Belgium
| | | | - Ignacio García-Bolao
- Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Ante Anic
- University Hospital Center Split, Split, Croatia
| | | | | | | | - Yves Guyomar
- GHICL Hôpital Saint Philibert, Saint Philibert, France
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | - Pascal Defaye
- Cardiology Department, Grenoble Alpes University Hospital and University, Grenoble, France
| | | | - Philipp Sommer
- Heart and Diabetes Center NRW, Ruhr University Bochum, Bochum, Germany
| | - Pavel Kucera
- Regional Hospital Liberec, Liberec, Czech Republic
| | - Joaquin Osca
- Polytechnic and University La Fe Hospital, Valencia, Spain
| | | | - Antoine Roux
- Pole Sante Republique Elsan, Clermont-Ferrand, France
| | - Michael Gramlich
- Uniklinikum RWTH Aachen, Department of Cardiology, Aachen, Germany
| | | | | | | | - Claudio Tondo
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Antonio Dello Russo
- Department of Biomedical Science and Public Health, UNIVPM, Ancona, Italy
- Arrhythmology Clinic Department, Azienda Ospedaliera Universitaria delle Marche, Ancona, Italy
| | | | - Armin Luik
- Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Obaida Rana
- Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Gerrit Frommeyer
- Clinic for Cardiology II, Electrophysiology, University of Münster, Münster, Germany
| | | | - Ingo Kreis
- St. Johannes Hospital Dortmund, Dortmund, Germany
| | | | | | - Laszlo Geller
- Semmelweis University, Cardiovascular Center, Budapest, Hungary
| | | | - Angel Ferrero
- Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St. Vincenz-Hospital, Paderborn, Germany
- MAESTRIA Consortium at AFNET, Münster, Germany
- Otto-von-Guericke University, Magdeburg, Germany
| | - Greg Mellor
- Cardiology Department, Royal Papworth Hospital, Cambridge, UK
| | | | | | - Roland Tilz
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Center for Cardiovascular Research, Partner Site Lübeck, Lübeck, Germany
| | | | | | | | | | | | | | | | | | - Andrzej Glowniak
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | | | | | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Peter Reil
- Klinikum Ingolstadt, Ingolstadt, Germany
| | | | - Daniel Steven
- Universitätsklinikum Köln AöR, Köln, Germany
- Department for Electrophysiology, Heart Center University Cologne, Cologne, Germany
| | - Juan José Olalla
- Arrhytmia Service, Cardiology Department, University Hospital Marqués de Valdecilla, Santander, Spain
| | | | - Reza Wakili
- University Duisburg-Essen, Duisburg, Germany
- University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Selim Abbey
- L'Hôpital Privé du Confluent, Nantes, France
| | | | | | - Tom Wong
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, King's College and Imperial College, London, UK
| | | | | | | | | | | | | | - Jaakko Inkovaara
- Tampere Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Samir Fareh
- Hopital de la Croix Rousse Nord, Nord, France
| | | | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
- Faculty of Health and Medical Sciences, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Patrick Müller
- Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
| | - Javier Ramos-Maqueda
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Zaragoza, Spain
- Aragón Health Research Institute, Zaragoza, Spain
| | - Thomas Beiert
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | | | | | - Günter Stix
- Allgemeines Krankenhaus Universitätsklinik Wien, Wien, Austria
| | | | - Jakub Baran
- Department of Internal Medicine and Cardiology University Clinical Center, Medical University of Warsaw, Warsaw, Poland
| | | | | | - João de Sousa
- Arrhythmia Unit, Cardiology Department, Lisbon Academic Medical Center, Santa Maria University Hospital, Lisbon, Portugal
| | - Michalis Efremidis
- Onassis Cardiac Surgery Center, Department of Cardiac Electrophysiology and Pacing, Athens, Greece
| | - Pawel Balsam
- 1st Chair and Department of Cardiology, Warsaw Medical University, Warsaw, Poland
| | - Jan Petru
- Homolka Hospital, Prague, Czech Republic
| | - Thomas Küffer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Lukas Dekker
- Catharina Ziekenhuis Eindhoven, Eindhoven, the Netherlands
| | - Domenico G Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | | | | | | | - Gael Jauvert
- Atrial Fibrillation Institute, Mater Private Hospital, Dublin, Ireland
| | - Julian Chun
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | | | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | | | | | - Mikael Laredo
- Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Institute of Cardiology, ICAN Institute for Cardiometabolism and Nutrition, Paris, France
| | | | - Jim Hansen
- Copenhagen University Hospital Gentofte, Gentofte, Denmark
| | | | - Anne Rollin
- University Hospital Rangueil, Toulouse, France
| | | | - Thomas Fink
- Heart and Diabetes Center NRW, Ruhr University Bochum, Bochum, Germany
| | | | | | | | - Claire Martin
- Cardiology Department, Royal Papworth Hospital, Cambridge, UK
| | - Bettina Kirstein
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Center for Cardiovascular Research, Partner Site Lübeck, Lübeck, Germany
| | | | | | - Arian Sultan
- Universitätsklinikum Köln AöR, Köln, Germany
- Department for Electrophysiology, Heart Center University Cologne, Cologne, Germany
| | - Jan Bohnen
- University Duisburg-Essen, Duisburg, Germany
- University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | | | - Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Homolka Hospital, Prague, Czech Republic.
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7
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Kim J, Slotwiner D. Phrenic nerve injury with pulsed field ablation: A lesson to be learned? HeartRhythm Case Rep 2024; 10:451-452. [PMID: 39129745 PMCID: PMC11312014 DOI: 10.1016/j.hrcr.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Affiliation(s)
- Joonhyuk Kim
- New York Presbyterian/Queens, Flushing, New York
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8
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Gerstenfeld EP, Mansour M, Whang W, Venkateswaran R, Harding JD, Ellis CR, Ellenbogen KA, Osorio J, DeLurgio DB, Daccarett M, Mangrum M, McElderry T, Richards E, Albrecht EM, Schneider CW, Sutton BS, Reddy VY. Autonomic Effects of Pulsed Field vs Thermal Ablation for Treating Atrial Fibrillation: Subanalysis of ADVENT. JACC Clin Electrophysiol 2024; 10:1634-1644. [PMID: 38869507 DOI: 10.1016/j.jacep.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Autonomic denervation is an ancillary phenomenon during thermal ablation of atrial fibrillation (AF), that may have synergistic effects on symptomatic improvement and long-term freedom from AF. Pulsed field ablation (PFA), a nonthermal ablation modality, was noninferior to thermal ablation in treating AF; however, PFA's relative myocardial selectivity may minimize autonomic effects. OBJECTIVES This study sought to compare heart rate (HR) and heart rate variability (HRV) metrics as markers of autonomic function after ablation using PFA vs thermal ablation. METHODS ADVENT (FARAPULSE ADVENT PIVOTAL Trial PFA System vs SOC Ablation for Paroxysmal Atrial Fibrillation) was a randomized pivotal study comparing PFA (pentaspline catheter) with thermal ablation (radiofrequency [RF] or cryoballoon [CB]) for treating paroxysmal AF. Baseline HR was acquired from a pre-ablation 12-lead electrocardiogram, whereas follow-up HRs, as well as HRV (standard deviation of all normal to normal RR intervals, standard deviation of 5-minute average RR intervals) metrics, were derived from 72-hour Holter monitors at 6 and 12 months. RESULTS This study included 379 paroxysmal AF patients undergoing PFA (n = 194) or thermal ablation (n = 185; n = 102 RF, n = 83 CB) completing 6- and 12-month Holter monitoring. Compared with PFA, thermal patients had significantly greater increases in HR from baseline to 6 months (ΔHR; 10.1 vs 5.9 beats/min; P = 0.02) and 12 months (ΔHR; 8.8 vs 5.2 beats/min; P = 0.03). This increase in HR at 6 and 12 months was similar between CB and RF (P = 0.94 and 0.83, respectively). HRV, both standard deviation of all normal to normal RR intervals and standard deviation of 5-minute average RR intervals, were significantly lower at both 6 and 12 months after thermal ablation compared with PFA (P < 0.01). CONCLUSIONS PFA's effect on the autonomic nervous system was attenuated compared with thermal ablation. Whether this affects long-term freedom from AF or symptomatic bradycardia/pauses after AF ablation requires further study.
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Affiliation(s)
| | - Moussa Mansour
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William Whang
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, New York, USA
| | | | | | | | | | - Jose Osorio
- Grandview Medical Center, Birmingham, Alabama, USA
| | | | | | - Michael Mangrum
- University of Virginia Medical Center, Charlottesville, Virgina, USA
| | - Tom McElderry
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | | | | | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, New York, USA
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9
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Chun KRJ, Miklavčič D, Vlachos K, Bordignon S, Scherr D, Jais P, Schmidt B. State-of-the-art pulsed field ablation for cardiac arrhythmias: ongoing evolution and future perspective. Europace 2024; 26:euae134. [PMID: 38848447 PMCID: PMC11160504 DOI: 10.1093/europace/euae134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/07/2024] [Indexed: 06/09/2024] Open
Abstract
Pulsed field ablation (PFA) is an innovative approach in the field of cardiac electrophysiology aimed at treating cardiac arrhythmias. Unlike traditional catheter ablation energies, which use radiofrequency or cryothermal energy to create lesions in the heart, PFA utilizes pulsed electric fields to induce irreversible electroporation, leading to targeted tissue destruction. This state-of-the-art review summarizes biophysical principles and clinical applications of PFA, highlighting its potential advantages over conventional ablation methods. Clinical data of contemporary PFA devices are discussed, which combine predictable procedural outcomes and a reduced risk of thermal collateral damage. Overall, these technological developments have propelled the rapid evolution of contemporary PFA catheters, with future advancements potentially impacting patient care.
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Affiliation(s)
- Kyoung-Ryul Julian Chun
- CCB Frankfurt, Med. Klinik III, Markuskrankenhaus, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
- Klinik für Rhythmologie, UKSH, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, Laboratory of Biocybernetics, University of Ljubljana, Trzaska cesta 25, SI-1000 Ljubljana, Slovenia
| | - Konstantinos Vlachos
- Site Hôpital Xavier Arnozan, Bordeaux University Hospital, University of Bordeaux, Avenue du Haut-Lévêque, –Pessac, France
| | - Stefano Bordignon
- CCB Frankfurt, Med. Klinik III, Markuskrankenhaus, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - Daniel Scherr
- Klinische Abteilung für Kardiologie, Medizinische Universität Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Pierre Jais
- Site Hôpital Xavier Arnozan, Bordeaux University Hospital, University of Bordeaux, Avenue du Haut-Lévêque, –Pessac, France
| | - Boris Schmidt
- CCB Frankfurt, Med. Klinik III, Markuskrankenhaus, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
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Enriquez A, Muser D, Markman TM, Garcia F. Mapping and Ablation of Premature Ventricular Complexes: State of the Art. JACC Clin Electrophysiol 2024; 10:1206-1222. [PMID: 38639702 DOI: 10.1016/j.jacep.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/20/2024]
Abstract
Premature ventricular complexes (PVCs) are common arrhythmias in clinical practice. Although benign and asymptomatic in most cases, PVCs may result in disabling symptoms, left ventricular systolic dysfunction, or PVC-induced ventricular fibrillation. Catheter ablation has emerged as a first-line therapy in such cases, with high rates of efficacy and low risk of complications. Significant progress in mapping and ablation technology has been made in the past 2 decades, along with the development of a growing body of knowledge and accumulated experience regarding PVC sites of origin, anatomical relationships, electrocardiographic characterization, and mapping/ablation strategies. This paper provides an overview of the main indications for catheter ablation of PVCs, electrocardiographic features, PVC mapping techniques, and contemporary ablation approaches. The authors also review the most common sites of PVC origin and the main considerations and challenges with ablation in each location.
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Affiliation(s)
- Andres Enriquez
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Daniele Muser
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy M Markman
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin Garcia
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Lennerz C, O'Connor M, Schaarschmidt C, Reents T, Bourier F, Telishevska M, Lengauer S, Popa M, Wimbauer K, Holmgren E, Thoma M, Spitzauer L, Bahlke F, Krafft H, Englert F, Knoll K, Friedrich L, Blazek P, Hessling G, Kolb C, Deisenhofer I, Kottmaier M. Pulsed field ablation in patients with cardiac implantable electronic devices: an ex vivo assessment of safety. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01758-2. [PMID: 38775921 DOI: 10.1007/s10840-024-01758-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/21/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND Pulse field ablation (PFA) is a novel catheter ablation technology with potential safety benefits due to its tissue selectivity. It has the potential to directly damage or interact with the functionality of cardiac implantable electronic devices (CIEDs) in the form of electromagnetic interference (EMI). The aim of our study was to assess the impact of PFA on CIEDs. METHODS PFA lesions (45 per CIED) were applied from the Farapulse system to CIEDs (< 5 cm from the lead tip and < 15 cm from the generator). All devices were checked before and after PFA application for proper sensing and pacing functionality as well as for integrity of shock circuits in ICDs using a heart simulator. Moreover, devices were then interrogated for any spontaneous reprogramming, mode switching or other EMI effects. RESULTS In total, 44 CIEDs were tested (16 pacemaker, 21 ICDs, 7 CRT-P/D) with 1980 PFA applications. There was no change in device settings, functionality and electrical parameters, and there was no macroscopic damage to the devices. The risk of damage to the electric components or leads on a patient-based analysis is 0/44 (95% CI 0-8%) and on a PFA pulse-based analysis is 0/1980 (95% CI 0-0.2%). Clinically relevant EMI appeared with oversensing and pacing inhibition but not tachycardia detection. CONCLUSIONS Bipolar PFA appears safe and does not result in damage to CIEDs or leads. Clinically relevant EMI does occur, but appropriate peri-procedural programming may mitigate this. In vivo studies are needed to confirm our findings.
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Affiliation(s)
- Carsten Lennerz
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany.
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.
| | - Matthew O'Connor
- Cardiology Department, Auckland City Hospital, Auckland, New Zealand
| | - Claudia Schaarschmidt
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Tilko Reents
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Felix Bourier
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Marta Telishevska
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Sarah Lengauer
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Miruna Popa
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Katharina Wimbauer
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Ellen Holmgren
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Mara Thoma
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Lovis Spitzauer
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Fabian Bahlke
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Hannah Krafft
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Florian Englert
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Katharina Knoll
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Lena Friedrich
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Patrick Blazek
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Gabriele Hessling
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Christof Kolb
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Marc Kottmaier
- Department of Electrophysiology, German Heart Centre Munich, Technical University of Munich, Lazarettstr. 36, 80636, Munich, Germany
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Ford P, Cheung AR, Khan MS, Rollo G, Paidy S, Hutchinson M, Chaudhry R. Anesthetic Techniques for Ablation in Atrial Fibrillation: A Comparative Review. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00315-X. [PMID: 39164166 DOI: 10.1053/j.jvca.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/15/2024] [Accepted: 05/02/2024] [Indexed: 08/22/2024]
Abstract
Atrial fibrillation, the most prevalent cardiac arrhythmia, has witnessed significant advancements in treatment modalities, transitioning from invasive procedures like the maze procedure to minimally invasive catheter ablation techniques. This review focuses on recent improvements in anesthetic approaches that enhance outcomes in catheter atrial fibrillation ablation. We highlight the efficacy of contact force sensing catheters with steerable introducer sheaths, which outperform traditional catheters by ensuring more effective contact time and lesion formation. Comparing general anesthesia with conscious sedation, we find that general anesthesia provides superior catheter stability due to reduced respiratory variability, resulting in more effective lesion formation, and reduced pulmonary vein reconnection. The use of high-frequency jet ventilation under general anesthesia, delivering low tidal volumes, effectively minimizes left atrial movement, decreasing catheter displacement and procedure time, and reducing recurrence in paroxysmal atrial fibrillation. An alternative, high-frequency low tidal volume ventilation using conventional ventilators, also shows improved catheter stability and lesion durability compared to traditional ventilation methods. However, a detailed comparative study of high-frequency jet ventilation, high-frequency low tidal volume ventilation, and conventional mechanical ventilation in catheter ablation for atrial fibrillation is lacking. This review emphasizes the need for such studies to identify optimal anesthetic techniques, potentially enhancing patient outcomes in atrial fibrillation treatment. Our findings suggest that careful selection of anesthetic methods, including ventilation strategies, plays a crucial role in the success of catheter ablation for atrial fibrillation, warranting further research for evidence-based practice.
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Affiliation(s)
- Paul Ford
- Banner University Medical Center, Department of Anesthesiology and Pain Medicine, University of Arizona COM-T, Tucson, Arizona
| | - Andrew Russell Cheung
- Banner University Medical Center, Department of Anesthesiology and Pain Medicine, University of Arizona COM-T, Tucson, Arizona
| | - Maaz Shah Khan
- Banner University Medical Center, Department of Anesthesiology and Pain Medicine, University of Arizona COM-T, Tucson, Arizona
| | - Gabriella Rollo
- Banner University Medical Center, Department of Anesthesiology and Pain Medicine, University of Arizona COM-T, Tucson, Arizona
| | - Samata Paidy
- Banner University Medical Center, Department of Anesthesiology and Pain Medicine, University of Arizona COM-T, Tucson, Arizona
| | - Mathew Hutchinson
- Banner University Medical Center, Division of Cardiology, Department of Medicine, University of Arizona COM-T, Tucson, Arizona
| | - Rabail Chaudhry
- Banner University Medical Center, Department of Anesthesiology and Pain Medicine, University of Arizona COM-T, Tucson, Arizona.
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Malyshev Y, Neuzil P, Petru J, Funasako M, Hala P, Kopriva K, Schneider C, Achyutha A, Vanderper A, Musikantow D, Turagam M, Dukkipati SR, Reddy VY. Nitroglycerin to Ameliorate Coronary Artery Spasm During Focal Pulsed-Field Ablation for Atrial Fibrillation. JACC Clin Electrophysiol 2024; 10:885-896. [PMID: 38385916 DOI: 10.1016/j.jacep.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/21/2023] [Accepted: 12/24/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND In treating atrial fibrillation, pulsed-field ablation (PFA) has comparable efficacy to conventional thermal ablation, but with important safety advantages: no esophageal injury or pulmonary vein stenosis, and rare phrenic nerve injury. However, when PFA is delivered in proximity to coronary arteries using a pentaspline catheter, which generates a broad electrical field, severe vasospasm can be provoked. OBJECTIVES The authors sought to study the vasospastic potential of a focal PFA catheter with a narrower electrical field and develop a preventive strategy with nitroglycerin. METHODS During atrial fibrillation ablation, a focal PFA catheter was used for cavotricuspid isthmus ablation. Angiography of the right coronary artery (some with fractional flow reserve measurement) was performed before, during, and after PFA. Beyond no nitroglycerin (n = 5), and a few testing strategies (n = 8), 2 primary nitroglycerin administration strategies were studied: 1) multiple boluses (3-2 mg every 2 min) into the right atrium (n = 10), and 2) a bolus (3 mg) into the right atrium with continuous peripheral intravenous infusion (1 mg/min; n = 10). RESULTS Without nitroglycerin, cavotricuspid isthmus ablation provoked moderate-severe vasospasm in 4 of 5 (80%) patients (fractional flow reserve 0.71 ± 0.08). With repetitive nitroglycerin boluses, severe spasm did not occur, and mild-moderate vasospasm occurred in only 2 of 10 (20%). Using the bolus + infusion strategy, severe and mild-moderate spasm occurred in 1 and 3 of 10 patients (aggregate 40%). No patient had ST-segment changes. CONCLUSIONS Ablation of the cavotricuspid isthmus using a focal PFA catheter routinely provokes right coronary vasospasm. Pretreatment with high doses of parenteral nitroglycerin prevents severe spasm.
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Affiliation(s)
- Yury Malyshev
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jan Petru
- Homolka Hospital, Prague, Czech Republic
| | | | - Pavel Hala
- Homolka Hospital, Prague, Czech Republic
| | | | | | - Anitha Achyutha
- Farapulse-Boston Scientific, Inc, Menlo Park, California, USA
| | | | | | - Mohit Turagam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Homolka Hospital, Prague, Czech Republic.
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Maurhofer J, Tanner H, Kueffer T, Madaffari A, Thalmann G, Kozhuharov N, Galuszka O, Servatius H, Haeberlin A, Noti F, Roten L, Reichlin T. Pulsed-field ablation for repeat procedures after failed prior thermal ablation for atrial fibrillation. Heart Rhythm O2 2024; 5:257-265. [PMID: 38840763 PMCID: PMC11148502 DOI: 10.1016/j.hroo.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Background Pulsed-field ablation (PFA) is a novel nonthermal ablation technology. Its potential value for repeat procedures after unsuccessful thermal ablation for atrial fibrillation has not been assessed. Objective The purpose of this study was to summarize our initial experience with patients undergoing repeat procedures using PFA. Methods Consecutive patients with arrhythmia recurrences after a prior thermal ablation undergoing a repeat procedure using a multipolar PFA catheter from May 2021 and December 2022 were included. After 3-dimensional electroanatomic mapping, reconnected pulmonary veins (PVs) were reisolated and veins with only ostial isolation wither ablated to widen antral PV isolation. Posterior wall ablation was performed if all PVs were durably isolated or in case of low-voltage areas on the posterior wall at the discretion of the operator. Patients underwent follow-up with 7-day Holter electrocardiography after 3, 6, and 12 months. Results A total of 186 patients undergoing a repeat procedure using PFA were included. The median number of previous ablations was 1 (range 1-6). The prior ablation modality was radiofrequency in 129 patients (69.4%), cryoballoon in 51 (27.4%), and epicardial ablation in 6 (3.2%). At the beginning of the procedure, 258 of 744 PVs (35%) showed reconnections. Additional antral ablations were applied in 236 of 486 still isolated veins (49%). Posterior wall ablation was added in 125 patients (67%). Major complications occurred in 1 patient (transient ischemic attack 0.5%). Freedom from arrhythmia recurrence in Kaplan-Meier-analysis was 78% after 6 months and 54% after 12 months. Conclusion PFA is a versatile and safe option for repeat procedures after failed prior thermal ablation.
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Affiliation(s)
- Jens Maurhofer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Kueffer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Antonio Madaffari
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gregor Thalmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikola Kozhuharov
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oskar Galuszka
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Bern, Switzerland
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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Aldaas OM, Malladi C, Han FT, Hoffmayer KS, Krummen D, Ho G, Raissi F, Birgersdotter-Green U, Feld GK, Hsu JC. Pulsed field ablation versus thermal energy ablation for atrial fibrillation: a systematic review and meta-analysis of procedural efficiency, safety, and efficacy. J Interv Card Electrophysiol 2024; 67:639-648. [PMID: 37855992 PMCID: PMC11016003 DOI: 10.1007/s10840-023-01660-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Pulsed field ablation (PFA) induces cell death through electroporation using ultrarapid electrical pulses. We sought to compare the procedural efficiency characteristics, safety, and efficacy of ablation of atrial fibrillation (AF) using PFA compared with thermal energy ablation. METHODS We performed an extensive literature search and systematic review of studies that compared ablation of AF with PFA versus thermal energy sources. Risk ratio (RR) 95% confidence intervals (CI) were measured for dichotomous variables and mean difference (MD) 95% CI were measured for continuous variables, where RR < 1 and MD < 0 favor the PFA group. RESULTS We included 6 comparative studies for a total of 1012 patients who underwent ablation of AF: 43.6% with PFA (n = 441) and 56.4% (n = 571) with thermal energy sources. There were significantly shorter procedures times with PFA despite a protocolized 20-min dwell time (MD - 21.95, 95% CI - 33.77, - 10.14, p = 0.0003), but with significantly longer fluroscopy time (MD 5.71, 95% CI 1.13, 10.30, p = 0.01). There were no statistically significant differences in periprocedural complications (RR 1.20, 95% CI 0.59-2.44) or recurrence of atrial tachyarrhythmias (RR 0.64, 95% CI 0.31, 1.34) between the PFA and thermal ablation cohorts. CONCLUSIONS Based on the results of this meta-analysis, PFA was associated with shorter procedural times and longer fluoroscopy times, but no difference in periprocedural complications or rates of recurrent AF when compared to ablation with thermal energy sources. However, larger randomized control trials are needed.
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Affiliation(s)
- Omar Mahmoud Aldaas
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Chaitanya Malladi
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Frederick T Han
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Kurt S Hoffmayer
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - David Krummen
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Gordon Ho
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Farshad Raissi
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Ulrika Birgersdotter-Green
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Gregory K Feld
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Jonathan C Hsu
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA.
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of CA - San Diego, 9452 Medical Center Drive, 3rd Floor, Room 3E-417, La Jolla, CA, 92037, USA.
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Maurhofer J, Kueffer T, Madaffari A, Stettler R, Stefanova A, Seiler J, Thalmann G, Kozhuharov N, Galuszka O, Servatius H, Haeberlin A, Noti F, Tanner H, Roten L, Reichlin T. Pulsed-field vs. cryoballoon vs. radiofrequency ablation: a propensity score matched comparison of one-year outcomes after pulmonary vein isolation in patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2024; 67:389-397. [PMID: 37776355 PMCID: PMC10902096 DOI: 10.1007/s10840-023-01651-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Pulsed-field ablation (PFA) has shown favourable data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI). We sought to compare procedural and 1-year follow-up data of patients with paroxysmal atrial fibrillation (AF) undergoing PVI using PFA, cryoballoon ablation (CBA) and radiofrequency ablation (RFA). METHODS Consecutive patients with paroxysmal AF undergoing a first PVI with PFA at our institution were included. For comparison, patients with paroxysmal AF undergoing a first PVI with CBA and RFA were selected using a 1:2:2 propensity score matching. The PFA group followed the standard 32-applications lesion-set protocol, the CBA group a time-to-effect plus 2-min strategy, and the RFA group the CLOSE protocol. Patients were followed with 7d-Holter ECGs 3, 6, and 12 months after ablation. The primary endpoint was recurrence of atrial tachyarrhythmia (ATa) following a blanking period of 3 months. RESULTS A total of 200 patients were included (PFA n = 40; CBA n = 80; RFA n = 80). Median procedure times were shortest with CBA (75 min) followed by PFA (94 min) and RFA (182 min; p < 0.001). Fluoroscopy dose was lowest with RFA (1.6Gycm2) followed by PFA (5.0Gycm2) and CBA (5.7Gycm2; p < 0.001). After a 1-year follow-up, freedom from ATa recurrence was 85.0% with PFA, 66.2% with CBA and 73.8% with RFA (p = 0.12 PFA vs. CBA; p = 0.27 PFA vs. RFA). CONCLUSION In a propensity score matched analysis of patients with paroxysmal AF, freedom from any ATa 1 year after PVI using PFA was favourable and at least as good as for PVI with CBA or RFA.
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Affiliation(s)
- Jens Maurhofer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Kueffer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Antonio Madaffari
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robin Stettler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita Stefanova
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jens Seiler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gregor Thalmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikola Kozhuharov
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oskar Galuszka
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Bern, Switzerland
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Qamar U, Agarwal S, Krishan S, Deshmukh A, DeSimone CV, Stavrakis S, Piccini JP, Ul Abideen Asad Z. Efficacy and safety of pulsed field ablation for atrial fibrillation: A systematic review and meta-analysis. Pacing Clin Electrophysiol 2024; 47:474-480. [PMID: 38341625 DOI: 10.1111/pace.14947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/10/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Usama Qamar
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Siddharth Agarwal
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Satyam Krishan
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | | | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jonathan P Piccini
- Department of Cardiovascular Medicine, Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina, USA
| | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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18
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Chen B, Lv C, Cui Y, Lu C, Cai H, Xue Z, Xu X, Su S. A pilot clinical assessment of biphasic asymmetric pulsed field ablation catheter for pulmonary vein isolation. Front Cardiovasc Med 2024; 11:1266195. [PMID: 38385135 PMCID: PMC10879394 DOI: 10.3389/fcvm.2024.1266195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/24/2024] [Indexed: 02/23/2024] Open
Abstract
Pulsed field ablation (PFA) is a new treatment for atrial fibrillation (AF), and its selective ablation characteristics give it a significant advantage in treatment. In previous cellular and animal experiments, we have demonstrated that biphasic asymmetric pulses can be used to ablate myocardial tissue. However, small-scale clinical trials are needed to test whether this approach is safe and feasible before extensive clinical trials can be performed. Therefore, the purpose of this experiment is to determine the safety and feasibility of biphasic asymmetric pulses in patients with AF and is to lay the foundation for a larger clinical trial. Ablation was performed in 10 patients with AF using biphasic asymmetric pulses. Voltage mapping was performed before and after PFA operation to help us detect the change in the electrical voltage of the pulmonary veins (PV). 3-Dimensional mapping system showed continuous low potential in the ablation site, and pulmonary vein isolation (PVI) was achieved in all four PV of the patients. There were no recurrences, PV stenosis, or other serious adverse events during the 12 months follow-up. The results suggest that PFA using biphasic asymmetric waveforms for patients with AF is safe, durable, and effective and that a larger clinical trial could begin. Clinical Trial Registration https://www.chictr.org.cn/, identifier, ChiCTR2100051894.
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Affiliation(s)
- Bingwei Chen
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
- Department of Cardiology, Tianjin First Central Hospital, Tianjin, China
| | - Chang Lv
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
| | - Yingjian Cui
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
| | - Chengzhi Lu
- Department of Cardiology, Tianjin First Central Hospital, Tianjin, China
| | - Heng Cai
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhixiao Xue
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
| | - Xinyu Xu
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
| | - Siying Su
- Department of Research and Development, Tianjin Intelligent Health Medical Co., Ltd., Tianjin, China
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19
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Avitall B. Have the cake and eat it too: PFA, a case of a technological miracle? J Cardiovasc Electrophysiol 2024; 35:94-96. [PMID: 38031813 DOI: 10.1111/jce.16127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023]
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20
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Badertscher P, Weidlich S, Knecht S, Stauffer N, Krisai P, Voellmin G, Osswald S, Sticherling C, Kühne M. Efficacy and safety of pulmonary vein isolation with pulsed field ablation vs. novel cryoballoon ablation system for atrial fibrillation. Europace 2023; 25:euad329. [PMID: 38036293 PMCID: PMC10751845 DOI: 10.1093/europace/euad329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
AIMS Pulsed-field ablation (PFA) has emerged as a novel treatment technology for patients with atrial fibrillation (AF). Cryoballoon (CB) is the most frequently used single shot technology. A direct comparison to a novel CB system is lacking. We aimed to compare pulmonary vein isolation (PVI) using PFA vs. a novel CB system regarding efficiency, safety, myocardial injury, and outcomes. METHODS AND RESULTS One hundred and eighty-one consecutive patients underwent PVI and were included (age 64 ± 9.7 years, ejection fraction 0.58 ± 0.09, left atrial size 40 ± 6.4 mm, paroxysmal AF 64%). 106 patients (59%) underwent PFA (FARAPULSE, Boston Scientific) and 75 patients (41%) underwent CB ablation (PolarX, Boston Scientific). The median procedure time, left atrial dwell time and fluoroscopic time were similar between the PFA and the CB group with 55 [interquartile range (IQR) 43-64] min vs. 58 (IQR 48-69) min (P < 0.087), 38 (30-49) min vs. 37 (31-48) min, (P = 0.871), and 11 (IQR 9.3-14) min vs. 11 (IQR 8.7-16) min, (P < 0.81), respectively. Three procedural complications were observed in the PFA group (two tamponades, one temporary ST elevation) and three complications in the CB group (3× reversible phrenic nerve palsies). During the median follow-up of 404 days (IQR 208-560), AF recurrence was similar in the PFA group and the CB group with 24 vs. 30%, P = 0.406. CONCLUSION Procedural characteristics were very similar between PFA and CB in regard to procedure duration fluoroscopy time and complications. Atrial fibrillation free survival did not differ between the PFA and CB groups.
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Affiliation(s)
- Patrick Badertscher
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Simon Weidlich
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Sven Knecht
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Niklas Stauffer
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Philipp Krisai
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Gian Voellmin
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Christian Sticherling
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Michael Kühne
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, Switzerland
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21
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Turagam MK, Neuzil P, Schmidt B, Reichlin T, Neven K, Metzner A, Hansen J, Blaauw Y, Maury P, Arentz T, Sommer P, Anic A, Anselme F, Boveda S, Deneke T, Willems S, van der Voort P, Tilz R, Funasako M, Scherr D, Wakili R, Steven D, Kautzner J, Vijgen J, Jais P, Petru J, Chun J, Roten L, Füting A, Lemoine MD, Ruwald M, Mulder BA, Rollin A, Lehrmann H, Fink T, Jurisic Z, Chaumont C, Adelino R, Nentwich K, Gunawardene M, Ouss A, Heeger CH, Manninger M, Bohnen JE, Sultan A, Peichl P, Koopman P, Derval N, Kueffer T, Reddy VY. Clinical Outcomes by Sex After Pulsed Field Ablation of Atrial Fibrillation. JAMA Cardiol 2023; 8:1142-1151. [PMID: 37910101 PMCID: PMC10620676 DOI: 10.1001/jamacardio.2023.3752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/10/2023] [Indexed: 11/03/2023]
Abstract
Importance Previous studies evaluating the association of patient sex with clinical outcomes using conventional thermal ablative modalities for atrial fibrillation (AF) such as radiofrequency or cryoablation are controversial due to mixed results. Pulsed field ablation (PFA) is a novel AF ablation energy modality that has demonstrated preferential myocardial tissue ablation with a unique safety profile. Objective To compare sex differences in patients undergoing PFA for AF in the Multinational Survey on the Methods, Efficacy, and Safety on the Postapproval Clinical Use of Pulsed Field Ablation (MANIFEST-PF) registry. Design, Setting, and Participants This was a retrospective cohort study of MANIFEST-PF registry data, which included consecutive patients undergoing postregulatory approval treatment with PFA to treat AF between March 2021 and May 2022 with a median follow-up of 1 year. MANIFEST-PF is a multinational, retrospectively analyzed, prospectively enrolled patient-level registry including 24 European centers. The study included all consecutive registry patients (age ≥18 years) who underwent first-ever PFA for paroxysmal or persistent AF. Exposure PFA was performed on patients with AF. All patients underwent pulmonary vein isolation and additional ablation, which was performed at the discretion of the operator. Main Outcomes and Measures The primary effectiveness outcome was freedom from clinically documented atrial arrhythmia for 30 seconds or longer after a 3-month blanking period. The primary safety outcome was the composite of acute (<7 days postprocedure) and chronic (>7 days) major adverse events (MAEs). Results Of 1568 patients (mean [SD] age, 64.5 [11.5] years; 1015 male [64.7%]) with AF who underwent PFA, female patients, as compared with male patients, were older (mean [SD] age, 68 [10] years vs 62 [12] years; P < .001), had more paroxysmal AF (70.2% [388 of 553] vs 62.4% [633 of 1015]; P = .002) but had fewer comorbidities such as coronary disease (9% [38 of 553] vs 15.9% [129 of 1015]; P < .001), heart failure (10.5% [58 of 553] vs 16.6% [168 of 1015]; P = .001), and sleep apnea (4.7% [18 of 553] vs 11.7% [84 of 1015]; P < .001). Pulmonary vein isolation was performed in 99.8% of female (552 of 553) and 98.9% of male (1004 of 1015; P = .90) patients. Additional ablation was performed in 22.4% of female (124 of 553) and 23.1% of male (235 of 1015; P = .79) patients. The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was similar in male and female patients (79.0%; 95% CI, 76.3%-81.5% vs 76.3%; 95% CI, 72.5%-79.8%; P = .28). There was also no significant difference in acute major AEs between groups (male, 1.5% [16 of 1015] vs female, 2.5% [14 of 553]; P = .19). Conclusion and Relevance Results of this cohort study suggest that after PFA for AF, there were no significant sex differences in clinical effectiveness or safety events.
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Affiliation(s)
- Mohit K. Turagam
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Petr Neuzil
- Cardiology Department, Na Homolce Hospital, Homolka Hospital, Prague, Czechia
| | - Boris Schmidt
- Medizinisches Versorgungszentrum Cardioangiologisches Centrum Bethanien Frankfurt und Main-Taunus GbR, Frankfurt, Germany
| | - Tobias Reichlin
- Inselspital—Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kars Neven
- Department of Medicine, Witten/Herdecke University, Witten, Germany
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
| | - Andreas Metzner
- University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jim Hansen
- Department of Cardiology, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Yuri Blaauw
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Philippe Maury
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
- I2MC Institute, INSERM UMR 1297, Toulouse, France
| | - Thomas Arentz
- Department of Cardiology and Angiology, Medical Center and Faculty of Medicine—University of Freiburg, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum North Rhine Westfalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Ante Anic
- Department for Cardiovascular Diseases, University Hospital Center Split, Split, Croatia
| | | | - Serge Boveda
- Heart Rhythm Department, Clinique Pasteur, Toulouse, France
- Universitair Ziekenhuis, Brussels, Belgium
| | - Tom Deneke
- Heart Center Bad Neustadt, Rhoen-Clinic Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | | | - Pepijn van der Voort
- Catharina Hospital, Eindhoven, the Netherlands instead of Catharina Ziekenhuis Eindhoven, the Netherlands
| | - Roland Tilz
- University Heart Center Lübeck, Department of Rhythmology, University Hospital Schleswig-Holstein, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Moritoshi Funasako
- Cardiology Department, Na Homolce Hospital, Homolka Hospital, Prague, Czechia
- Neuron Medical, Brno, Czech Republic
| | - Daniel Scherr
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Reza Wakili
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Duisburg, Germany
| | - Daniel Steven
- Heart Center University Hospital of Cologne, Department for Electrophysiology, Cologne, Germany
| | - Josef Kautzner
- IKEM—Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Johan Vijgen
- Department of Cardiology, Jessa Hospitals, Hasselt, Belgium
| | - Pierre Jais
- IHU LIRYC—Institute Des Maladies Du Rythme Cardiaque, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Jan Petru
- Cardiology Department, Na Homolce Hospital, Homolka Hospital, Prague, Czechia
| | - Julian Chun
- Medizinisches Versorgungszentrum Cardioangiologisches Centrum Bethanien Frankfurt und Main-Taunus GbR, Frankfurt, Germany
| | - Laurent Roten
- Inselspital—Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Füting
- Department of Medicine, Witten/Herdecke University, Witten, Germany
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
| | - Marc D. Lemoine
- University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Ruwald
- Department of Cardiology, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Bart A. Mulder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anne Rollin
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
| | - Heiko Lehrmann
- Department of Cardiology and Angiology, Medical Center and Faculty of Medicine—University of Freiburg, Germany
| | - Thomas Fink
- Clinic for Electrophysiology, Herz- und Diabeteszentrum North Rhine Westfalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Zrinka Jurisic
- Department for Cardiovascular Diseases, University Hospital Center Split, Split, Croatia
| | | | - Raquel Adelino
- Heart Rhythm Department, Clinique Pasteur, Toulouse, France
- Universitair Ziekenhuis, Brussels, Belgium
| | - Karin Nentwich
- Heart Center Bad Neustadt, Rhoen-Clinic Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | | | - Alexandre Ouss
- Catharina Hospital, Eindhoven, the Netherlands instead of Catharina Ziekenhuis Eindhoven, the Netherlands
| | - Christian-Hendrik Heeger
- University Heart Center Lübeck, Department of Rhythmology, University Hospital Schleswig-Holstein, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Martin Manninger
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jan-Eric Bohnen
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Duisburg, Germany
| | - Arian Sultan
- Heart Center University Hospital of Cologne, Department for Electrophysiology, Cologne, Germany
| | - Petr Peichl
- IKEM—Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Pieter Koopman
- Department of Cardiology, Jessa Hospitals, Hasselt, Belgium
| | - Nicolas Derval
- IHU LIRYC—Institute Des Maladies Du Rythme Cardiaque, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Thomas Kueffer
- Inselspital—Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vivek Y. Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
- Cardiology Department, Na Homolce Hospital, Homolka Hospital, Prague, Czechia
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22
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Reddy VY, Gerstenfeld EP, Natale A, Whang W, Cuoco FA, Patel C, Mountantonakis SE, Gibson DN, Harding JD, Ellis CR, Ellenbogen KA, DeLurgio DB, Osorio J, Achyutha AB, Schneider CW, Mugglin AS, Albrecht EM, Stein KM, Lehmann JW, Mansour M. Pulsed Field or Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med 2023; 389:1660-1671. [PMID: 37634148 DOI: 10.1056/nejmoa2307291] [Citation(s) in RCA: 144] [Impact Index Per Article: 144.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Catheter-based pulmonary vein isolation is an effective treatment for paroxysmal atrial fibrillation. Pulsed field ablation, which delivers microsecond high-voltage electrical fields, may limit damage to tissues outside the myocardium. The efficacy and safety of pulsed field ablation as compared with conventional thermal ablation are not known. METHODS In this randomized, single-blind, noninferiority trial, we assigned patients with drug-refractory paroxysmal atrial fibrillation in a 1:1 ratio to undergo pulsed field ablation or conventional radiofrequency or cryoballoon ablation. The primary efficacy end point was freedom from a composite of initial procedural failure, documented atrial tachyarrhythmia after a 3-month blanking period, antiarrhythmic drug use, cardioversion, or repeat ablation. The primary safety end point included acute and chronic device- and procedure-related serious adverse events. RESULTS A total of 305 patients were assigned to undergo pulsed field ablation, and 302 were assigned to undergo thermal ablation. At 1 year, the primary efficacy end point was met (i.e., no events occurred) in 204 patients (estimated probability, 73.3%) who underwent pulsed field ablation and 194 patients (estimated probability, 71.3%) who underwent thermal ablation (between-group difference, 2.0 percentage points; 95% Bayesian credible interval, -5.2 to 9.2; posterior probability of noninferiority, >0.999). Primary safety end-point events occurred in 6 patients (estimated incidence, 2.1%) who underwent pulsed field ablation and 4 patients (estimated incidence, 1.5%) who underwent thermal ablation (between-group difference, 0.6 percentage points; 95% Bayesian credible interval, -1.5 to 2.8; posterior probability of noninferiority, >0.999). CONCLUSIONS Among patients with paroxysmal atrial fibrillation receiving a catheter-based therapy, pulsed field ablation was noninferior to conventional thermal ablation with respect to freedom from a composite of initial procedural failure, documented atrial tachyarrhythmia after a 3-month blanking period, antiarrhythmic drug use, cardioversion, or repeat ablation and with respect to device- and procedure-related serious adverse events at 1 year. (Funded by Farapulse-Boston Scientific; ADVENT ClinicalTrials.gov number, NCT04612244.).
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Affiliation(s)
- Vivek Y Reddy
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Edward P Gerstenfeld
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Andrea Natale
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - William Whang
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Frank A Cuoco
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Chinmay Patel
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Stavros E Mountantonakis
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Douglas N Gibson
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - John D Harding
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Christopher R Ellis
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Kenneth A Ellenbogen
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - David B DeLurgio
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Jose Osorio
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Anitha B Achyutha
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Christopher W Schneider
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Andrew S Mugglin
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Elizabeth M Albrecht
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Kenneth M Stein
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - John W Lehmann
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Moussa Mansour
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
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Yu F, Dong X, Ding L, Reddy V, Tang M. Pulsed field ablation for pulmonary vein isolation: Preclinical safety and effectiveness of a novel hexaspline ablation catheter. J Cardiovasc Electrophysiol 2023; 34:2195-2202. [PMID: 37712346 DOI: 10.1111/jce.16067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 08/11/2023] [Accepted: 09/02/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Pulsed-field ablation (PFA) has emerged as a nonthermal energy source for cardiac ablation, with potential safety advantages over radiofrequency ablation (RFA) and cryoballoon ablation. OBJECTIVE To report the preclinical results of a novel hexaspline PFA catheter for pulmonary vein isolation (PVI), and to verify the influence of PFA on esophagus by comparing with RFA. METHODS This study included a total of 15 canines for the efficacy and safety study and four swine for the esophageal safety study. The 15 canines were divided into an acute cohort (n = 3), a 30-day follow-up cohort (n = 5) and a 90-day follow-up cohort (n = 7), PVI was performed with the novel hexaspline PFA ablation catheter. In the esophageal safety study, four swine were divided into PFA cohort (n = 2) and RFA cohort (n = 2), esophageal injury swine model was adopted, the esophagus was intubated with an esophageal balloon retractor, under fluoroscopy, the DV8 device was inflated with a mixture of saline and contrast and rotated to displace the esophagus rightward and anteriorly toward the ablation catheter in the inferior vena cava (IVC) and right inferior pulmonary vein (PV). Nine PFA applications were delivered at four locations on IVC and two locations on the right inferior PV in the PFA cohort, six RFA applications were delivered at each location in the RFA group. Histopathological analysis of all PVs, esophagus, IVC, and the adjacent lungs was performed. RESULTS Acute PV isolation was achieved in all 15 canines (100%), with energy delivery times of less than 3 min/animal. In the 30 and 90 days group, the overall success rates were 88.9% and 88.5% per PVs, respectively. Two right superior pulmonary veins (RSPVs) in the 30-day group, two RSPVs and one left superior PV in the 90-day group with recovered potentials. At follow-up, gross pathological examination revealed the lesions around the PVs were continuous and transmural. Masson's trichrome staining revealed the myocardial cells in the PVs became fibrotic, but small arteries and nervous tissue were preserved. Results of swine esophageal injury model revealed the esophageal luminal surface was smooth and without evidence for esophageal injury in the PFA group, whereas obvious ulceration was detected on the esophagus tunica mucosa in the RFA group. CONCLUSION In the chronic canine study, PFA-based PVI were safe and effective with demonstrable sparing of nerves and venous tissue. Compared with RFA, there was also good evidence for safety of PFA, avoiding PV stenosis and esophageal injury. This preclinical study provided the scientific basis for the first-in-human endocardial PFA studies.
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Affiliation(s)
- Fengyuan Yu
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaonan Dong
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Lei Ding
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Vivek Reddy
- Icahn School of Medicine at Mount Sinai, Helmsley Electrophysiology Center, New York, New York, USA
| | - Min Tang
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Aldaas OM, Malladi C, Aldaas AM, Han FT, Hoffmayer KS, Krummen D, Ho G, Raissi F, Birgersdotter-Green U, Feld GK, Hsu JC. Safety and acute efficacy of catheter ablation for atrial fibrillation with pulsed field ablation vs thermal energy ablation: A meta-analysis of single proportions. Heart Rhythm O2 2023; 4:599-608. [PMID: 37936671 PMCID: PMC10626185 DOI: 10.1016/j.hroo.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background Pulsed field ablation (PFA) has emerged as a novel energy source for the ablation of atrial fibrillation (AF) using ultrarapid electrical pulses to induce cell death via electroporation. Objective The purpose of this study was to compare the safety and acute efficacy of ablation for AF with PFA vs thermal energy sources. Methods We performed an extensive literature search and systematic review of studies that evaluated the safety and efficacy of ablation for AF with PFA and compared them to landmark clinical trials for ablation of AF with thermal energy sources. Freeman-Tukey double arcsine transformation was used to establish variance of raw proportions followed by the inverse with the random-effects model to combine the transformed proportions and generate the pooled prevalence and 95% confidence interval (CI). Results We included 24 studies for a total of 5203 patients who underwent AF ablation. Among these patients, 54.6% (n = 2842) underwent PFA and 45.4% (n = 2361) underwent thermal ablation. There were significantly fewer periprocedural complications in the PFA group (2.05%; 95% CI 0.94-3.46) compared to the thermal ablation group (7.75%; 95% CI 5.40-10.47) (P = .001). When comparing AF recurrence up to 1 year, there was a statistically insignificant trend toward a lower prevalence of recurrence in the PFA group (14.24%; 95% CI 6.97-23.35) compared to the thermal ablation group (25.98%; 95% CI 15.75-37.68) (P = .132). Conclusion Based on the results of this meta-analysis, PFA was associated with lower rates of periprocedural complications and similar rates of acute procedural success and recurrent AF with up to 1 year of follow-up compared to ablation with thermal energy sources.
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Affiliation(s)
- Omar M. Aldaas
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Chaitanya Malladi
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Amer M. Aldaas
- T. Still University School of Osteopathic Medicine, Mesa, Arizona
| | - Frederick T. Han
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Kurt S. Hoffmayer
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - David Krummen
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Gordon Ho
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Farshad Raissi
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Ulrika Birgersdotter-Green
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Gregory K. Feld
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Jonathan C. Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
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25
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Yavin HD, Higuchi K, Younis A, Anter E. Lattice-tip catheter for single-shot pulmonary vein isolation with pulsed field ablation. J Interv Card Electrophysiol 2023; 66:1741-1748. [PMID: 36441424 DOI: 10.1007/s10840-022-01414-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND A compressible lattice-tip catheter designed for focal ablation using radiofrequency or pulsed-field energies has been recently described. The objective of this study is to describe a new lattice catheter designed for single-shot pulmonary vein isolation (PVI). METHODS This 8F catheter consists of a compressible lattice tip that is delivered over the wire and is expandable up to 34 mm (SpherePVI™, Affera Inc.). Pulsed field ablation (PFA) was applied from 6 elements using a biphasic waveform of microsecond scale (± 1.3-2.0 kV, 5 s per application). In 12 swine, the superior vena cava (SVC) and right superior pulmonary vein (RSPV) were targeted for isolation. Animals were survived for 12-24 h (n = 6) or 3 weeks (n = 6) for evaluation of short and long-term safety and efficacy parameters. PVI was evaluated immediately after ablation and at the terminal procedure. Ablation-related microbubbles were examined using intracardiac echocardiography and phrenic nerve function by pacing. The tissue was examined by histopathology. RESULTS In all 12 animals, PFA resulted in successful acute isolation of the SVC and RSPV using 2.8 ± 1.1 and 3.2 ± 1.2 applications per vein, respectively. After a survival period of 23 ± 5.9 days, all targeted veins remained isolated, and the level of isolation persisted without significant regression or expansion. In one animal, SVC isolation at the level of the right atrial appendage resulted in sinus node arrest. PFA did not affect phrenic nerve function, and it was associated with a few isolated bubbles formation. CONCLUSIONS In this pre-clinical study, a new expandable lattice catheter designed for single-shot PVI was able to achieve rapid and durable isolation.
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Affiliation(s)
- Hagai D Yavin
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Shamir Medical Center, Be'er Ya'akov, Israel
| | - Koji Higuchi
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Shamir Medical Center, Be'er Ya'akov, Israel
| | - Arwa Younis
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Shamir Medical Center, Be'er Ya'akov, Israel
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA.
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Shamir Medical Center, Be'er Ya'akov, Israel.
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26
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Tohoku S, Schmidt B, Schaack D, Bordignon S, Hirokami J, Chen S, Ebrahimi R, Efe TH, Urbanek L, Chun KRJ. Impact of Pulsed-Field Ablation on Intrinsic Cardiac Autonomic Nervous System After Pulmonary Vein Isolation. JACC Clin Electrophysiol 2023; 9:1864-1875. [PMID: 37480870 DOI: 10.1016/j.jacep.2023.05.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Although the autonomic reaction such as bradycardia is observed frequently during pulsed-field ablation (PFA)-guided pulmonary vein isolation (PVI), its mechanism and effect on the adjacent intrinsic cardiac autonomic nervous system (ICANS) are unclear. OBJECTIVES This study aimed to reveal the clinical impact of PFA on ICANS by investigating the serum S100 increase (ΔS100), a well-known denervation relevant biomarker. METHODS Pre- and postprocedural serum S100 analyses were systematically conducted in patients undergoing PVI using either the pentaspline PFA or cryoballoon ablation (CBA) system. ΔS100 release kinetics were compared between both technologies. Cerebral magnetic resonance imaging was conducted to eliminate the effect of central nervous system release. RESULTS A total of 97 patients (PFA: n = 54 and CBA: n = 43) were enrolled. Overall S100 increased in both groups with a lower amount in PFA (0.035 μg/L; IQR: 0.02-0.063 μg/L) compared with CBA (0.12 μg/L; IQR: 0.09-0.17 μg/L; P < 0.0001). In cerebral magnetic resonance imaging, silent emboli were detected in 10 patients (18.5%) in PFA and 7 patients (16.3%) in CBA (P = 0.773). Even after excluding patients with cerebral emboli, ΔS100 was lower in PFA. During PFA PVI, 30 patients (56%) demonstrated transient bradycardia in 70 of 210 PVs (35%). ΔS100 was similar between patients with or without transient bradycardia. CONCLUSIONS We report a significantly lower S100 release following PFA PVI vs CBA PVI even if silent cerebral emboli were excluded. Notably, vagal response during PFA was not associated with S100 release. These observations are in line with lower nervous tissue destruction of PFA compared with CBA.
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Affiliation(s)
- Shota Tohoku
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany; Klinik für Rhythmologie, Universität zu Lübeck, Lübeck, Germany.
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany; Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - David Schaack
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | | | - Jun Hirokami
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Ramin Ebrahimi
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Tolga Han Efe
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Lukas Urbanek
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - K R Julian Chun
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany; Klinik für Rhythmologie, Universität zu Lübeck, Lübeck, Germany
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27
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Tabaja C, Younis A, Hussein AA, Taigen TL, Nakagawa H, Saliba WI, Sroubek J, Santangeli P, Wazni OM. Catheter-Based Electroporation: A Novel Technique for Catheter Ablation of Cardiac Arrhythmias. JACC Clin Electrophysiol 2023; 9:2008-2023. [PMID: 37354168 DOI: 10.1016/j.jacep.2023.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 06/26/2023]
Abstract
Catheter ablation of arrhythmias is now standard of care in invasive electrophysiology. Current ablation strategies are based on the use of thermal energy. With continuous efforts to optimize thermal energy delivery, effectiveness has greatly improved; however, safety concerns persist. This review focuses on a novel ablation technology, irreversible electroporation (IRE), also known as pulsed-field ablation which may be a safer alternative for arrhythmia management. Pulsed-field ablation is thought to be a nonthermal ablation that applies short-duration high-voltage electrical fields to ablate myocardial tissue with high selectivity and durability while sparing important neighboring structures such as the esophagus and phrenic nerves. There are multiple ongoing studies investigating the potential superior outcomes of IRE compared to radiofrequency ablation in treating patients with atrial and ventricular arrhythmias. In this review, we describe the current evidence of preclinical and clinical trials that have shown promising results of catheter-based IRE.
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Affiliation(s)
- Chadi Tabaja
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arwa Younis
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ayman A Hussein
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tyler L Taigen
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hiroshi Nakagawa
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walid I Saliba
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jakub Sroubek
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Oussama M Wazni
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
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28
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Musikantow DR, Reddy VY, Skalsky I, Shaburishvili T, van Zyl M, O'Brien B, Coffey K, Reilly J, Neuzil P, Asirvatham S, de Groot JR. Targeted ablation of epicardial ganglionated plexi during cardiac surgery with pulsed field electroporation (NEURAL AF). J Interv Card Electrophysiol 2023:10.1007/s10840-023-01615-8. [PMID: 37561246 DOI: 10.1007/s10840-023-01615-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/30/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Modulation of the cardiac autonomic nervous system (ANS) is a promising adjuvant therapy in the treatment of atrial fibrillation (AF). In pre-clinical models, pulsed field (PF) energy has the advantage of selectively ablating the epicardial ganglionated plexi (GP) that govern the ANS. This study aims to demonstrate the feasibility and safety of epicardial ablation of the GPs with PF during cardiac surgery with a primary efficacy outcome of prolongation of the atrial effective refractory period (AERP). METHODS In a single-arm, prospective analysis, patients with or without a history of AF underwent epicardial GP ablation with PF during coronary artery bypass grafting (CABG). AERP was determined immediately pre- and post- GP ablation to assess cardiac ANS function. Holter monitors were performed to determine rhythm status and heart rate variability (HRV) at baseline and at 1-month post-procedure. RESULTS Of 24 patients, 23 (96%) received the full ablation protocol. No device-related adverse effects were noted. GP ablation resulted in a 20.7 ± 19.9% extension in AERP (P < 0.001). Post-operative AF was observed in 7 (29%) patients. Holter monitoring demonstrated an increase in mean heart rate (74.0 ± 8.7 vs. 80.6 ± 12.3, P = 0.01). There were no significant changes in HRV. There were no study-related complications. CONCLUSIONS This study demonstrates the safety and feasibility of epicardial ablation of the GP using PF to modulate the ANS during cardiac surgery. Large, randomized analyses are necessary to determine whether epicardial PF ablation can offer a meaningful impact on the cardiac ANS and reduce AF. TRIAL REGISTRATION Clinical trial registration: NCT04775264.
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Affiliation(s)
- Daniel R Musikantow
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, Box 1030, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, Box 1030, One Gustave L. Levy Place, New York, NY, 10029, USA.
- Homolka Hospital, Prague, Czech Republic.
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Gasperetti A, Assis F, Tripathi H, Suzuki M, Gonuguntla A, Shah R, Sampognaro J, Schiavone M, Karmarkar P, Tandri H. Determinants of acute irreversible electroporation lesion characteristics after pulsed field ablation: the role of voltage, contact, and adipose interference. Europace 2023; 25:euad257. [PMID: 37649337 PMCID: PMC10485186 DOI: 10.1093/europace/euad257] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/28/2023] [Indexed: 09/01/2023] Open
Abstract
AIMS Pulsed field ablation (PFA) is a non-thermal ablative approach in which cardiomyocyte death is obtained through irreversible electroporation (IRE). Data correlating the biophysical characteristics of IRE and lesion characteristics are limited. The aim of this study was to assess the effect of different procedural parameters [voltage, number of cycles (NoCs), and contact] on lesion characteristics in a vegetal and animal model for IRE. METHODS AND RESULTS Two hundred and four Russet potatoes were used. Pulsed field ablation lesions were delivered on 3 cm cored potato specimens using a multi-electrode circular catheter with its dedicated IRE generator. Different voltage (from 300 to 1200 V) and NoC (from 1 to 5×) protocols were used. The impact of 0.5 and 1 mm catheter-to-specimen distances was tested. A swine animal model was then used to validate the results observed in the vegetable model. The association between voltage, the NoCs, distance, and lesion depth was assessed through linear regression. An almost perfect linear association between lesion depth and voltage was observed (R2 = 0.95; P < 0.001). A similarly linear relationship was observed between the NoCs and the lesion depth (R2 = 0.73; P < 0.001). Compared with controls at full contact, a significant dampening on lesion depth was observed at 0.5 mm distance (1000 V 2×: 2.11 ± 0.12 vs. 0.36 ± 0.04, P < 0.001; 2.63 ± 0.10 vs. 0.43 ± 0.08, P < 0.001). No lesions were observed at 1.0 mm distance. CONCLUSION In a vegetal and animal model for IRE assessment, PFA lesion characteristics were found to be strongly dependent on voltage settings and the NoCs, with a quasi-linear relationship. The lack of catheter contact was associated with a dampening in lesion depth.
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Affiliation(s)
- Alessio Gasperetti
- Division of Cardiology, School of Medicine, Johns Hopkins University, 600 N. Wolfe St. Blalock 545, Baltimore, MD 21287, USA
| | - Fabrizio Assis
- Division of Cardiology, School of Medicine, Johns Hopkins University, 600 N. Wolfe St. Blalock 545, Baltimore, MD 21287, USA
| | - Hemantkumar Tripathi
- Division of Cardiology, School of Medicine, Johns Hopkins University, 600 N. Wolfe St. Blalock 545, Baltimore, MD 21287, USA
| | - Masahito Suzuki
- Division of Cardiology, School of Medicine, Johns Hopkins University, 600 N. Wolfe St. Blalock 545, Baltimore, MD 21287, USA
| | - Akhilesh Gonuguntla
- Division of Cardiology, School of Medicine, Johns Hopkins University, 600 N. Wolfe St. Blalock 545, Baltimore, MD 21287, USA
| | - Rushil Shah
- Division of Cardiology, School of Medicine, Johns Hopkins University, 600 N. Wolfe St. Blalock 545, Baltimore, MD 21287, USA
| | - James Sampognaro
- Division of Cardiology, School of Medicine, Johns Hopkins University, 600 N. Wolfe St. Blalock 545, Baltimore, MD 21287, USA
| | - Marco Schiavone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milano, Italy
| | - Parag Karmarkar
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Harikrishna Tandri
- Division of Cardiology, School of Medicine, Johns Hopkins University, 600 N. Wolfe St. Blalock 545, Baltimore, MD 21287, USA
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Reddy VY, Peichl P, Anter E, Rackauskas G, Petru J, Funasako M, Minami K, Koruth JS, Natale A, Jais P, Marinskis G, Aidietis A, Kautzner J, Neuzil P. A Focal Ablation Catheter Toggling Between Radiofrequency and Pulsed Field Energy to Treat Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:1786-1801. [PMID: 37227340 DOI: 10.1016/j.jacep.2023.04.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Because of its safety, "single-shot" pulsed field ablation (PFA) catheters have been developed for pulmonary vein isolation (PVI). However, most atrial fibrillation (AF) ablation procedures are performed with focal catheters to permit flexibility of lesion sets beyond PVI. OBJECTIVES This study sought to determine the safety and efficacy of a focal ablation catheter able to toggle between radiofrequency ablation (RFA) or PFA to treat paroxysmal or persistent AF. METHODS In a first-in-human study, a focal 9-mm lattice tip catheter was used for PFA posteriorly and either irrigated RFA (RF/PF) or PFA (PF/PF) anteriorly. Protocol-driven remapping was at ∼3 months postablation. The remapping data prompted PFA waveform evolution: PULSE1 (n = 76), PULSE2 (n = 47), and the optimized PULSE3 (n = 55). RESULTS The study included 178 patients (paroxysmal/persistent AF = 70/108). Linear lesions, either PFA or RFA, included 78 mitral, 121 cavotricuspid isthmus, and 130 left atrial roof lines. All lesion sets (100%) were acutely successful. Invasive remapping of 122 patients revealed improvement of PVI durability with waveform evolution: PULSE1: 51%; PULSE2: 87%; and PULSE3: 97%. After 348 ± 652 days of follow-up, the 1-year Kaplan-Meier estimates for freedom from atrial arrhythmias were 78.3% ± 5.0% and 77.9% ± 4.1% for paroxysmal and persistent AF, respectively, and 84.8% ± 4.9% for the subset of persistent AF patients receiving the PULSE3 waveform. There was 1 primary adverse event-inflammatory pericardial effusion not requiring intervention. CONCLUSIONS AF ablation with a focal RF/PF catheter allows efficient procedures, chronic lesion durability, and good freedom from atrial arrhythmias-for both paroxysmal and persistent AF. (Safety and Performance Assessment of the Sphere-9 Catheter and the Affera Mapping and RF/PF Ablation System to Treat Atrial Fibrillation; NCT04141007 and NCT04194307).
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Affiliation(s)
- Vivek Y Reddy
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic; Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gediminas Rackauskas
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Jan Petru
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | | | - Kentaro Minami
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Pierre Jais
- University of Bordeaux, CHU Bordeaux, IHU LIRYC (L'Institut des maladies du rhythm cardiaque) ANR-10-IAHU-04, Bordeaux, France
| | - Germanas Marinskis
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Audrius Aidietis
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
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31
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Kos B, Mattison L, Ramirez D, Cindrič H, Sigg DC, Iaizzo PA, Stewart MT, Miklavčič D. Determination of lethal electric field threshold for pulsed field ablation in ex vivo perfused porcine and human hearts. Front Cardiovasc Med 2023; 10:1160231. [PMID: 37424913 PMCID: PMC10326317 DOI: 10.3389/fcvm.2023.1160231] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction Pulsed field ablation is an emerging modality for catheter-based cardiac ablation. The main mechanism of action is irreversible electroporation (IRE), a threshold-based phenomenon in which cells die after exposure to intense pulsed electric fields. Lethal electric field threshold for IRE is a tissue property that determines treatment feasibility and enables the development of new devices and therapeutic applications, but it is greatly dependent on the number of pulses and their duration. Methods In the study, lesions were generated by applying IRE in porcine and human left ventricles using a pair of parallel needle electrodes at different voltages (500-1500 V) and two different pulse waveforms: a proprietary biphasic waveform (Medtronic) and monophasic 48 × 100 μs pulses. The lethal electric field threshold, anisotropy ratio, and conductivity increase by electroporation were determined by numerical modeling, comparing the model outputs with segmented lesion images. Results The median threshold was 535 V/cm in porcine ((N = 51 lesions in n = 6 hearts) and 416 V/cm in the human donor hearts ((N = 21 lesions in n = 3 hearts) for the biphasic waveform. The median threshold value was 368 V/cm in porcine hearts ((N = 35 lesions in n = 9 hearts) cm for 48 × 100 μs pulses. Discussion The values obtained are compared with an extensive literature review of published lethal electric field thresholds in other tissues and were found to be lower than most other tissues, except for skeletal muscle. These findings, albeit preliminary, from a limited number of hearts suggest that treatments in humans with parameters optimized in pigs should result in equal or greater lesions.
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Affiliation(s)
- Bor Kos
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Lars Mattison
- Cardiac Ablation Solutions, Medtronic, Inc., Minneapolis, MN, United States
| | - David Ramirez
- Department of Surgery, Visible Heart® Laboratories, University of Minnesota, Minneapolis, MN, United States
| | - Helena Cindrič
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Daniel C. Sigg
- Cardiac Ablation Solutions, Medtronic, Inc., Minneapolis, MN, United States
| | - Paul A. Iaizzo
- Department of Surgery, Visible Heart® Laboratories, University of Minnesota, Minneapolis, MN, United States
| | - Mark T. Stewart
- Cardiac Ablation Solutions, Medtronic, Inc., Minneapolis, MN, United States
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
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32
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Anić A, Phlips T, Brešković T, Koopman P, Girouard S, Mediratta V, Jurišić Z, Sikirić I, Lisica L, Vijgen J. Pulsed field ablation using focal contact force-sensing catheters for treatment of atrial fibrillation: acute and 90-day invasive remapping results. Europace 2023; 25:euad147. [PMID: 37335976 PMCID: PMC10279421 DOI: 10.1093/europace/euad147] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/17/2023] [Indexed: 06/21/2023] Open
Abstract
AIMS Pulsed field ablation (PFA) has emerged as a promising alternative to thermal ablation for treatment of atrial fibrillation (AF). We report performance and safety using the CENTAURI™ System (Galvanize Therapeutics) with three commercial, focal ablation catheters. METHODS AND RESULTS ECLIPSE AF (NCT04523545) was a prospective, single-arm, multi-centre study evaluating safety and acute and chronic pulmonary vein isolation (PVI) durability using the CENTAURI System in conjunction with the TactiCath SE, StablePoint, and ThermoCool ST ablation catheters. Patients with paroxysmal or persistent AF were treated at two centres. Patients were analysed in five cohorts based upon ablation settings, catheter, and mapping system. Pulsed field ablation was performed in 82 patients (74% male, 42 paroxysmal AF). Pulmonary vein isolation was achieved in 100% of pulmonary veins (322/322) with first-pass isolation in 92.2% (297/322). There were four serious adverse events of interest (three vascular access complications and one lacunar stroke). Eighty patients (98%) underwent invasive remapping. Pulsed field ablation development Cohorts 1 and 2 showed a per-patient isolation rate of 38% and 26% and a per-PV isolation rate of 47% and 53%, respectively. Optimized PFA Cohorts 3-5 showed a per-patient isolation rate of 60%, 73%, and 81% and a per-PV isolation rate of 84%, 90%, and 92%, respectively. CONCLUSION ECLIPSE AF demonstrated that optimized PFA using the CENTAURI System with three commercial, contact force-sensing, solid-tip focal ablation catheters resulted in transmural lesion formation and high proportion of durable PVI with a favourable safety profile, thus providing a viable treatment option for AF that integrates with contemporary focal ablation workflows.
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Affiliation(s)
- Ante Anić
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
| | | | - Toni Brešković
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
| | | | - Steven Girouard
- Galvanize Therapeutics, Inc. (previously Galaxy Medical), Redwood City, CA, USA
| | | | - Zrinka Jurišić
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
| | - Ivan Sikirić
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
| | - Lucija Lisica
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
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33
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O'Brien B, Reilly J, Coffey K, González-Suárez A, Quinlan L, van Zyl M. Cardioneuroablation Using Epicardial Pulsed Field Ablation for the Treatment of Atrial Fibrillation. J Cardiovasc Dev Dis 2023; 10:238. [PMID: 37367403 DOI: 10.3390/jcdd10060238] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting millions of people worldwide. The cardiac autonomic nervous system (ANS) is widely recognized as playing a key role in both the initiation and propagation of AF. This paper reviews the background and development of a unique cardioneuroablation technique for the modulation of the cardiac ANS as a potential treatment for AF. The treatment uses pulsed electric field energy to selectively electroporate ANS structures on the epicardial surface of the heart. Insights from in vitro studies and electric field models are presented as well as data from both pre-clinical and early clinical studies.
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Affiliation(s)
- Barry O'Brien
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - John Reilly
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - Ken Coffey
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - Ana González-Suárez
- School of Engineering, University of Galway, H91 TK33 Galway, Ireland
- Translational Medical Device Lab, University of Galway, H91 YR71 Galway, Ireland
| | - Leo Quinlan
- Physiology and Cellular Physiology Research Laboratory, CURAM SFI Centre for Research in Medical Device, University of Galway, H91 TK33 Galway, Ireland
| | - Martin van Zyl
- Cardiac Electrophysiology, Royal Jubilee Hospital, Victoria, BC V8R 1J8, Canada
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Davong B, Adeliño R, Delasnerie H, Albenque JP, Combes N, Cardin C, Voglimacci-Stephanopoli Q, Combes S, Boveda S. Pulsed-Field Ablation on Mitral Isthmus in Persistent Atrial Fibrillation: Preliminary Data on Efficacy and Safety. JACC Clin Electrophysiol 2023:S2405-500X(23)00261-X. [PMID: 37354173 DOI: 10.1016/j.jacep.2023.03.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Pulsed-field ablation (PFA) is a new and promising modality of ablation that has been shown to specifically ablate cardiac tissue while sparing other anatomic structures, thus avoiding thermal ablation-related complications. Recent studies have certified safety and efficacy of PFA for pulmonary vein isolation (PVI) in the setting of paroxysmal atrial fibrillation (AF). However, there are very limited data assessing the feasibility and safety of PFA ablation of different substrates within the left atrium in the setting of persistent AF. OBJECTIVES The purpose of this study was to evaluate the feasibility and safety of mitral isthmus (MI) ablation in addition to PVI and posterior wall (PW) ablation with PFA in patients with persistent AF. METHODS We prospectively included all consecutive patients with persistent AF who underwent a first ablation procedure with PFA. We performed in all these patients a substrate ablation strategy comprising PVI, PW, and MI ablation with the use of PFA only. The primary feasibility endpoint was obtaining a persistent MI block at the end of the procedure. The safety endpoint was a composite of major safety events. RESULTS From November 2021 to September 2022, we included 45 patients. Complete MI block was achieved in all 45 (100%). Three patients presented with complications, among them 2 cases (4.4%) of reversible and nonfatal coronary spasm. During a mean follow-up time of 107.8 ± 59.5 days, a 20% recurrence rate was observed. CONCLUSIONS PFA is a feasible and safe ablation approach for mitral isthmus ablation in addition to PVI in patients with persistent AF.
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Affiliation(s)
- Baptiste Davong
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Raquel Adeliño
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Hubert Delasnerie
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | | | - Nicolas Combes
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Christelle Cardin
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | | | - Stéphane Combes
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France.
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Hartl S, Reinsch N, Füting A, Neven K. Pearls and Pitfalls of Pulsed Field Ablation. Korean Circ J 2023; 53:273-293. [PMID: 37161743 PMCID: PMC10172271 DOI: 10.4070/kcj.2023.0023] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 05/11/2023] Open
Abstract
Pulsed field ablation (PFA) was recently rediscovered as an emerging treatment modality for the ablation of cardiac arrhythmias. Ultra-short high voltage pulses are leading to irreversible electroporation of cardiac cells subsequently resulting in cell death. Current literature of PFA for pulmonary vein isolation (PVI) consistently reported excellent acute and long-term efficacy along with a very low adverse event rate. The undeniable benefit of the novel ablation technique is that cardiac cells are more susceptible to electrical fields whereas surrounding structures such as the pulmonary veins, the phrenic nerve or the esophagus are not, or if at all, minimally affected, which results in a favorable safety profile that is expected to be superior to the current standard of care without compromising efficacy. Nevertheless, the exact mechanisms of electroporation are not yet entirely understood on a cellular basis and pulsed electrical field protocols of different manufactures are not comparable among one another and require their own validation for each indication. Importantly, randomized controlled trials and comparative data to current standard of care modalities, such as radiofrequency- or cryoballoon ablation, are still missing. This review focuses on the "pearls" and "pitfalls" of PFA, a technology that has the potential to become the future leading energy source for PVI and beyond.
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Affiliation(s)
- Stefan Hartl
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany.
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Phlips T, Verhaeghe L, Antole N, Koopman P, Vijgen J. Pulsed field ablation using a focal contact force catheter allowed successful ablation of a focal right atrial tachycardia in the proximity of the phrenic nerve. HeartRhythm Case Rep 2023. [PMID: 37492053 PMCID: PMC10363427 DOI: 10.1016/j.hrcr.2023.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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PV Isolation Using a Spherical Array PFA Catheter: Application Repetition and Lesion Durability (PULSE-EU Study). JACC Clin Electrophysiol 2023; 9:638-648. [PMID: 36828771 DOI: 10.1016/j.jacep.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Preclinical studies have revealed that pulsed field ablation (PFA) lesion dimensions increase with repetitive applications at a similar electric field. OBJECTIVES This study investigated whether pulmonary vein isolation (PVI) durability varies with single vs repetitive pulsed field (PF) applications. METHODS Atrial fibrillation patients underwent PVI using a spherical multielectrode array PFA catheter delivered with a 19-F deflectable sheath under intracardiac echocardiographic guidance. Esophagogastroduodenoscopy and brain magnetic resonance imaging were performed within 1 to 3 days, and invasive remapping at ∼2 to 3 months. RESULTS The patient cohort (n = 21; age 63 ± 11 years; 67% women) underwent PVI in either of 2 groups: group 1 (n = 11)-single PF application/PV; and group 2 (n = 10)-3 PF applications/PV. In both groups, PVI was acutely successful in all (100%) patients. Despite significantly longer pulse delivery times (75.2 ± 7.4 s/patient vs 24.5 ± 5.5 s/patient) the procedure times (73.2 ± 13.7 minutes vs 93.7 ± 18.5 minutes) were shorter with group 2 vs group 1. There was no stroke/transient ischemic attack, pericardial effusion, phrenic nerve injury, or esophageal complications. Esophagogastroduodenoscopy was normal in both groups of patients (n = 9). Screening brain magnetic resonance imaging revealed asymptomatic cerebral lesions (diffusion weighted imaging+/ fluid attenuated inversion recovery-) in 3 of 16 (18.7%) patients. PV remapping revealed durable PVI in 62.5% PVs in group 1 (n = 10), compared with all 100% PVs in group 2 (n = 9); this translates to all PVs being durably isolated in 30% vs 100% (P < 0.05) of patients in groups 1 and 2, respectively. CONCLUSIONS In his first-in-human trial, the "single-shot" spherical array PFA catheter was shown to safely isolate PVs. Repetitive PF application is key for lesion consolidation to maximize PVI durability.
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Buist TJ, Groen MHA, Wittkampf FHM, Loh P, Doevendans PAFM, van Es R, Elvan A. Feasibility of Linear Irreversible Electroporation Ablation in the Coronary Sinus. Cardiovasc Eng Technol 2023; 14:60-66. [PMID: 35710861 DOI: 10.1007/s13239-022-00633-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Previous studies demonstrated that the coronary sinus (CS) is an important target for ablation in persistent atrial fibrillation. However, radiofrequency ablation in the CS is associated with coronary vessel damage and tamponade. Animal data suggest irreversible electroporation (IRE) ablation can be a safe ablation modality in vicinity of coronary arteries. We investigated the feasibility of IRE in the CS in a porcine model. METHODS Ablation and pacing was performed in the CS in six pigs (weight 60-75 kg) using a modified 9-French steerable linear hexapolar Tip-Versatile Ablation Catheter. Pacing maneuvers were performed from distal to proximal segments of the CS to assess atrial capture thresholds before and after IRE application. IRE ablations were performed with 100 J IRE pulses. After 3-week survival animals were euthanized and histological sections from the CS were analyzed. RESULTS A total of 27 IRE applications in six animals were performed. Mean peak voltage was 1509 ± 36 V, with a mean peak current of 22.9 ± 1.0 A. No complications occurred during procedure and 3-week survival. At 30 min post ablation 100% isolation was achieved in all animals. At 3 weeks follow-up pacing thresholds were significant higher as compared to baseline. Histological analysis showed transmural ablation lesions in muscular sleeves surrounding the CS. CONCLUSION IRE ablation of the musculature along the CS using a multi-electrode catheter is feasible in a porcine model.
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Affiliation(s)
- Thomas J Buist
- Heart Centre, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marijn H A Groen
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Fred H M Wittkampf
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Peter Loh
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Pieter A F M Doevendans
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Central Military Hospital, Utrecht, The Netherlands
| | - René van Es
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arif Elvan
- Heart Centre, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
- Department of Cardiology, Isala Heart Centre, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
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Verma A, Neal R, Evans J, Castellvi Q, Vachani A, Deneke T, Nakagawa H. Characteristics of pulsed electric field cardiac ablation porcine treatment zones with a focal catheter. J Cardiovasc Electrophysiol 2023; 34:99-107. [PMID: 36335638 PMCID: PMC10100505 DOI: 10.1111/jce.15734] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/06/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Pulsed electric field (PEF) therapies employ punctuated energy delivery to kill cells in a volume of tissue through mechanisms that are not dependent on thermal processes. A key component to successful cardiac ablation procedures is ensuring the generation of transmural, contiguous ablation zones, which requires in-depth knowledge regarding treatment sizes for a given therapeutic application. METHODS In this study, a series of acute treatments were delivered to porcine ventricles, where triphenyl tetrazolium chloride (TTC) vitality stain was used to identify treatment effect sizes for the three focal monopolar CENTAURI PEF cardiac ablation energy settings. RESULTS Treatment depths were 5.7, 7.2, and 8.2 mm for the 19, 22, and 25 A energy settings, respectively. Gross pathology indicated umbral zones of hemorrhage surrounded by pale avital TTC-negative-negative tissue, which contrasted significantly from radiofrequency ablation (RF) controls. Histologically, treatment zones are identified by regions of contraction band necrosis and cardiomyocytolysis, which contrasted with RF control lesions composed primarily of coagulation necrosis. CONCLUSIONS Together, these data indicate the ability for focal monopolar PEF treatments to generate deep treatment zones in cardiac ablation without incurring the gross or histological coagulative characteristics of RF thermal lesions.
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Affiliation(s)
- Atul Verma
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, Canada
| | | | - John Evans
- Galaxy Medical, San Carlos, California, USA
| | | | | | - Thomas Deneke
- Division of Cardiology, Cardiovascular Clinic Bad Neustadt ad Saale, Bad Neustadt ad Saale, Germany
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Sanchez-Somonte P, Verma A. Globe Pulsed Field System for High-definition Mapping and Ablation for Atrial Fibrillation. Heart Int 2022; 16:85-90. [PMID: 36741105 PMCID: PMC9872786 DOI: 10.17925/hi.2022.16.2.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 12/25/2022] Open
Abstract
Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation ablation. Radiofrequency ablation has been the most common source of energy used to achieve PVI until now. In recent years, cryoballoon ablation has gained popularity due to its ability to perform PVI in a 'single-shot' fashion. In both cases (radiofrequency and cryoablation), the main limitation is their inability to achieve durable lesions without causing collateral damage to adjacent structures. In contrast, pulsed electric field (PEF) ablation is a non-thermal energy source that causes cell apoptosis by applying an electric current to the tissue. Lesions created by a field of energy seem to be more contiguous than traditional ablation, and the risk of damage to adjacent tissues is largely avoided due to the properties of the tissues and electrical fields. In recent years, new catheters capable of delivering PEF have been developed and are now undergoing clinical testing. In this article, we describe a complete solution for PVI: a single multielectrode catheter with 3D mapping capabilities that can deliver PEF in a single-shot PVI fashion with targeting beyond the pulmonary veins.
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Affiliation(s)
- Paula Sanchez-Somonte
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Québec, Canada
| | - Atul Verma
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Québec, Canada
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41
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Reddy VY, Petru J, Funasako M, Kopriva K, Hala P, Chovanec M, Janotka M, Kralovec S, Neuzil P. Coronary Arterial Spasm During Pulsed Field Ablation to Treat Atrial Fibrillation. Circulation 2022; 146:1808-1819. [PMID: 36134574 DOI: 10.1161/circulationaha.122.061497] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pulsed field ablation (PFA) has a unique safety profile when used to treat atrial fibrillation, largely related to its preferentiality for myocardial tissue ablation, in particular, esophageal sparing. A pentaspline catheter was the first such PFA system studied clinically for atrial fibrillation ablation; in these initial regulatory trials, the catheter was used for pulmonary vein isolation and left atrial posterior wall ablation. Since its regulatory approval in Europe, in clinical practice, physicians have ablated beyond pulmonary vein isolation and left atrial posterior wall ablation to expanded lesion sets in closer proximity to coronary arteries. This is an unstudied important issue because preclinical and clinical data have raised the potential for coronary arterial spasm. Herein, we studied the vasospastic potential of PFA lesion sets, both remote from and adjacent to coronary arteries. METHODS During routine atrial fibrillation ablation using the pentaspline PFA catheter, coronary angiography was performed before, during, and after pulsed field applications. The lesion sets studied included: (1) those remote from the coronary arteries such as pulmonary vein isolation (n=25 patients) and left atrial posterior wall ablation (n=5), and (2) ablation of the cavotricuspid isthmus (n=20) that is situated adjacent to the right coronary artery. RESULTS During pulmonary vein isolation and left atrial posterior wall ablation, coronary spasm did not occur, but cavotricuspid isthmus ablation provoked severe subtotal vasospasm in 5 of 5 (100%) consecutive patients, and this was relieved by intracoronary nitroglycerin in 5.5±3.5 minutes. ST-segment elevation was not observed. However, no patient (0%, P=0.004) had severe spasm if first administered parenteral nitroglycerin, either intracoronary (n=5) or intravenous (n=10), before treatment. CONCLUSIONS Coronary vasospasm was not provoked during PFA at locations remote from coronary arteries, but when the energy is delivered adjacent to a coronary artery, PFA routinely provokes subclinical vasospasm. This phenomenon is attenuated by nitroglycerin, administered either post hoc to treat spasm or as prophylaxis.
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Affiliation(s)
- Vivek Y Reddy
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.).,Icahn School of Medicine at Mount Sinai, New York (V.Y.R.)
| | - Jan Petru
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Moritoshi Funasako
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Karel Kopriva
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Pavel Hala
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Milan Chovanec
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Marek Janotka
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Stepan Kralovec
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Petr Neuzil
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
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Nakagawa H, Ikeda A, Yokoyama K, An Y, Hussein AA, Saliba WI, Wazni OM, Castellvi Q. Improvement in Lesion Formation with Radiofrequency Energy and Utilization of Alternate Energy Sources (Cryoablation and Pulsed Field Ablation) for Ventricular Arrhythmia Ablation. Card Electrophysiol Clin 2022; 14:757-767. [PMID: 36396191 DOI: 10.1016/j.ccep.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Current ablation systems rely on thermal energy to produce ablation lesions (heating: RF, laser and ultrasound, and cooling: cryo-thermia). While thermal ablation has been proven to be effective, there are several limitations: 1) relatively long procedural times; 2) high recurrence rate of ventricular arrhythmias; and 3) excessive heating potentially leading to serious complications, including steam pop (perforation), coronary arterial injury and thrombo-embolism. Pulsed field ablation (PFA)/irreversible electroporation (IRE) offers a unique non-thermal ablation strategy which has the potential to overcome these limitations. Recent pre-clinical studies suggest that PFA/IRE might be effective and safe for the treatment of cardiac arrhythmias.
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Affiliation(s)
- Hiroshi Nakagawa
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA.
| | - Atsushi Ikeda
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Katsuaki Yokoyama
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshimori An
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ayman A Hussein
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Walid I Saliba
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Oussama M Wazni
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Quim Castellvi
- Department of Information and Communications Technologies, Pompeu Fabra University, Barcelona, Spain
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Pulsed Field Ablation to Treat Atrial Fibrillation: Autonomic Nervous System Effects. JACC Clin Electrophysiol 2022; 9:481-493. [PMID: 36752473 DOI: 10.1016/j.jacep.2022.10.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND During atrial fibrillation ablations using thermal energy, the treatment effect is attributed to not just pulmonary vein isolation (PVI), but also to modulation of the autonomic nervous system by ablation of cardiac ganglionated plexi (GP). OBJECTIVES This study sought to assess the impact of pulsed field ablation (PFA) on the GP in patients undergoing PVI. METHODS In the retrospective phase, heart rate was assessed pre- versus post-PVI using PFA, cryoballoon ablation, or radiofrequency ablation. In the prospective phase, a pentaspline PFA catheter was used in a protocol: 1) pre-PFA, high-frequency stimulation (HFS) identified GP sites by vagal effects; 2) PVI was performed assessing for repetitive vagal effects over each set of PF applications; 3) mapping defined PVI extent to identify those GP in the ablation zone; and 4) repeat HFS at GP sites to assess for persistence of vagal effects. RESULTS Between baseline and 3 months, heart rates in the retrospective radiofrequency ablation (n = 40), cryoballoon (n = 40), and PFA (n = 40) cohorts increased by 8.9 ± 11.4, 11.1 ± 9.4, and -0.1 ± 9.2 beats/min, respectively (P= 0.01 PFA vs radiofrequency ablation; P= 0.01 PFA vs cryoballoon ablation). In the prospective phase, pre-PFA HFS in 20 additional patients identified 65 GP sites. During PFA, vagal effects were noted in 45% of first PF applications, persisting through all applications in 83%. HFS post-PFA reproduced vagal effects in 29 of 38 sites (76%) in low-voltage tissue. CONCLUSIONS PFA has minimal effect on GP. Unlike with thermal ablation, the mechanism by which PFA treats atrial fibrillation is mediated solely by durable PVI.
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Reinsch N, Füting A, Höwel D, Bell J, Lin Y, Neven K. Cerebral safety after pulsed field ablation for paroxysmal atrial fibrillation. Heart Rhythm 2022; 19:1813-1818. [PMID: 35718318 DOI: 10.1016/j.hrthm.2022.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a novel, nonthermal ablation modality that can ablate myocardial tissue with minimal effects on surrounding tissue. Preclinical data show an absence of cerebral emboli after extensive PFA. However, clinical data on silent cerebral lesions (SCLs) and/or silent cerebral events (SCEs) after PFA are lacking. OBJECTIVES The purpose of this study was to investigate the occurrence of neurological deficits and SCL and/or SCE after PFA in paroxysmal atrial fibrillation (AF) using National Institutes of Health Stroke Scale (NIHSS) scores and magnetic resonance imaging (MRI). METHODS In patients with symptomatic paroxysmal AF, pulmonary vein isolation (PVI) using PFA was performed. NIHSS scores were assessed before and 2 days and 30 days after PVI. One day after PVI, patients underwent cerebral 1.5-T MRI scanning using diffusion-weighted imaging and fluid-attenuated inversion recovery sequences to document the occurrence of SCL/SCE. RESULTS PFA was performed in 30 patients (age 63 ± 10 years). No patient showed neurological deficits. All NIHSS scores showed the minimum value of 0. Cerebral MRI scans were normal in 29 of 30 patients (97%). In 1 patient (3%), a single 7-mm cerebellar lesion was observed. Forty days after the procedure, follow-up cerebral MRI scan showed complete regression of the lesion. CONCLUSION In patients treated with PFA for symptomatic paroxysmal AF, the incidence of MRI-detected asymptomatic thromboembolic cerebral events or lesions was as low as 3%. No neurological deficits occurred in any of the patients.
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Affiliation(s)
- Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany.
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Dennis Höwel
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - John Bell
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Yali Lin
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
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Moshkovits Y, Grynberg D, Heller E, Maizels L, Maor E. Differential effect of high-frequency electroporation on myocardium vs. non-myocardial tissues. Europace 2022; 25:748-755. [PMID: 36305566 PMCID: PMC9935033 DOI: 10.1093/europace/euac191] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/30/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS Pulsed-field ablation (PFA) is an emerging non-thermal ablation method based on the biophysical phenomenon of electroporation. Data on PFA cardiac selectivity nature and tissue-specific thresholds are lacking. We aim to compare the in vivo differential effect of high-frequency irreversible electroporation (HF-IRE) protocols on various tissues. METHODS AND RESULTS Twenty-three Sprague-Dawle rodents were allocated into three different protocols of 300, 600, and 900 V, respectively, while delivering twenty 100 µs bursts of a 150 kHz biphasic square wave to five tissues; cardiac muscle, skeletal muscle, liver, carotid artery and sciatic nerve. Lesions were evaluated quantitatively by histologic analysis and by morphometric evaluation. There were eight, seven and eight animals in the 300, 600, and 900 V protocols, respectively. High-frequency electroporation protocols showed a graded effect on myocardial tissue with larger lesions in the 900 V protocol compared with the other two protocols as demonstrated by width (P = 0.02), length (P = 0.01) and fibrosis ratio (P = 0.001). This effect was not observed for other tissues with attenuated degree of damage. No damage to the carotid artery was observed in all protocols. Partial damage to the sciatic nerve was observed in only two samples (25%) in the 600 V group and in one sample (14.3%) in the 900 V group. CONCLUSION Electroporation effect is tissue-specific such that myocardium is more prone to electroporation damage compared with neural and vascular tissues. Our results suggest no neural or vascular damage with using a low-amplitude HF-IRE protocol. Further investigation is warranted to better identify other tissue-specific thresholds.
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Affiliation(s)
| | | | - Eyal Heller
- Leviev Heart Center, Sheba Medical Center, Derech Sheba 2, Ramat-Gan 52621, Israel,Sackler School of Medicine, Tel Aviv University, Tel-Aviv 39040, Israel
| | - Leonid Maizels
- Leviev Heart Center, Sheba Medical Center, Derech Sheba 2, Ramat-Gan 52621, Israel,Sackler School of Medicine, Tel Aviv University, Tel-Aviv 39040, Israel
| | - Elad Maor
- Corresponding author. Tel: +972546444022; fax: +97246385777. E-mail address:
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46
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Gómez-Barea M, García-Sánchez T, Ivorra A. A computational comparison of radiofrequency and pulsed field ablation in terms of lesion morphology in the cardiac chamber. Sci Rep 2022; 12:16144. [PMID: 36167959 PMCID: PMC9515184 DOI: 10.1038/s41598-022-20212-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 09/09/2022] [Indexed: 11/15/2022] Open
Abstract
Pulsed Field Ablation (PFA) has been developed over the last years as a novel electrical ablation technique for treating cardiac arrhythmias. It is based on irreversible electroporation which is a non-thermal phenomenon innocuous to the extracellular matrix and, because of that, PFA is considered to be safer than the reference technique, Radiofrequency Ablation (RFA). However, possible differences in lesion morphology between both techniques have been poorly studied. Simulations including electric, thermal and fluid physics were performed in a simplified model of the cardiac chamber which, in essence, consisted of a slab of myocardium with blood in motion on the top. Monopolar and bipolar catheter configurations were studied. Different blood velocities and catheter orientations were assayed. RFA was simulated assuming a conventional temperature-controlled approach. The PFA treatment was assumed to consist in a sequence of 20 biphasic bursts (100 µs duration). Simulations indicate that, for equivalent lesion depths, PFA lesions are wider, larger and more symmetrical than RFA lesions for both catheter configurations. RFA lesions display a great dependence on blood velocity while PFA lesions dependence is negligible on it. For the monopolar configuration, catheter angle with respect to the cardiac surface impacted both ablation techniques but in opposite sense. The orientation of the catheter with respect to blood flow direction only affected RFA lesions. In this study, substantial morphological differences between RFA and PFA lesions were predicted numerically. Negligible dependence of PFA on blood flow velocity and direction is a potential important advantage of this technique over RFA.
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Affiliation(s)
- Mario Gómez-Barea
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, 08018, Barcelona, Spain.
| | - Tomás García-Sánchez
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, 08018, Barcelona, Spain
| | - Antoni Ivorra
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, 08018, Barcelona, Spain
- Serra Húnter Fellow Programme, Universitat Pompeu Fabra, 08018, Barcelona, Spain
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Pansera F, Bordignon S, Bologna F, Tohoku S, Chen S, Urbanek L, Schmidt B, Chun KRJ. Catheter ablation induced phrenic nerve palsy by pulsed field ablation—completely impossible? A case series. Eur Heart J Case Rep 2022; 6:ytac361. [PMID: 36128440 PMCID: PMC9477201 DOI: 10.1093/ehjcr/ytac361] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/05/2022] [Accepted: 08/30/2022] [Indexed: 11/29/2022]
Abstract
Background Pulsed field ablation (PFA) is a new feasible and safe method for the ablative treatment of cardiac arrhythmias, such as atrial fibrillation (AF). Through the use of electric fields, it causes pore-like openings in the cell’s wall, leading to cell death. The most appealing characteristic of this new technique is its selectivity for cardiomyocytes and consequently its low risk of collateral damage to extracardiac tissues. We present three cases of a PFA-induced transient phrenic nerve (PN) injury documented during pulmonary vein isolation (PVI). Case summaries Three patients aged 55–81 years underwent PFA for symptomatic AF. Cases 1 and 3 were affected by paroxysmal AF without evidence of structural heart disease. Case 2 had persistent AF and ischaemic cardiomyopathy with preserved ejection fraction. We observed a transient right hemidiaphragm palsy during the delivery of impulses in the right superior pulmonary vein (Cases 1 and 2) and in the right inferior pulmonary vein (Case 3). The palsy lasted <1 min and was followed by spontaneous full recovery in all cases. Discussion Transient PN dysfunction can be observed following PFA in AF ablation. According to our initial experience, a full recovery of the PN function can be expected within seconds. We hypothesize a hyperpolarization of neuronal cells or a depletion of acetylcholine in the motoric endplate to explain this event. Further studies are required to understand the exact pathophysiological mechanism.
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Affiliation(s)
- Francesco Pansera
- Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien , Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main , Germany
| | - Stefano Bordignon
- Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien , Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main , Germany
| | - Fabrizio Bologna
- Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien , Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main , Germany
| | - Shota Tohoku
- Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien , Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main , Germany
| | - Shaojie Chen
- Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien , Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main , Germany
| | - Lukas Urbanek
- Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien , Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main , Germany
| | - Boris Schmidt
- Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien , Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main , Germany
| | - Kyoung-Ryul Julian Chun
- Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien , Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main , Germany
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48
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Qiu J, Lan L, Wang Y. Pulsed Electrical Field in Arrhythmia Treatment: Current Status and Future Directions. Pacing Clin Electrophysiol 2022; 45:1255-1262. [PMID: 36029174 DOI: 10.1111/pace.14586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
Pulsed electrical field (PEF) ablation is a promising novel ablation modality for the treatment of arrhythmia, especially for atrial fibrillation(AF). It relies on electroporation inducing cellular permeabilization by the formation of pores in cell membranes, potentially resulting in cell death. Due to its' non-thermal nature and remarkable tissue selectivity, PEF ablation has be expected largely to replace conventional energy sources, such as radiofrequency (RF) and cryothermy. Up to now, the results in almost all clinical studies of PFA for AF ablation are optimistic, both in terms of effectiveness and safety. The possibility of clinical application of this technology to ventricular tachycardia(VT) has also been supported by several animal models. In this review, we aim to give an overview of the mechanism and technical progress of PFA in cardiac arrhythmia treatment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jie Qiu
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lan Lan
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Avazzadeh S, Hosseinzahdehkordi M, Owens P, Jalali A, O'Brien B, Coffey K, O'Halloran M, Fernhead HO, Keane D, Quinlan LR. Establishing electroporation thresholds for targeted cell specific cardiac ablation in a 2D culture model. J Cardiovasc Electrophysiol 2022; 33:2050-2061. [PMID: 35924470 PMCID: PMC9543844 DOI: 10.1111/jce.15641] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/05/2022] [Accepted: 05/24/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Irreversible electroporation has emerged as a new modality to overcome issues associated with other energy sources for cardiac ablation. Strong evidence on the optimal, effective, and selective voltage threshold is lacking for both in-vitro and pre-clinical in-vivo studies. The aim of this study is to examine the optimal threshold for selective cell ablation on cardiac associated cell types. METHODS Conventional monophasic and biphasic pulses of different field strength were delivered in a monolayer culture system of cardiomyocytes, neurons and adipocytes. The dynamics of cell death mechanisms were examined at different time points. RESULTS Neurons exhibit higher susceptibility to electroporation and cell death at higher field strength of 1250 V/cm in comparison to cardiomyocytes. Cardiac adipocytes showed lower susceptibility to electroporation in comparison to other cell types. A significant proportion of cardiomyocytes recovered after 24 hours post-electroporation, while neuronal cell death remained consistent but with a significant delayed cell death at a higher voltage threshold. Caspase 3/7 activity was observed in both cardiomyocytes and neurons, with a higher level of activity in cardiomyocytes in response to electroporation. Biphasic and monophasic pulses showed no significant difference in both cell types, and significantly lower cell death in neurons when inter pulse interval was reduced. CONCLUSIONS This study presents important findings on the differences in the susceptibility of neurons and cardiomyocytes to IRE. Cell type alone yielded selective and different dynamics in terms of the evolution and signaling mechanism of cell death in response to electroporation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sahar Avazzadeh
- Physiology and Cellular Physiology Research Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human biology building, National University of Ireland (NUI) Galway, Ireland
| | - Mahshid Hosseinzahdehkordi
- Pharmacology and Therapeutics, School of Medicine, Biomedical Research Building, National University of Ireland (NUI) Galway, Ireland
| | - Peter Owens
- Centre for Microscopy and Imaging, Human Biology Building, National University of Ireland (NUI) Galway, Ireland
| | - Amirhossein Jalali
- Department of Mathematics and statistics, University of limerick, Limerick, Ireland
| | - Barry O'Brien
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, Galway, Ireland
| | - Ken Coffey
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, Galway, Ireland
| | - Martin O'Halloran
- Translational Medical Devise Lab (TMDLab), Lambe Institute of Translational Research, University College Hospital Galway, Galway, Ireland.,Electrical & Electronic Engineering, School of Engineering, National University of Ireland Galway
| | - Howard O Fernhead
- Pharmacology and Therapeutics, School of Medicine, Biomedical Research Building, National University of Ireland (NUI) Galway, Ireland
| | - David Keane
- Cardiac Arrhythmia Service, St Vincent's University Hospital, Dublin, Ireland
| | - Leo R Quinlan
- Physiology and Cellular Physiology Research Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human biology building, National University of Ireland (NUI) Galway, Ireland
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50
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Del Monte A, Pannone L, Bisignani A, Osório TG, Iacopino S, Chierchia GB, de Asmundis C. Cryoballoon ablation for atrial fibrillation: Effects on neuromodulation. Front Cardiovasc Med 2022; 9:958316. [PMID: 35966567 PMCID: PMC9366392 DOI: 10.3389/fcvm.2022.958316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary vein isolation (PVI) represents the mainstay of atrial fibrillation (AF) ablation, and PVI with cryoballoon catheter (CB) ablation (CB-A) has proven to be as effective and safe as radiofrequency ablation (RF-A). Although AF is initiated by triggers arising from the pulmonary veins (PV) and non-PV foci, the intrinsic cardiac nervous system (ICNS) plays a significant role in the induction and maintenance of AF. The ICNS is an epicardial neural system composed of ganglionated plexi (GPs) and a complex network of interconnecting neurons. In the left atrium, the major GPs are located in proximity to the PV-left atrial junction. Vagal reactions have been described as markers of autonomic modulation during PVI with both RF-A and CB-A. The occurrence of neuromodulation during PVI with CB-A may be explained by both the anatomical relationship between the GPs and the PVs and the characteristics of the CB. Due to the CB/PV size mismatch, the CB creates a wide ablation area that extends from the PV ostium toward the antrum, possibly including the GPs. Although targeted GPs ablation, as a supplemental strategy to PVI, has been associated with a better AF outcome in patients undergoing RF-A, the additional clinical benefit of neuromodulation during PVI with CB-A remains a matter of debate. In this review, we provide an overview of the anatomy of the ICNS, the relationship between the ICNS and AF pathophysiology, and the current evidence on the clinical relevance of neuromodulation during PVI with CB-A.
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Affiliation(s)
- Alvise Del Monte
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Antonio Bisignani
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Thiago G. Osório
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Saverio Iacopino
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- Arrhythmology Department, Maria Cecilia Hospital, Cotignola, Italy
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- *Correspondence: Gian-Battista Chierchia
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
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