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Calvert P, Ding WY, Mills MT, Snowdon R, Borbas Z, Modi S, Hall M, Morgan M, Clarkson N, Chackochen S, Barton J, Kemp I, Luther V, Gupta D. Durability of thermal pulmonary vein isolation in persistent atrial fibrillation assessed by mandated repeat invasive study. Heart Rhythm 2024; 21:1545-1554. [PMID: 38636929 DOI: 10.1016/j.hrthm.2024.04.061] [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: 02/13/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND No study has assessed the durability of pulmonary vein isolation (PVI) with radiofrequency (RF) and cryoballoon (CB) in patients with persistent atrial fibrillation. These data are especially lacking for those with significantly diseased left atria (LA). OBJECTIVES The goals of this study were to assess PVI durability in patients with significant LA disease and to compare reconnection rates between RF and CB. METHODS Forty-four patients (mean age 63 years; 34 (77%) male; median time since atrial fibrillation diagnosis 22.5 months; median indexed LA volume 36 mL/m2) were randomized 1:1 to RF or CB PVI. A redo procedure using ultra-high-density electroanatomic mapping was mandated at 2 months, where PV reconnections were identified and reisolated. RESULTS Thirty-eight patients underwent both procedures (CB n = 17; RF n = 21). Index RF procedures were longer (median 158 minutes vs 97 minutes; P < .001) but required less fluoroscopy (9.5 minutes vs 23 minutes; P < .001). At the index RF procedure, a median of 47% of LA myocardium had voltage < 0.5 mV, suggesting that half of the mapped LA comprised scar. PV reconnection was observed in 73 of 152 PVs (48.0%) and was more frequent with CB (58.8%) than with RF (39.3%) (P = .022). Reconnection of at least 1 PV was detected in >75% of patients. Significantly more ablation was required during the redo procedure to reisolate PVs in the CB arm (median 10.8 minutes vs 1.2 minutes; P < .001). CONCLUSION PVI durability may be poor in those with significant LA scarring and dilatation, even with modern thermal ablation technologies. RF resulted in significantly better PVI durability than did CB in this complex population.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Wern Yew Ding
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark T Mills
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Richard Snowdon
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Zoltan Borbas
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Simon Modi
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark Hall
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Maureen Morgan
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | | | - Janet Barton
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ian Kemp
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Vishal Luther
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom.
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Takigawa M, Yamaguchi J, Goya M, Iwakawa H, Yamamoto T, Amemiya M, Ikenouchi T, Negishi M, Kawamura I, Goto K, Shigeta T, Nishimura T, Takamiya T, Tao S, Ohuchi K, Suzuki S, Miyazaki S, Sasano T. An optimized approach for increasing lesion size in temperature-controled setting using a catheter with a surface thermocouple and efficient irrigation. J Arrhythm 2024; 40:536-551. [PMID: 38939786 PMCID: PMC11199823 DOI: 10.1002/joa3.13040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/15/2024] [Accepted: 04/07/2024] [Indexed: 06/29/2024] Open
Abstract
Background We explore an optimized approach for increasing lesion size using a novel ablation catheter with a surface thermocouple and efficient irrigation in a temperature-control setting. Methods We conducted radiofrequency applications at various power levels (35 W, 40 W, and 45 W), contact forces (CFs, 10 g/20 g), and durations (60 s/120 s/180 s) in perpendicular/parallel catheter orientations, with normal saline irrigation (NS-irrigation) and Half NS-irrigation (HNS-irrigation) in an ex-vivo model (Step 1). In addition, we performed applications (35 W/40 W/45 W for 60 s/120 s/180 s in NS-irrigation and 35 W/40 W for 60 s/120 s/180 s in HNS-irrigation) in four swine (Step 2), evaluating lesion characteristics and the occurrence of steam pops. Results In Step 1, out of 288 lesions, we observed 47 (16.3%) steam pops, with 13 in NS-irrigation and 34 in HNS-irrigation (p = .001). Although steam pops were mostly observed with the most aggressive setting (45 W/180 s, 54%) with NS-irrigation, they happened in less aggressive settings with HNS irrigation. Lesion size significantly increased with longer-duration ablation but not with HNS-irrigation. The optimal %impedance-drop cutoff to predict steam pops was 20% with a negative-predictive-value (NPV) = 95.1% including NS- and HNS-irrigation groups, and 22% with an NPV = 96.1% in NS-irrigation group. In Step 2, similar to the ex-vivo model, lesion size significantly increased with longer-duration ablation but not with HNS-irrigation. Steam pops were absent with NS-irrigation (0/35) even with the largest %impedance-drop reaching 31% at 45 W/180 s. All steam pops were observed with HNS-irrigation (6/21, 29%). The optimal %impedance-drop cutoff predicting steam pops was 24% with an NPV = 96.3% including both NS- and HNS-irrigation groups. Conclusions Rather than using HNS-irrigation, very long-duration of radiofrequency applications up to 45 W/180 s may be recommended to safely and effectively increase lesion dimensions using this catheter with NS-irrigation.
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Affiliation(s)
- Masateru Takigawa
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Division of Advanced Arrhythmia ResearchTokyo Medical and Dental University HospitalTokyoJapan
| | - Junji Yamaguchi
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Masahiko Goya
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Hidehiro Iwakawa
- Department of Cardiovascular MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Tasuku Yamamoto
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Miki Amemiya
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Takashi Ikenouchi
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Miho Negishi
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Iwanari Kawamura
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Kentaro Goto
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Division of Advanced Arrhythmia ResearchTokyo Medical and Dental University HospitalTokyoJapan
| | - Takatoshi Shigeta
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Takuro Nishimura
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Tomomasa Takamiya
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Susumu Tao
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Katsuhiro Ohuchi
- Center for Experimental AnimalsTokyo Medical and Dental UniversityTokyoJapan
| | | | - Shinsuke Miyazaki
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Division of Advanced Arrhythmia ResearchTokyo Medical and Dental University HospitalTokyoJapan
| | - Tetsuo Sasano
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
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Tonko JB, Lambiase P. Exploring the Full Potential of Radiofrequency Technology: A Practical Guide to Advanced Radiofrequency Ablation for Complex Ventricular Arrhythmias. Curr Cardiol Rep 2024; 26:269-282. [PMID: 38700597 PMCID: PMC11136806 DOI: 10.1007/s11886-024-02048-z] [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] [Accepted: 03/19/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Percutaneous radiofrequency (RF) catheter ablation is an established strategy to prevent ventricular tachycardia (VT) recurrence and ICD shocks. Yet delivery of durable lesion sets by means of traditional unipolar radiofrequency ablation remains challenging, and left ventricular transmurality is rarely achieved. Failure to ablate and eliminate functionally relevant areas is particularly common in deep intramyocardial substrates, e.g. septal VT and cardiomyopathies. Here, we aim to give a practical-orientated overview of advanced and emerging RF ablation technologies to target these complex VT substrates. We summarize recent evidence in support of these technologies and share experiences from a tertiary VT centre to highlight important "hands-on" considerations for operators new to advanced RF ablation strategies. RECENT FINDINGS A number of innovative and modified radiofrequency ablation approaches have been proposed to increase energy delivery to the myocardium and maximize RF lesion dimensions and depth. These include measures of impedance modulation, combinations of simultaneous unipolar ablations or true bipolar ablation, intramyocardial RF delivery via wires or extendable RF needles and investigational linear or spherical catheter designs. Recent new clinical evidence for the efficacy and safety of these investigational technologies and strategies merits a re-evaluation of their role and clinic application for percutaneous VT ablations. Complexity of substrates targeted with percutaneous VT ablation is increasing and requires detailed preprocedural imaging to characterize the substrate to inform the procedural approach and selection of ablation technology. Depending on local experience, options for additional and/or complementary interventional treatments should be considered upfront in challenging substrates to improve the success rates of index procedures. Advanced RF technologies available for clinical VT ablations include impedance modulation via hypotonic irrigation or additional dispersive patches and simultaneous unipolar as well as true bipolar ablation. Promising investigational RF technologies involve an extendable needle RF catheter, intramyocardial RF delivery over intentionally perforated wires as well as a variety of innovative ablation catheter designs including multipolar linear, spherical and partially insulated ablation catheters.
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Affiliation(s)
- J B Tonko
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London, WC1E 6DD, UK.
- Bartholomew s Hospital, W Smithfield, London, UK.
| | - P Lambiase
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London, WC1E 6DD, UK
- Bartholomew s Hospital, W Smithfield, London, UK
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Sanders D, Du-Fay-de-Lavallaz JM, Winterfield J, Santangeli P, Liang J, Rhodes P, Ravi V, Badertscher P, Mazur A, Larsen T, Sharma PS, Huang HD. Surpoint algorithm for improved guidance of ablation for ventricular tachycardia (SURFIRE-VT): A pilot study. J Cardiovasc Electrophysiol 2024; 35:625-638. [PMID: 38174841 DOI: 10.1111/jce.16165] [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: 10/25/2023] [Revised: 11/27/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION The utility of ablation index (AI) to guide ventricular tachycardia (VT) ablation in patients with structural heart disease is unknown. The aim of this study was to assess procedural characteristics and clinical outcomes achieved using AI-guided strategy (target value 550) or conventional non-AI-guided parameters in patients undergoing scar-related VT ablation. METHODS Consecutive patients (n = 103) undergoing initial VT ablation at a single center from 2017 to 2022 were evaluated. Patient groups were 1:1 propensity-matched for baseline characteristics. Single lesion characteristics for all 4707 lesions in the matched cohort (n = 74) were analyzed. The impact of ablation characteristics was assessed by linear regression and clinical outcomes were evaluated by Cox proportional hazard model. RESULTS After propensity-matching, baseline characteristics were well-balanced between AI (n = 37) and non-AI (n = 37) groups. Lesion sets were similar (scar homogenization [41% vs. 27%; p = .34], scar dechanneling [19% vs. 8%; p = .18], core isolation [5% vs. 11%; p = .4], linear and elimination late potentials/local abnormal ventricular activities [35% vs. 44%; p = .48], epicardial mapping/ablation [11% vs. 14%; p = .73]). AI-guided strategy had 21% lower procedure duration (-47.27 min, 95% confidence interval [CI] [-81.613, -12.928]; p = .008), 49% lower radiofrequency time per lesion (-13.707 s, 95% CI [-17.86, -9.555]; p < .001), 21% lower volume of fluid administered (1664 cc [1127, 2209] vs. 2126 cc [1750, 2593]; p = .005). Total radiofrequency duration (-339 s [-24%], 95%CI [-776, 62]; p = .09) and steam pops (-155.6%, 95% CI [19.8%, -330.9%]; p = .08) were nonsignificantly lower in the AI group. Acute procedural success (95% vs. 89%; p = .7) and VT recurrence (0.97, 95% CI [0.42-2.2]; p = .93) were similar for both groups. Lesion analysis (n = 4707) demonstrated a plateau in the magnitude of impedance drops once reaching an AI of 550-600. CONCLUSION In this pilot study, an AI-guided ablation strategy for scar-related VT resulted in shorter procedure time and average radiofrequency time per lesion with similar acute procedural and intermediate-term clinical outcomes to a non-AI-guided approach utilizing traditional ablation parameters.
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Affiliation(s)
- David Sanders
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Jeffrey Winterfield
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jackson Liang
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Venkatesh Ravi
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Alexander Mazur
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy Larsen
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Parikshit S Sharma
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Henry D Huang
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
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Cheung JW. Applying ablation index to catheter ablation of ventricular tachycardia: The search for the more perfect ablation lesion continues. J Cardiovasc Electrophysiol 2024; 35:639-640. [PMID: 38424451 DOI: 10.1111/jce.16230] [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: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Jim W Cheung
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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Sławiński G, Hawryszko M, Dyda-Kristowska J, Królak T, Kempa M, Świetlik D, Kozłowski D, Daniłowicz-Szymanowicz L, Lewicka E. Clinical and Laboratory Predictors of Long-Term Outcomes after Catheter Ablation for a Ventricular Electrical Storm. J Interv Cardiol 2024; 2024:5524668. [PMID: 38352195 PMCID: PMC10861284 DOI: 10.1155/2024/5524668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 02/16/2024] Open
Abstract
Background Ventricular electrical storm (VES) is characterized by the occurrence of multiple episodes of sustained ventricular arrhythmias (VA) over a short period of time. Radiofrequency ablation (RFA) has been reported as an effective treatment in patients with ventricular tachycardia (VT). Objective The aim of the present study was to indicate the short-term and long-term predictors of recurrent VA after RFA was performed due to VES. Methods A retrospective, single-centre study included patients, who had undergone RFA due to VT between 2012 and 2021. In terms of the short-term (at the end of RFA) effectiveness of RFA, the following scenarios were distinguished: complete success: inability to induce any VT; partial success: absence of clinical VT; failure: inducible clinical VT. In terms of the long-term (12 months) effectiveness of RFA, the following scenarios were distinguished: effective ablation: no recurrence of any VT; partially successful ablation: VT recurrence; ineffective ablation: VES recurrence. Results The study included 62 patients. Complete short-term RFA success was obtained in 77.4% of patients. The estimated cumulative VT-free survival and VES-free survival were, respectively, 28% and 33% at the 12-month follow-up. Ischemic cardiomyopathy and complete short-term RFA success were predictors of long-term RFA efficacy. Neutrophil to lymphocyte ratio (NLR) and GFR <60 mL/min/1.73 m2 were associated with VES recurrence. NLR ≥2.95 predicted VT and/or VES recurrence with a sensitivity of 66.7% and specificity of 72.2%. Conclusion Ischemic cardiomyopathy and short-term complete success of RFA were predictors of no VES recurrence during the 12-month follow-up, while NLR and GFR <60 ml/min/1.73 m2 were associated with VES relapse.
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Affiliation(s)
- Grzegorz Sławiński
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Smoluchowskiego 17 Street, 80-214 Gdańsk, Poland
| | - Maja Hawryszko
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Smoluchowskiego 17 Street, 80-214 Gdańsk, Poland
| | - Julia Dyda-Kristowska
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Smoluchowskiego 17 Street, 80-214 Gdańsk, Poland
| | - Tomasz Królak
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Smoluchowskiego 17 Street, 80-214 Gdańsk, Poland
| | - Maciej Kempa
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Smoluchowskiego 17 Street, 80-214 Gdańsk, Poland
| | - Dariusz Świetlik
- Division of Biostatistics and Neural Networks, Medical University of Gdańsk, Dębinki 1 Street, 80-211 Gdansk, Poland
| | - Dariusz Kozłowski
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Smoluchowskiego 17 Street, 80-214 Gdańsk, Poland
| | - Ludmiła Daniłowicz-Szymanowicz
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Smoluchowskiego 17 Street, 80-214 Gdańsk, Poland
| | - Ewa Lewicka
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Smoluchowskiego 17 Street, 80-214 Gdańsk, Poland
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