Contact force threshold for permanent lesion formation in atrial fibrillation ablation: A cardiac magnetic resonance-based study to detect ablation gaps. Heart Rhythm. 2016;13:37-45. [PMID: 26272524 DOI: 10.1016/j.hrthm.2015.08.010]

High-Frequency Low-Tidal Volume Ventilation Improves Long-Term Outcomes in AF Ablation: A Multicenter Prospective Study

BACKGROUND

High-frequency, low-tidal-volume (HFLTV) ventilation is a safe and simple strategy to improve catheter stability and first-pass isolation during pulmonary vein (PV) isolation. However, the impact of this technique on long-term clinical outcomes has not been determined.

OBJECTIVES

This study sought to assess acute and long-term outcomes of HFLTV ventilation compared with standard ventilation (SV) during radiofrequency (RF) ablation of paroxysmal atrial fibrillation (PAF).

METHODS

In this prospective multicenter registry (REAL-AF), patients undergoing PAF ablation using either HFLTV or SV were included. The primary outcome was freedom from all-atrial arrhythmia at 12 months. Secondary outcomes included procedural characteristics, AF-related symptoms, and hospitalizations at 12 months.

RESULTS

A total of 661 patients were included. Compared with those in the SV group, patients in the HFLTV group had shorter procedural (66 [IQR: 51-88] minutes vs 80 [IQR: 61-110] minutes; P < 0.001), total RF (13.5 [IQR: 10-19] minutes vs 19.9 [IQR: 14.7-26.9] minutes; P < 0.001), and PV RF (11.1 [IQR: 8.8-14] minutes vs 15.3 [IQR: 12.4-20.4] minutes; P < 0.001) times. First-pass PV isolation was higher in the HFLTV group (66.6% vs 63.8%; P = 0.036). At 12 months, 185 of 216 (85.6%) in the HFLTV group were free from all-atrial arrhythmia, compared with 353 of 445 (79.3%) patients in the SV group (P = 0.041). HLTV was associated with a 6.3% absolute reduction in all-atrial arrhythmia recurrence, lower rate of AF-related symptoms (12.5% vs 18.9%; P = 0.046), and hospitalizations (1.4% vs 4.7%; P = 0.043). There was no significant difference in the rate of complications.

CONCLUSIONS

HFLTV ventilation during catheter ablation of PAF improved freedom from all-atrial arrhythmia recurrence, AF-related symptoms, and AF-related hospitalizations with shorter procedural times.

Optimal Ablation Settings Predicting Durable Scar Detected Using LGE-MRI after Modified Left Atrial Anterior Line Ablation

(1) Background: The modified anterior line (MAL) has been described as an alternative to the mitral isthmus line. Despite better ablation results, achieving a bidirectional line block can be challenging. We aimed to investigate the ablation parameters that determine a persistent scar on late-gadolinium enhancement magnet resonance imaging (LGE-MRI) as a surrogate parameter for successful ablation 3 months after MAL ablation. (2) Methods: Twenty-four consecutive patients who underwent a MAL ablation have been included. The indication for MAL was perimitral flutter (n = 5) or substrate ablation in the diffuse anterior left atrial (LA) low-voltage area in persistent atrial fibrillation (AF) (n = 19). The MAL was divided into three segments: segment 1 (S1) from mitral annulus to height of lower region of left atrial appendage (LAA) antrum; segment 2 (S2) height of lower region of LAA antrum to end of upper LAA antrum; segment 3 (S3) from end of upper LAA antrum to left superior pulmonary vein. Ablation was performed using a contact force irrigated catheter with a power of 40 Watt and guided by automated lesion tagging and the Ablation Index (AI). The AI target was left to the operator’s choice. An inter-lesion distance of ≤6 mm was recommended. The bidirectional block was systematically evaluated using stimulation maneuvers at the end of procedure. All patients underwent LGE-MRI imaging at 3 months, regardless of symptoms, to identify myocardial lesions (scars). (3) Results: Bidirectional MAL block was achieved in all patients. LGE-MRI imaging revealed scarring in 45 of 72 (63%) segments. In all three segments of MAL, ablation time and AI were significantly higher in scarred areas compared with non-scar areas. The mean AI value to detect a durable scar was 514.2 in S1, 486.7 in S2 and 485.9 in S3. The mean ablation time to detect a scar was 20.4 s in S1, 22.1 s in S2 and 20.2 s in S3. Mean contact force and impedance drop were not significantly different between scar and non-scar areas. (4) Conclusions: Targeting optimal AI values is crucial to determine persistent left atrial scars on an LGE-MRI scan 3 months after ablation. AI guided linear left atrial ablation seems to be effective in producing durable lesions.

Cardiovascular Magnetic Resonance-Guided Radiofrequency Ablation: Where Are We Now?

The possibilities of cardiovascular magnetic resonance (CMR) imaging for myocardial tissue characterization and catheter ablation guidance are accompanied by some fictional concepts. In this review, we present the available facts about CMR-guided catheter ablation procedures as well as promising, however unproven, theoretical concepts. CMR promises to visualize the respective arrhythmogenic substrate and may thereby make it more localizable for electrophysiology (EP)-based ablation. Robust CMR imaging is challenged by motion of the heart resulting from cardiac and respiratory cycles. In contrast to conventional "passive" tracking of the catheter tip by real-time CMR, novel approaches based on "active" tracking are performed by integrating microcoils into the catheter tip that send a receiver signal. Several experimental and clinical studies were already performed based on real-time CMR for catheter ablation of atrial and ventricular arrhythmias. Importantly, successful ablation of the cavotricuspid isthmus was already performed in patients with typical atrial flutter. However, a complete EP procedure with real-time CMR-guided transseptal puncture and subsequent pulmonary vein isolation has not been shown so far in patients with atrial fibrillation. Moreover, real-time CMR-guided EP for ventricular tachycardia ablation was only performed in animal models using a transseptal, retrograde, or epicardial access-but not in humans. Essential improvements within the next few years regarding basic technical requirements, such as higher spatial and temporal resolution of real-time CMR imaging as well as clinically approved cardiac magnetic resonance-conditional defibrillators, are ultimately required-but can also be expected-and will move this field forward.

Left atrial evaluation by cardiovascular magnetic resonance: sensitive and unique biomarkers

Left atrial (LA) imaging is still not routinely used for diagnosis and risk stratification, although recent studies have emphasized its importance as an imaging biomarker. Cardiovascular magnetic resonance is able to evaluate LA structure and function, metrics that serve as early indicators of disease, and provide prognostic information, e.g. regarding diastolic dysfunction, and atrial fibrillation (AF). MR angiography defines atrial anatomy, useful for planning ablation procedures, and also for characterizing atrial shapes and sizes that might predict cardiovascular events, e.g. stroke. Long-axis cine images can be evaluated to define minimum, maximum, and pre-atrial contraction LA volumes, and ejection fractions (EFs). More modern feature tracking of these cine images provides longitudinal LA strain through the cardiac cycle, and strain rates. Strain may be a more sensitive marker than EF and can predict post-operative AF, AF recurrence after ablation, outcomes in hypertrophic cardiomyopathy, stratification of diastolic dysfunction, and strain correlates with atrial fibrosis. Using high-resolution late gadolinium enhancement (LGE), the extent of fibrosis in the LA can be estimated and post-ablation scar can be evaluated. The LA LGE method is widely available, its reproducibility is good, and validations with voltage-mapping exist, although further scan-rescan studies are needed, and consensus regarding atrial segmentation is lacking. Using LGE, scar patterns after ablation in AF subjects can be reproducibly defined. Evaluation of 'pre-existent' atrial fibrosis may have roles in predicting AF recurrence after ablation, predicting new-onset AF and diastolic dysfunction in patients without AF. LA imaging biomarkers are ready to enter into diagnostic clinical practice.

Late gadolinium enhancement-MRI determines definite lesion formation most accurately at 3 months post ablation compared to later time points

AIMS

Neither the long-term development of ablation lesions nor the capability of late gadolinium enhancement (LGE)-MRI to detect ablation-induced fibrosis at late stages of scar formation have been defined. We sought to assess the development of atrial ablation lesions over time using LGE-MRI and invasive electroanatomical mapping (EAM).

METHODS AND RESULTS

Ablation lesions and total atrial fibrosis were assessed in serial LGE-MRI scans 3 months and >12 months post pulmonary vein (PV) isolation. High-density EAM performed in subsequent repeat ablation procedures served as a reference. Serial LGE-MRI of 22 patients were analyzed retrospectively. The PV encircling ablation lines displayed an average LGE, indicative of ablation-induced fibrosis, of 91.7% ± 7.0% of the circumference at 3 months, but only 62.8% ± 25.0% at a median of 28 months post ablation (p < 0.0001). EAM performed in 18 patients undergoing a subsequent repeat procedure revealed that the consistent decrease in LGE over time was owed to a reduced detectability of ablation-induced fibrosis by LGE-MRI at time-points > 12 months post ablation. Accordingly, the agreement with EAM regarding detection of ablation-induced fibrosis and functional gaps was good for the LGE-MRI at 3 months (κ .74; p < .0001), but only weak for the LGE-MRI at 28 months post-ablation (κ .29; p < .0001).

CONCLUSION

While non-invasive lesion assessment with LGE-MRI 3 months post ablation provides accurate guidance for future redo-procedures, detectability of atrial ablation lesions appears to decrease over time. Thus, it should be considered to perform LGE-MRI 3 months post-ablation rather than at later time-points > 12 months post ablation, like for example, prior to a planned redo-ablation procedure.

Comparison of the lesion formation and safety in ex vivo porcine heart study: Using ThermoCool SmartTouch and ThermoCool SmartTouch-SF catheters

BACKGROUND

The study was performed to compare the efficacy and safety during radiofrequency ablation (RFA) using ThermoCool SmartTouch (ST) and ThermoCool SmartTouch-SF (STSF) catheters in the porcine heart.

METHODS AND RESULTS

RFA was performed on the porcine myocardium by using two irrigated ablation catheters. Three groups were divided based on the different contact forces (CFs): low contact force (LCF) (1-3 g), medium contact force (MCF) (5-10 g), and high contact force (HCF) (15-20 g). In each group, RFA was delivered at four power settings of 30, 40, 50, 60 W. At each power, RFA was applied to reach the target ablation index (AI) of 350, 450, and 500. Altogether, 360 RF lesions were created by using 72 ablation conditions. AI value was positively correlated with lesion size using ST and STSF catheters. At a fixed power, lesion dimensions significantly smaller in the LCF group, whereas did not differ between MCF and HCF groups. Furthermore, at a fixed CF, lesion dimensions increased with power set at 40 W compared with 30 W but decreased with high-power RF energy (50 and 60 W). Although the average lesion surface diameter and the maximum diameter was increased using the STSF catheter, there were no significant differences in LV between the two catheters. The steam pop provoked more frequently using ST catheter and showed a negative correlation with CF and positive correlation with high-power energy.

CONCLUSION

The STSF catheter is safer and equally effective in lesion formation compared with the ST catheter. LV was increased along with the early increase of CF and power, whereas a further increase of CF and power significantly reduces the lesion size.

Cardiac MRI and Fibrosis Quantification

Left atrial fibrosis plays an important role in the pathophysiology of atrial fibrillation. Left atrial ablation is an effective and increasingly used strategy to restore and maintain sinus rhythm in patients with atrial fibrillation. Late gadolinium enhancement (LGE) MRI and custom image analysis software have been used to visualize and quantify preablation atrial fibrosis and postablation scar and new fibrosis formation. This article reviews technical aspects of imaging atrial fibrosis/scar by LGE-MRI; use of atrial fibrosis and scar in predicting outcomes; applications of LGE-MRI to assess ablation lesions and optimize ablation parameters while avoiding collateral damage.

Cryoballoon vs. radiofrequency lesions as detected by late-enhancement cardiac magnetic resonance after ablation of paroxysmal atrial fibrillation: a case-control study

AIMS

Cryoballoon (CB) ablation has emerged as a reliable modality to isolate pulmonary veins (PVs) in atrial fibrillation. Ablation lesions and the long-term effects of energy delivery can be assessed by delayed-enhancement cardiac magnetic resonance (DE-CMR). The aim of the study was to compare the number, extension, and localization of gaps in CB and radiofrequency (RF) techniques in pulmonary vein isolation (PVI).

METHODS AND RESULTS

Consecutive patients submitted to PVI with CB in whom DE-CMR images were available (n = 30) were matched (1:1) to patients who underwent PVI with RF (n = 30), considering age, sex, hypertension, and diabetes. Delayed-enhancement cardiac magnetic resonance was obtained at 3 months post-procedure, and images were processed to assess the mean number of gaps around PV ostia, their localization, and the normalized gap length (NGL), calculated as the difference between total gap length and total PV perimeter. Patients were followed up for 12 months. The CB and RF procedures did not differ in the mean number of gaps per patient (4.40 vs. 5.13 gaps, respectively; P = 0.21) nor NGL (0.35 vs. 0.32, P = 0.59). For both techniques, a higher mean number of gaps were detected in right vs. left PVs (3.18 vs. 1.58, respectively; P = 0.01). The incidence of recurrences did not differ between techniques (odds ratio 1.87, 95% confidence interval 0.66-4.97; P = 0.29).

CONCLUSION

Location and extension of ablation gaps in PVI did not differ between CB and RF groups in DE-CMR image analysis.

Impact of cryoballoon applications on lesion gaps detected by magnetic resonance after pulmonary vein isolation

INTRODUCTION

Ablation with second-generation cryoballoon technology evolves as an effective and safe alternative to radiofrequency for atrial fibrillation ablation procedures. Nevertheless, the optimal freezing strategy remains unknown. Our objective was to identify the procedural cryoablation parameters predicting successful peri-pulmonary vein (PV) lesions by directly analyzing Postablation gaps in late-gadolinium-enhanced cardiac magnetic resonance (LGE-CMR).

METHODS AND RESULTS

Forty-nine consecutive patients (196 PVs) undergoing ablation with second-generation cryoballoon at our center were included. The number and duration of cryoballoon application to achieve PV isolation were left to operator discretion. Gap number and length were quantified in all patients with a LGE-CMR performed 3 months postablation. Application time (420 ± 217 seconds), number of applications (2.1 ± 1.2), application time after electrical isolation (311 ± 194 seconds) and minimum temperature (-45.8 ± 6.5°C) were similar in the 4 PVs. Gaps were observed in 148 PVs (76%), averaging 1.3 ± 1 gaps per vein. Gaps were longer and more frequent in the right PVs (91% vs 59% in left PVs, P < .001). Neither the number, total duration of applications, nor postisolation application time predicted relative length or number of gaps.

CONCLUSIONS

After successful PV isolation was achieved in patients undergoing cryoablation, increasing the number of applications, the total application time or application time postisolation did not result in a reduction in the number or the relative length of gaps.

Delayed Gadolinium Enhancement Magnetic Resonance Imaging Detected Anatomic Gap Length in Wide Circumferential Pulmonary Vein Ablation Lesions Is Associated With Recurrence of Atrial Fibrillation

BACKGROUND

There is limited knowledge about the impact of anatomic gaps as assessed by delayed gadolinium enhancement cardiac magnetic resonance on atrial fibrillation (AF) recurrence after first pulmonary vein (PV) isolation.

METHODS

Consecutive patients underwent delayed gadolinium enhancement cardiac magnetic resonance 3 months after radiofrequency circumferential PV isolation. Delayed gadolinium enhancement cardiac magnetic resonance images were assessed from 360 PV resulting in 2880 segments in the 2×8-segment model from 94 patients (52±11 years, 62% paroxysmal AF). Left atria were segmented using dedicated software. Anatomic gap was defined as discontinuation of the ablation line by ≥3 mm. Relative gap length was calculated as absolute gap length divided by the total length of the ablation line. AF recurrence was assessed after a mean follow-up duration of 15±10 months Results: Mean number of anatomic gaps was 5.4 per patient. Recurrence within the first year of ablation was observed in 21 patients with paroxysmal AF (36%) and 19 patients with persistent AF (53%). In the univariate analysis, CHA₂DS₂-VASc score, AF type, and relative gap length were predictive of recurrence. In the multivariate analysis, only relative gap length was significantly associated with recurrence (hazard ratio, 1.16 [1.02-1.31] per each 10% of gap).

CONCLUSIONS

The total relative gap length but not the number of anatomic gaps in the PV ablation line as assessed by delayed gadolinium enhancement cardiac magnetic resonance was associated with AF recurrence 1 year after first PV isolation. An increase of 10% relative gap length increased the likelihood of AF recurrence by 16%.

Benefit of Contact Force Sensing Catheter Technology for Successful Left Atrial Anterior Line Formation: A Prospective Randomized Trial

Introduction

The value of contact force information for ablation of LA anterior line is unknown. In a prospective randomized clinical trial, we investigated if information on contact force during left atrial (LA) anterior line ablation reduces total radiofrequency time and results in higher rates of bidirectional line block in patients undergoing pulmonary vein isolation (PVI) plus substrate modification.

Methods

We included patients with indication for pulmonary vein isolation (PVI) and additional substrate modification. For LA anterior line ablation, patients were randomized to contact force information visible (n=35) or blinded (n=37). Patients received contrast enhanced cardiac magnetic resonance imaging (cMRI) before and 3-6 months after ablation to visualize the LA anterior line. Primary endpoint was radiofrequency time to achieve bidirectional line block. Secondary endpoints were completeness of the LA anterior line on cMRI, distribution of contact force, procedural data, adverse events, and 12 months success rate.

Results

In 72 patients (64±9 years, 68% male), bidirectional LA anterior line block was achieved in 70 (97%) patients. Radiofrequency time to bidirectional block did not differ significantly across groups (contact force information visible 23±18min versus contact force information blinded 21±15min, p=0.50). The LA anterior line was discernable on cMRI in 40 patients (82%) without significant differences across randomization groups (p=0.46). No difference in applied contact force was found depending on cMRI line visibility. Twelve-month success and adverse event rates were comparable across groups.

Conclusion

Information on contact force does not significantly improve the ablation of LA anterior lines.

Clinical Trial Registration

The trial was registered at http://www.clinicaltrials.gov by identifier: NCT02217657.

Contact force-sensing catheters: performance in an ex vivo porcine heart model

PURPOSE

Contact force (CF) catheters are useful to address proper contact during ablation. However, interactions between the ablation process, or its associated irrigation flow changes, with the CF sensing may translate into unexpected CF value fluctuations. We aimed to test for unintentional CF value variations during radiofrequency applications at a fixed applied force, with two commercially available catheters (TactiCath™ and SmartTouch™), and to evaluate its theoretical clinical significance by correlating CF-derived automatic ablation algorithms (force-time integral and lesion index) and actual lesion size at two standard CF values.

METHODS

Four series of 20 perpendicular epicardial ablations (20 W, 60 s, 17 ml/min) were performed on porcine left ventricle submerged in 37 °C saline. Catheters were mechanically fixed at a constant position and evaluated at 10 and 20 g. CF values were digitally analysed before each application changing irrigation rate (2-17-30 ml/min), and during ablation. Finally, lesions were quantified.

RESULTS

Increasing irrigation before ablation led to a slight but significant CF decrease. During ablation, CF showed a reproducible pattern: fast initial decrease, subsequent increase until higher-than-initial values and final plateau phase (CF variation up to 69% at 10 g). CF variability was significantly higher at 10 g and using TactiCath™. There were no major differences in lesion size between catheters at the same initial CF. CF only correlated mildly to lesion measures, and automatic algorithms globally failed to predict lesion size.

CONCLUSIONS

CF measured values spontaneously vary during ablation following a predictable pattern (initial decrease, subsequent increase and final plateau). This is especially remarkable applying lower CF.

Postprocedural LGE-CMR comparison of laser and radiofrequency ablation lesions after pulmonary vein isolation

INTRODUCTION

The purpose of this study was to compare the anatomical characteristics of scar formation achieved by visual-guided laser balloon (Laser) and radiofrequency (RF) pulmonary vein isolation (PVI), using late-gadolinium-enhanced cardiac magnetic resonance imaging (LGE-CMR).

METHODS AND RESULTS

We included 17 patients with paroxysmal or early persistent drug resistant AF who underwent Laser ablation; 2 were excluded due to procedure-related complications. The sample was matched with a historical group of 15 patients who underwent PVI using RF. LGE-CMR sequences were acquired before and 3 months post-PVI. Ablation gaps were defined as pulmonary vein (PV) perimeter sections showing no gadolinium enhancement. The number of ablation gaps was lower in Laser versus RF ablations (median 7 vs. 14, P  =  0.015). Complete anatomical PVI (circumferential scar around PV, without gaps) was more frequently achieved with Laser than with RF (39% vs. 19% of PVs, P  =  0.025). Fewer gaps were present at the superior and anterior left PV and posterior right PV antral regions in the Laser group, compared to RF. Scar extension into the PVs was similar in both groups, although RF produced more extensive ablation scar toward the LA body. AF recurrences at 1 year were similar in both groups (Laser 36% vs. RF 27%, P  =  1.00).

CONCLUSIONS

Compared to RF, Laser ablation achieved more complete anatomical PVI, with less LA scar extension. However, AF recurrence appears to be similar after Laser compared to RF ablation. Further studies are needed to assess whether the anatomical advantages of Laser ablation translate into clinical benefit in patients with AF.

Left atrial fibrosis quantification by late gadolinium-enhanced magnetic resonance: a new method to standardize the thresholds for reproducibility

Aims

Identification of left atrial (LA) fibrosis through late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) remains controversial due to the heterogeneity and lack of reproducibility of proposed methods. Our aim is to describe a normalized, reproducible, standardized method to evaluate LA fibrosis through LGE-CMR.

Methods and results

Electrocardiogram- and respiratory-gated 3-Tesla LGE-CMR was performed in 10 healthy young volunteers and 30 patients with atrial fibrillation (AF): 10 with paroxysmal AF, 10 with persistent AF, and 10 with a previous AF ablation procedure. Local image intensity ratio (IIR) of the LA was calculated as the absolute pixel intensity to mean blood pool intensity ratio. The healthy atrial tissue threshold was defined in young healthy volunteers (upper limit of normality set at IIR tissue mean plus 2 SDs). Dense atrial scarring was characterized in patients with previous radiofrequency-induced scarring (post-AF ablation patients). Validation groups consisted of patients with paroxysmal and persistent AFs. The upper limit of normal IIR was 1.20; IIR values higher than 1.32 (60% of mean maximum pixel intensity in post-ablation patients) were considered dense scar. Image intensity ratio values between 1.2 and 1.32 identified interstitial fibrosis. Patients with paroxysmal and persistent AFs had less atrial fibrotic tissue compared with post-ablation patients. Endocardial bipolar voltage was correlated to IIR values.

Conclusions

An IIR of 1.2 identifies the upper limit of normality in healthy young individuals. An IIR of >1.32 defines dense atrial fibrosis in post-ablation patients. Our results provide a consistent, comparable, and normalized tool to assess atrial arrhythmogenic substrate.

Paroxysmal atrial fibrillation ablation: Achieving permanent pulmonary vein isolation by point-by-point radiofrequency lesions

Pulmonary vein isolation by point-by-point radiofrequency catheter ablation constitutes the cornerstone of catheter ablation strategies for the treatment of atrial fibrillation. However, despite advances in pulmonary vein isolation ablation strategies, long-term success rates after ablation remain suboptimal, which highlights the need to develop techniques to achieve more durable lesions. Strategies proposed to improve the durability of pulmonary vein isolation can be divided into two groups: Those addressed to improving the quality of the lesion and those that optimize the detection of acute PV reconnection during the ablation procedure. This manuscript reviews the role and potential benefits of these techniques according to current clinical evidence.

Impact of contact force technology on reducing the recurrence and major complications of atrial fibrillation ablation: A systematic review and meta-analysis

Contact force (CF) monitoring can be useful in accomplishing circumferential pulmonary vein (PV) isolation for atrial fibrillation (AF). This meta-analysis aimed to assess the efficacy and safety of a CF-sensing catheter in treating AF. Randomized controlled trials or non-randomized observational studies comparing AF ablation using CF-sensing or standard non-CF (NCF)-sensing catheters were identified from PubMed, EMBASE, Cochrane Library, Wanfang Data, and China National Knowledge Infrastructure (January 1, 1998-2016). A total of 19 studies were included. The primary efficacy endpoint was AF recurrence within 12 months, which significantly improved using CF-sensing catheters compared with using NCF-sensing catheters [31.1% vs. 40.5%; risk ratio (RR)=0.82; 95% confidence interval (CI), 0.73-0.93; p<0.05]. Further, the acute PV reconnection (10.1% vs. 24.2%; RR=0.45; 95% CI, 0.32-0.63; p<0.05) and incidence of major complications (1.8% vs. 3.1%; OR=0.59; 95% CI, 0.37-0.95; p<0.05) significantly improved using CF-sensing catheters compared with using NCF-sensing catheters. Procedure parameters such as procedure duration [mean difference (MD)=-28.35; 95% CI, -39.54 to -17.16; p<0.05], ablation time (MD=-3.8; 95% CI, -6.6 to -1.0; p<0.05), fluoroscopy duration (MD=-8.18; 95% CI, -14.11 to -2.24; p<0.05), and radiation dose (standard MD=-0.75; 95% CI, -1.32 to -0.18; p<0.05] significantly reduced using CF-sensing catheters. CF-sensing catheter ablation of AF can reduce the incidence of major complications and generate better outcomes compared with NCF-sensing catheters during the 12-month follow-up period.