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Maizels L, Kalman JM. Pulsed-field ablation: a revolution in atrial fibrillation therapy. Nat Rev Cardiol 2024; 21:519-520. [PMID: 38918558 DOI: 10.1038/s41569-024-01053-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Affiliation(s)
- Leonid Maizels
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Division of Cardiology and Talpiot Medical Leadership Program, Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Jonathan M Kalman
- Royal Melbourne Hospital, Melbourne, Victoria, Australia.
- University of Melbourne, Melbourne, Victoria, Australia.
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia.
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2
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Leyton-Mange JS, Haskell AD, Tandon K, Corsello AC, Black-Maier E, Sze EY, Sesselberg HW. Protocol modifications reduce risk of delayed pericardial effusions after vein of Marshall ethanol infusion: follow-up from the Maine experience. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01842-7. [PMID: 38914901 DOI: 10.1007/s10840-024-01842-7] [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: 02/26/2024] [Accepted: 05/29/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND While ethanol infusion into the vein of Marshall (VOM) as an adjunct to atrial fibrillation ablation has shown promise, adoption has been limited by the technical expertise required, unclear antiarrhythmic mechanism, and complication risk. Delayed pericardial effusions have been associated with ethanol infusion into the VOM in prior studies. Very little is known about how the procedural approach itself can impact the risk of delayed effusions. We sought to understand the incidence and influence of procedural technique on complications including delayed pericardial effusions from VOM ethanol infusion at a large single medical center. METHODS A total of 275 atrial ablation cases wherein VOM ethanol infusion was attempted were identified from the time of the program's inception in 2019 at Maine Medical Center (Portland, ME) until October of 2023. Cases were classified into phase I cases (early experience) and phase II cases (later experience) based upon temporal programmatic changes in the ethanol dose and infusion rate as well as the use of routine VOM venography. Procedural details and complications were adjudicated from the medical record. RESULTS The overall VOM ethanol infusion success was 91.4%. Nine complications (3.3%) occurred in eight patients (2.9% of patients). These were more frequent in phase I (5.8%) compared to phase II (1.3%, p = 0.047). This difference was driven by a difference in delayed presentations of tamponade, which occurred in four patients in phase I (3.3%) and in no patients in phase II (0%, p = 0.037). Twelve-month estimated atrial arrhythmia freedom did not differ between groups (73.8% phase I vs 70.4% phase II, p = 0.24). CONCLUSION In our single-center experience, adjustments to the procedural approach with lower ethanol infusion rate and dosage, combined with utilizing selective VOM venography, associated with a lowering of complication rates and in particular, delayed pericardial tamponade.
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Affiliation(s)
- Jordan S Leyton-Mange
- Department of Cardiology, Maine Medical Center, Portland, ME, 04102, USA.
- Maine Medical Partners MaineHealth Cardiology, 96 Campus Drive, Scarborough, ME, 04074, USA.
| | - Amanda D Haskell
- Department of Cardiology, Maine Medical Center, Portland, ME, 04102, USA
| | - Kunal Tandon
- Department of Cardiology, Maine Medical Center, Portland, ME, 04102, USA
- Maine Medical Partners MaineHealth Cardiology, 96 Campus Drive, Scarborough, ME, 04074, USA
| | - Andrew C Corsello
- Department of Cardiology, Maine Medical Center, Portland, ME, 04102, USA
- Maine Medical Partners MaineHealth Cardiology, 96 Campus Drive, Scarborough, ME, 04074, USA
| | - Eric Black-Maier
- Department of Cardiology, Maine Medical Center, Portland, ME, 04102, USA
- Maine Medical Partners MaineHealth Cardiology, 96 Campus Drive, Scarborough, ME, 04074, USA
| | - Edward Y Sze
- Department of Cardiology, Maine Medical Center, Portland, ME, 04102, USA
- Maine Medical Partners MaineHealth Cardiology, 96 Campus Drive, Scarborough, ME, 04074, USA
| | - Henry W Sesselberg
- Department of Cardiology, Maine Medical Center, Portland, ME, 04102, USA
- Maine Medical Partners MaineHealth Cardiology, 96 Campus Drive, Scarborough, ME, 04074, USA
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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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4
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Tohoku S, Bordignon S, Schaack D, Hirokami J, Urbanek L, Urbani A, Kheir J, Schmidt B, Chun KRJ. Initial real-world data on catheter ablation in patients with persistent atrial fibrillation using the novel lattice-tip focal pulsed-field ablation catheter. Europace 2024; 26:euae129. [PMID: 38916275 PMCID: PMC11197047 DOI: 10.1093/europace/euae129] [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: 03/14/2024] [Accepted: 05/07/2024] [Indexed: 06/26/2024] Open
Abstract
AIMS Technological advancements have contributed to the enhanced precision and lesion flexibility in pulsed-field ablation (PFA) by integrating a three-dimensional mapping system combined with a point-by-point ablation strategy. Data regarding the feasibility of this technology remain limited to some clinical trials. This study aims to elucidate initial real-world data on catheter ablation utilizing a lattice-tip focal PFA/radiofrequency ablation (RFA) catheter in patients with persistent atrial fibrillation (AF). METHODS AND RESULTS Consecutive patients who underwent catheter ablation for persistent AF via the lattice-tip PFA/RFA catheter were enrolled. We evaluated acute procedural data including periprocedural data as well as the clinical follow-up within a 90-day blanking period. In total, 28 patients with persistent AF underwent AF ablation either under general anaesthesia (n = 6) or deep sedation (n = 22). In all patients, pulmonary vein isolation was successfully achieved. Additional linear ablations were conducted in 21 patients (78%) with a combination of successful anterior line (n = 13, 46%) and roof line (n = 19, 68%). The median procedural and fluoroscopic times were 97 (interquartile range, IQR: 80-114) min and 8.5 (IQR: 7.2-9.5) min, respectively. A total of 27 patients (96%) were interviewed during the follow-up within the blanking period, and early recurrent AF was documented in four patients (15%) including one case of recurrent AF during the hospital stay. Neither major nor minor procedural complication occurred. CONCLUSION In terms of real-world data, our data confirmed AF ablation feasibility utilizing the lattice-tip focal PFA/RFA catheter in patients with persistent AF.
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Affiliation(s)
- Shota Tohoku
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
- Klinik für Rhythmologie, Universitätsklinikum Schleswig-Holstein der Universität zu Lübeck, Ratzeburger Allee 16023538 Lübeck, Germany
| | - Stefano Bordignon
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - David Schaack
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - Jun Hirokami
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - Lukas Urbanek
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - Andrea Urbani
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - Joseph Kheir
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
- Universitätsklinikum Frankfurt, Medizinische Klinik 3- Klinik für Kardiologie, Frankfurt, Germany
| | - Kyoung-Ryul Julian Chun
- Cardioangiologisches Centrum Bethanien Med. Klinik III, Markuskrankenhaus, Department of Cardiology, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
- Klinik für Rhythmologie, Universitätsklinikum Schleswig-Holstein der Universität zu Lübeck, Ratzeburger Allee 16023538 Lübeck, Germany
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5
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Turagam MK, Neuzil P, Petru J, Funasako M, Koruth JS, Skoda J, Kralovec S, Reddy VY. AF ablation using a novel "single-shot" map-and-ablate spherical array pulsed field ablation catheter: 1-Year outcomes of the first-in-human PULSE-EU trial. Heart Rhythm 2024:S1547-5271(24)02536-0. [PMID: 38768840 DOI: 10.1016/j.hrthm.2024.04.102] [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: 04/05/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND During pulsed field ablation (PFA), electrode-tissue proximity optimizes lesion quality. A novel "single-shot" map-and-ablate spherical multielectrode PFA array catheter that is able to verify electrode-tissue contact was recently studied in a first-in-human trial of atrial fibrillation (AF). OBJECTIVE The aim of this study was to report lesion durability data, safety, and 12-month effectiveness outcomes. METHODS The spherical PFA catheter, an all-in-one mapping and ablation system, was used to render anatomy and to deliver biphasic pulses (ungated 1.7 kV pulses; ∼40 seconds/application). Ablation sites included pulmonary veins (PVs) and, in selected patients, posterior wall and mitral isthmus. Follow-up was invasive remapping at ∼3 months, electrocardiograms, Holter monitoring at 6 and 12 months, and symptomatic and scheduled transtelephonic monitoring. The primary and secondary efficacy end points were acute PV isolation (PVI), PVI durability, and atrial arrhythmia recurrence. RESULTS In the 48-patient AF cohort (paroxysmal, 48%; persistent, 52%), lesion sets included PVI (n = 48; 1.2 applications/PV), posterior wall (n = 20; 3.6 applications/posterior wall), and mitral isthmus (n = 11; 2.9 applications/mitral isthmus). Lesions were acutely successful for all 187 of 187 PVs (100%), 20 of 20 posterior walls (100%), and 10 of 11 mitral isthmuses (91%). Pulse delivery time, left atrial catheter dwell time, and procedure time were 61.5 ± 32.8 seconds, 53.9 ± 26.5 minutes, and 87.8 ± 29.8 minutes, respectively. Remapping (43/48 patients [89.5%]) revealed that 158 of 169 PVs (93.5%) were durably isolated. The only complication was a drug-responsive pericarditis. The 1-year Kaplan-Meier estimates of freedom from atrial arrhythmia were 84.2% (paroxysmal AF) and 80.0% (persistent AF). CONCLUSION The single-shot spherical array PFA catheter can safely achieve durable lesions, translating into good clinical efficacy. CLINICALTRIALS GOV IDENTIFIER NCT05164107.
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Affiliation(s)
| | | | - Jan Petru
- Homolka Hospital, Prague, Czech Republic
| | | | - Jacob S Koruth
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jan Skoda
- Homolka Hospital, Prague, Czech Republic
| | | | - Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, New York; Homolka Hospital, Prague, Czech Republic.
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Pierucci N, Mariani MV, Laviola D, Silvetti G, Cipollone P, Vernile A, Trivigno S, La Fazia VM, Piro A, Miraldi F, Vizza CD, Lavalle C. Pulsed Field Energy in Atrial Fibrillation Ablation: From Physical Principles to Clinical Applications. J Clin Med 2024; 13:2980. [PMID: 38792520 PMCID: PMC11121906 DOI: 10.3390/jcm13102980] [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: 04/11/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Atrial fibrillation, representing the most prevalent sustained cardiac arrhythmia, significantly impacts stroke risk and cardiovascular mortality. Historically managed with antiarrhythmic drugs with limited efficacy, and more recently, catheter ablation, the interventional approach field is still evolving with technological advances. This review highlights pulsed field ablation (PFA), a revolutionary technique gaining prominence in interventional electrophysiology because of its efficacy and safety. PFA employs non-thermal electric fields to create irreversible electroporation, disrupting cell membranes selectively within myocardial tissue, thus preventing the non-selective damage associated with traditional thermal ablation methods like radiofrequency or cryoablation. Clinical studies have consistently shown PFA's ability to achieve pulmonary vein isolation-a cornerstone of AF treatment-rapidly and with minimal complications. Notably, PFA reduces procedure times and has shown a lower incidence of esophageal and phrenic nerve damage, two common concerns with thermal techniques. Emerging from oncological applications, the principles of electroporation provide a unique tissue-selective ablation method that minimizes collateral damage. This review synthesizes findings from foundational animal studies through to recent clinical trials, such as the MANIFEST-PF and ADVENT trials, demonstrating PFA's effectiveness and safety. Future perspectives point towards expanding indications and refinement of techniques that promise to improve AF management outcomes further. PFA represents a paradigm shift in AF ablation, offering a safer, faster, and equally effective alternative to conventional methods. This synthesis of its development and clinical application outlines its potential to become the new standard in AF treatment protocols.
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Affiliation(s)
- Nicola Pierucci
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Domenico Laviola
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Giacomo Silvetti
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Pietro Cipollone
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Antonio Vernile
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Sara Trivigno
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | | | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Fabio Miraldi
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Carmine Dario Vizza
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
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7
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Calvert P, Mills MT, Xydis P, Essa H, Ding WY, Koniari I, Farinha JM, Harding M, Mahida S, Snowdon R, Waktare J, Borbas Z, Modi S, Todd D, Ashrafi R, Luther V, Gupta D. Cost, efficiency, and outcomes of pulsed field ablation vs thermal ablation for atrial fibrillation: A real-world study. Heart Rhythm 2024:S1547-5271(24)02574-8. [PMID: 38763378 DOI: 10.1016/j.hrthm.2024.05.032] [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: 04/14/2024] [Revised: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND With the exponential growth of catheter ablation for atrial fibrillation (AF), there is increasing interest in associated health care costs. Pulsed field ablation (PFA) using a single-shot pentaspline multielectrode catheter has been shown to be safe and effective for AF ablation, but its cost efficiency compared to conventional thermal ablation modalities (cryoballoon [CB] or radiofrequency [RF]) has not been evaluated. OBJECTIVE The purpose of this study was to compare cost, efficiency, effectiveness, and safety between PFA, CB, and RF for AF ablation. METHODS We studied 707 consecutive patients (PFA: 208 [46.0%]; CB: 325 [29.4%]; RF: 174 [24.6%]) undergoing first-time AF ablation. Individual procedural costs were calculated, including equipment, laboratory use, and hospital stay, and compared between ablation modalities, as were effectiveness and safety. RESULTS Skin-to-skin times and catheter laboratory times were significantly shorter with PFA (68 and 102 minutes, respectively) than with CB (91 and 122 minutes) and RF (89 and 123 minutes) (P < .001). General anesthesia use differed across modalities (PFA 100%; CB 10.2%; RF 61.5%) (P < .001). Major complications occurred in 1% of cases, with no significant differences between modalities. Shorter procedural times resulted in lower staffing and laboratory costs with PFA, but these savings were offset by substantially higher equipment costs, resulting in higher overall median costs with PFA (£10,010) than with CB (£8106) and RF (£8949) (P < .001). CONCLUSION In this contemporary real-world study of the 3 major AF ablation modalities used concurrently, PFA had shorter skin-to-skin and catheter laboratory times than did CB and RF, with similarly low rates of complications. However, PFA procedures were considerably more expensive, largely because of higher equipment cost.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Mark T Mills
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Panagiotis Xydis
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Ioanna Koniari
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Jose Maria Farinha
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Mike Harding
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Saagar Mahida
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Richard Snowdon
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Johan Waktare
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Zoltan Borbas
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Simon Modi
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Derick Todd
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Reza Ashrafi
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Vishal Luther
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom.
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8
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Anter E, Mansour M, Nair DG, Sharma D, Taigen TL, Neuzil P, Kiehl EL, Kautzner J, Osorio J, Mountantonakis S, Natale A, Hummel JD, Amin AK, Siddiqui UR, Harlev D, Hultz P, Liu S, Onal B, Tarakji KG, Reddy VY. Dual-energy lattice-tip ablation system for persistent atrial fibrillation: a randomized trial. Nat Med 2024:10.1038/s41591-024-03022-6. [PMID: 38760584 DOI: 10.1038/s41591-024-03022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/26/2024] [Indexed: 05/19/2024]
Abstract
Clinical outcomes of catheter ablation for atrial fibrillation (AF) are suboptimal due, in part, to challenges in achieving durable lesions. Although focal point-by-point ablation allows for the creation of any required lesion set, this strategy necessitates the generation of contiguous lesions without gaps. A large-tip catheter, capable of creating wide-footprint ablation lesions, may increase ablation effectiveness and efficiency. In a randomized, single-blind, non-inferiority trial, 420 patients with persistent AF underwent ablation using a large-tip catheter with dual pulsed field and radiofrequency energies versus ablation using a conventional radiofrequency ablation system. The primary composite effectiveness endpoint was evaluated through 1 year and included freedom from acute procedural failure and repeat ablation at any time, plus arrhythmia recurrence, drug initiation or escalation or cardioversion after a 3-month blanking period. The primary safety endpoint was freedom from a composite of serious procedure-related or device-related adverse events. The primary effectiveness endpoint was observed for 73.8% and 65.8% of patients in the investigational and control arms, respectively (P < 0.0001 for non-inferiority). Major procedural or device-related complications occurred in three patients in the investigational arm and in two patients in the control arm (P < 0.0001 for non-inferiority). In a secondary analysis, procedural times were shorter in the investigational arm as compared to the control arm (P < 0.0001). These results demonstrate non-inferior safety and effectiveness of the dual-energy catheter for the treatment of persistent AF. Future large-scale studies are needed to gather real-world evidence on the impact of the focal dual-energy lattice catheter on the broader population of patients with AF. ClinicalTrials.gov identifier: NCT05120193 .
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Affiliation(s)
- Elad Anter
- Shamir Medical Center, Be'er Ya'Akov, Israel.
| | | | - Devi G Nair
- St. Bernards Medical Center & Arrhythmia Research Group, Jonesboro, AR, USA
| | | | | | | | | | | | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, TX, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - John D Hummel
- Division of Cardiology, Ohio State University, Columbus, OH, USA
| | - Anish K Amin
- Riverside Methodist Hospital, Upper Arlington, OH, USA
| | | | | | | | | | | | | | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, NY, USA
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9
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Duytschaever M, Račkauskas G, De Potter T, Hansen J, Knecht S, Phlips T, Vijgen J, Scherr D, Szeplaki G, Van Herendael H, Kronborg MB, Berte B, Pürerfellner H, Lukac P. Dual energy for pulmonary vein isolation using dual-energy focal ablation technology integrated with a three-dimensional mapping system: SmartfIRE 3-month results. Europace 2024; 26:euae088. [PMID: 38696675 PMCID: PMC11065353 DOI: 10.1093/europace/euae088] [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: 02/28/2024] [Accepted: 04/03/2024] [Indexed: 05/04/2024] Open
Abstract
AIMS Contact force (CF)-sensing radiofrequency (RF) catheters with an ablation index have shown reproducible outcomes for the treatment of atrial fibrillation (AF) in large multicentre studies. A dual-energy (DE) focal CF catheter to deliver RF and unipolar/biphasic pulsed field ablation (PFA), integrated with a three-dimensional (3D) mapping system, can provide operators with additional flexibility. The SmartfIRE study assessed the safety and efficacy of this novel technology for the treatment of drug-refractory, symptomatic paroxysmal AF. Results at 3 months post-ablation are presented here. METHODS AND RESULTS Pulmonary vein isolation (PVI) was performed using a DE focal, irrigated CF-sensing catheter with the recommendation of PFA at posterior/inferior and RF ablation at the anterior/ridge/carina segments. Irrespective of energy, a tag size of 3 mm; an inter-tag distance ≤6 mm; a target index of 550 for anterior, roof, ridge, and carina; and a target index of 400 for posterior and inferior were recommended. Cavotricuspid isthmus ablation was permitted in patients with documented typical atrial flutter. The primary effectiveness endpoint was acute procedural success. The primary safety endpoint was the rate of primary adverse events (PAEs) within 7 days of the procedure. A prespecified patient subset underwent oesophageal endoscopy (EE; 72 h post-procedure), neurological assessment (NA; pre-procedure and discharge), and cardiac computed tomography (CT)/magnetic resonance angiogram (MRA) imaging (pre-procedure and 3 months post-procedure) for additional safety evaluation, and a mandatory remapping procedure (Day 75 ± 15) for PVI durability assessment. Of 149 patients enrolled between February and June 2023, 140 had the study catheter inserted (safety analysis set) and 137 had ablation energy delivered (per-protocol analysis set). The median (Q1/Q3) total procedure and fluoroscopy times were 108.0 (91.0/126.0) and 4.2 (2.3/7.7) min (n = 137). The acute procedural success rate was 100%. First-pass isolation was achieved in 89.1% of patients and 96.8% of veins. Cavotricuspid isthmus ablations were successfully performed in 12 patients [pulsed field (PF) only: 6, RF only: 5, and RF/PF: 1]. The PAE rate was 4.4% [6/137 patients; 2 pulmonary vein (PV) stenoses, 2 cardiac tamponades/perforations, 1 stroke, and 1 pericarditis]. No coronary artery spasm was reported. No oesophageal lesion was seen in the EE subset (0/31, 0%). In the NA subset (n = 30), microemboli lesions were identified in 2 patients (2/30, 6.7%), both of which were resolved at follow-up; only 1 was symptomatic (silent cerebral lesion, 3.3%). In the CT/MRA subset (n = 30), severe PV narrowing (of >70%) was detected in 2 patients (2/30, 6.7%; vein level 2/128, 1.6%), of whom 1 underwent dilatation and stenting and 1 was asymptomatic; both were associated with high index values and a small inter-tag distance. In the PV durability subset (n = 30), 100/115 treated PVs (87%) were durably isolated and 18/30 patients (60.0%) had all PVs durably isolated. CONCLUSION A DE focal CF catheter with 3D mapping integration showed a 100% acute success rate with an acceptable safety profile in the treatment of paroxysmal AF. Prespecified 3-month remapping showed notable PVI durability. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05752487.
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Affiliation(s)
| | - Gediminas Račkauskas
- Vilnius University Hospital, Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | | | - Jim Hansen
- Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | | | | | | | | | - Gabor Szeplaki
- Heart and Vascular Centre, Mater Private Hospital, Dublin, Ireland
- Cardiovascular Research Institute, Royal College of Surgeons, Dublin, Ireland
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10
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Anic A. Top stories on pulsed field ablation (2024). Heart Rhythm 2024; 21:705-706. [PMID: 38692817 DOI: 10.1016/j.hrthm.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Ante Anic
- Department of Cardiology and Vascular Diseases, University Hospital Center Split, Split, Croatia.
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11
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Estevez-Laborí F, O'Brien B, González-Suárez A. Difference between endocardial and epicardial application of pulsed fields for targeting Epicardial Ganglia: An in-silico modelling study. Comput Biol Med 2024; 174:108490. [PMID: 38642490 DOI: 10.1016/j.compbiomed.2024.108490] [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: 11/29/2023] [Revised: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Pulsed Field Ablation (PFA) has recently been proposed as a non-thermal energy to treat atrial fibrillation by selective ablation of ganglionated plexi (GP) embedded in epicardial fat. While some of PFA-technologies use an endocardial approach, others use epicardial access with promising pre-clinical results. However, as each technology uses a different and sometimes proprietary pulse application protocol, the comparation between endocardial vs. epicardial approach is almost impossible in experimental terms. For this reason, our study, based on a computational model, allows a direct comparison of electric field distribution and thermal-side effects of both approaches under equal conditions in terms of electrode design, pulse protocol and anatomical characteristics of the tissues involved. METHODS 2D computational models with axial symmetry were built for endocardial and epicardial approaches. Atrial (1.5-2.5 mm) and fat (1-5 mm) thicknesses were varied to simulate a representative sample of what happens during PFA ablation for different applied voltage values (1000, 1500 and 2000 V) and number of pulses (30 and 50). RESULTS The epicardial approach was superior for capturing greater volumes of fat when the applied voltage was increased: 231 mm3/kV with the epicardial approach vs. 182 mm3/kV with the endocardial approach. In relation to collateral damage to the myocardium, the epicardial approach considerably spares the myocardium, unlike what happens with the endocardial approach. Although the epicardial approach caused much more thermal damage in the fat, there is not a significant difference between the approaches in terms of size of thermal damage in the myocardium. CONCLUSIONS Our results suggest that epicardial PFA ablation of GPs is more effective than an endocardial approach. The proximity and directionality of the electric field deposited using an epicardial approach are key to ensuring that higher electric field strengths and increased temperatures are obtained within the epicardial fat, thus contributing to selective ablation of the GPs with minimal myocardial damage.
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Affiliation(s)
| | | | - Ana González-Suárez
- Translational Medical Device Lab, School of Medicine, University of Galway, Ireland; IBIO, Escuela Superior de Ingeniería, Ciencia y Tecnología, Universidad Internacional de Valencia, Valencia, Spain.
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12
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De Potter T, Grimaldi M, Duytschaever M, Anic A, Vijgen J, Neuzil P, Van Herendael H, Verma A, Skanes A, Scherr D, Pürerfellner H, Rackauskas G, Jais P, Reddy VY. Predictors of Success for Pulmonary Vein Isolation With Pulsed-field Ablation Using a Variable-loop Catheter With 3D Mapping Integration: Complete 12-month Outcomes From inspIRE. Circ Arrhythm Electrophysiol 2024; 17:e012667. [PMID: 38655693 PMCID: PMC11111320 DOI: 10.1161/circep.123.012667] [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: 12/01/2023] [Accepted: 02/12/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND We previously presented the safety and early efficacy of the inspIRE study (Study for Treatment of Paroxysmal Atrial Fibrillation [PAF] by Pulsed-field Ablation [PFA] System With Irreversible Electroporation [IRE]). With the study's conclusion, we report the outcomes of the full pivotal study cohort, with an additional analysis of predictors of success. METHODS InspIRE was a prospective, multicenter, single-arm clinical trial of drug-refractory paroxysmal atrial fibrillation. Pulmonary vein isolation was performed with a variable-loop circular catheter integrated with a 3-dimensional mapping system. Follow-up with 24-hour Holter was at 3, 6, and 12 months, as well as remote rhythm monitoring: weekly from 3 to 5 months, monthly from 6 to 12 months, and for symptoms. The primary effectiveness end point (PEE) was acute pulmonary vein isolation plus freedom from any atrial arrhythmia at 12 months. Additional subanalyses report predictors of PEE success. RESULTS The patient cohort included 186 patients: aged 59±10 years, female 30%, and CHA2DS2-VASc 1.3±1.2. The previously reported primary adverse event rate was 0%. One serious procedure-related adverse event, urinary retention, was reported. The PEE was achieved in 75.6% (95% CI, 69.5%-81.8%). The clinical success of freedom from symptomatic recurrence was 81.7% (95% CI, 76.1%-87.2%). Simulating a monitoring method used in standard real-world practice (without protocol-driven remote rhythm monitoring), this translates to a freedom from all and symptomatic recurrence of 85.8% (95% CI, 80.8%-90.9%) or 94.0% (95% CI, 90.6%-97.5%), respectively. Multivariate analyses revealed that left ventricular ejection fraction ≥60% (adjusted odds ratio, 0.30) and patients receiving ≥48 PFA applications (adjusted odds ratio, 0.28) were independent predictors of PEE success. Moreover, PEE success was 79.2% in patients who received ≥12 PFA applications per vein compared with 57.1% in patients receiving fewer PFA applications. CONCLUSIONS The inspIRE study confirms the safety and effectiveness of pulmonary vein isolation using the novel 3-dimensional mapping integrated circular loop catheter. An optimal number of PFA applications (≥48 total or ≥12 per vein) resulted in an improved 1-year success rate of ≈80%. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04524364.
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Affiliation(s)
- Tom De Potter
- OLV Hospital, Dienst Cardiologie, Aalst, Belgium (T.D.P.)
| | - Massimo Grimaldi
- Ospedale Generale Regionale “F. Miulli” UOC Cardiologia, Bari, Italy (M.G.)
| | | | - Ante Anic
- University Hospital Center Split, Split, Croatia (A.A.)
| | | | - Petr Neuzil
- Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic (P.N.)
| | | | - Atul Verma
- McGill University Health Center, Montréal, Canada (A.V.)
| | - Allan Skanes
- University of Western Ontario, London, Canada (A.S.)
| | | | | | - Gediminas Rackauskas
- Centre for Cardiology & Angiology, Department of Cardiovascular Diseases, Vilnius University, Lithuania (G.R.)
| | - Pierre Jais
- IHU LIRYC ANR-10-IAHU-04, Centre Hospitalier Universitaire Bordeaux, Bordeaux University, Bordeaux, France (P.J.)
| | - Vivek Y. Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, NY; Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic (V.Y.R.)
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13
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O’Neill L, De Becker B, De Smet M, Francois C, Tavernier R, Duytschaever M, Le Polain De Waroux JB, Knecht S. Vein of Marshall Ethanol Infusion for AF Ablation; A Review. J Clin Med 2024; 13:2438. [PMID: 38673710 PMCID: PMC11050818 DOI: 10.3390/jcm13082438] [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: 02/28/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
The outcomes of persistent atrial fibrillation (AF) ablation are modest with various adjunctive strategies beyond pulmonary vein isolation (PVI) yielding largely disappointing results in randomised controlled trials. Linear ablation is a commonly employed adjunct strategy but is limited by difficulty in achieving durable bidirectional block, particularly at the mitral isthmus. Epicardial connections play a role in AF initiation and perpetuation. The ligament of Marshall has been implicated as a source of AF triggers and is known to harbour sympathetic and parasympathetic nerve fibres that contribute to AF perpetuation. Ethanol infusion into the Vein of Marshall, a remnant of the superior vena cava and key component of the ligament of Marshall, may eliminate these AF triggers and can facilitate the ease of obtaining durable mitral isthmus block. While early trials have demonstrated the potential of Vein of Marshall 'ethanolisation' to reduce arrhythmia recurrence after persistent AF ablation, further randomised trials are needed to fully determine the potential long-term outcome benefits afforded by this technique.
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Affiliation(s)
- Louisa O’Neill
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
- Department of Cardiology, Blackrock Clinic, A94 E4X7 Dublin, Ireland
- King’s College London, St. Thomas’ Hospital, London SE1 9NH, UK
| | - Benjamin De Becker
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | - Maarten De Smet
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | - Clara Francois
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | - Rene Tavernier
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | - Mattias Duytschaever
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | | | - Sebastien Knecht
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
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14
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01771-5. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [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] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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15
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Kueffer T, Stettler R, Maurhofer J, Madaffari A, Stefanova A, Iqbal SUR, Thalmann G, Kozhuharov NA, Galuszka O, Servatius H, Haeberlin A, Noti F, Tanner H, Roten L, Reichlin T. Pulsed-field vs cryoballoon vs radiofrequency ablation: Outcomes after pulmonary vein isolation in patients with persistent atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)02372-5. [PMID: 38614191 DOI: 10.1016/j.hrthm.2024.04.045] [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: 01/18/2024] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Pulsed-field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI), with similar long-term outcomes compared to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in patients with paroxysmal atrial fibrillation (AF). OBJECTIVE The purpose of this study was to compare the procedural and long-term outcomes in patients with persistent AF undergoing PVI using PFA, CBA, or RFA. METHODS Consecutive patients with persistent AF undergoing first PVI with PFA, CBA, or RFA were included. Patients underwent 7-day Holter electrocardiography at 3, 6, and 12 months postablation. The primary outcome was recurrence of any atrial arrhythmia after a 90-day blanking period. Safety outcomes included the composite of in-hospital major adverse events. RESULTS A total of 533 patients with persistent AF underwent PVI using PFA (n = 214, 39%), CBA (n = 190, 36%), or RFA (n = 129, 24%). Procedures with PFA guided by fluoroscopy were shorter than those with CBA (median 60 minutes; interquartile range [IQR] 53-80 minutes vs 84 minutes; IQR 68-101 minutes; P ≤ .001), and procedures with PFA in combination with 3-dimensional electroanatomic mapping were shorter than those with RFA (median 101 minutes; IQR 85-126 minutes vs 171 minutes; IQR 141-204 minutes; P < .001). Acute safety events occurred in 2.3%, 2.6%, and 0.8% in the PFA, CBA, and RFA groups, respectively (P = .545). The 1-year confounder-adjusted estimate for freedom from atrial arrhythmias was 62.1% for CBA, 55.3% for PFA, and 48.3% for RFA (CBA vs PFA: P = .79; CBA vs RFA: P = .009; PFA vs RFA: P = .010). CONCLUSION In patients with persistent AF undergoing first PVI, 1-year confounder-adjusted outcomes are better with PFA and CBA than with RFA.
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Affiliation(s)
- Thomas Kueffer
- 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
| | - Robin Stettler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jens Maurhofer
- 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
| | - Anita Stefanova
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salik Ur Rehman Iqbal
- 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 A 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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16
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [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: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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17
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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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18
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Metzner A, Rottner L, Moser F, My I, Lemoine M, Wenzel JP, Obergassel J, Ismaili D, Schäfer S, Kirchhof P, Ouyang F, Reissmann B, Rillig A. A novel platform allowing for pulsed field and radiofrequency ablation: First commercial atrial fibrillation ablation procedures worldwide with and without general anesthesia. Heart Rhythm 2024; 21:497-498. [PMID: 38215807 DOI: 10.1016/j.hrthm.2024.01.006] [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: 11/14/2023] [Revised: 01/02/2024] [Accepted: 01/06/2024] [Indexed: 01/14/2024]
Affiliation(s)
- Andreas Metzner
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany.
| | - Laura Rottner
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Fabian Moser
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Ilaria My
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Marc Lemoine
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Jan Per Wenzel
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Julius Obergassel
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Djemail Ismaili
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Sarina Schäfer
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Paulus Kirchhof
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Feifan Ouyang
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Bruno Reissmann
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
| | - Andreas Rillig
- University Heart and Vascular Center Hamburg-Eppendorf, Eppendorf, Germany
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19
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Reddy VY, Anter E, Peichl P, Rackauskas G, Petru J, Funasako M, Koruth JS, Marinskis G, Turagam M, Aidietis A, Kautzner J, Natale A, Neuzil P. First-in-human clinical series of a novel conformable large-lattice pulsed field ablation catheter for pulmonary vein isolation. Europace 2024; 26:euae090. [PMID: 38584468 PMCID: PMC11057205 DOI: 10.1093/europace/euae090] [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: 03/26/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024] Open
Abstract
AIMS Pulsed field ablation (PFA) has significant advantages over conventional thermal ablation of atrial fibrillation (AF). This first-in-human, single-arm trial to treat paroxysmal AF (PAF) assessed the efficiency, safety, pulmonary vein isolation (PVI) durability and one-year clinical effectiveness of an 8 Fr, large-lattice, conformable single-shot PFA catheter together with a dedicated electroanatomical mapping system. METHODS AND RESULTS After rendering the PV anatomy, the PFA catheter delivered monopolar, biphasic pulse trains (5-6 s per application; ∼4 applications per PV). Three waveforms were tested: PULSE1, PULSE2, and PULSE3. Follow-up included ECGs, Holters at 6 and 12 months, and symptomatic and scheduled transtelephonic monitoring. The primary and secondary efficacy endpoints were acute PVI and post-blanking atrial arrhythmia recurrence, respectively. Invasive remapping was conducted ∼75 days post-ablation. At three centres, PVI was performed by five operators in 85 patients using PULSE1 (n = 30), PULSE2 (n = 20), and PULSE3 (n = 35). Acute PVI was achieved in 100% of PVs using 3.9 ± 1.4 PFA applications per PV. Overall procedure, transpired ablation, PFA catheter dwell and fluoroscopy times were 56.5 ± 21.6, 10.0 ± 6.0, 19.1 ± 9.3, and 5.7 ± 3.9 min, respectively. No pre-defined primary safety events occurred. Upon remapping, PVI durability was 90% and 99% on a per-vein basis for the total and PULSE3 cohort, respectively. The Kaplan-Meier estimate of one-year freedom from atrial arrhythmias was 81.8% (95% CI 70.2-89.2%) for the total, and 100% (95% CI 80.6-100%) for the PULSE3 cohort. CONCLUSION Pulmonary vein isolation (PVI) utilizing a conformable single-shot PFA catheter to treat PAF was efficient, safe, and effective, with durable lesions demonstrated upon remapping.
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Affiliation(s)
- Vivek Y Reddy
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1030, New York, NY, USA
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Elad Anter
- Division of Cardiovascular Medicine, Shamir Medical Center, Be'er Yaakov, Tel Aviv, Israel
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | | | - Jan Petru
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | | | - Jacob S Koruth
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1030, New York, NY, USA
| | | | - Mohit Turagam
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1030, New York, NY, USA
| | - Audrius Aidietis
- Department of Cardiology, Vilnius University, Vilnius, Lithuania
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
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20
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Gunawardene MA, Harloff T, Jularic M, Dickow J, Wahedi R, Anwar O, Wohlmuth P, Gessler N, Hartmann J, Willems S. Contemporary catheter ablation of complex atrial tachycardias after prior atrial fibrillation ablation: pulsed field vs. radiofrequency current energy ablation guided by high-density mapping. Europace 2024; 26:euae072. [PMID: 38513110 PMCID: PMC11034699 DOI: 10.1093/europace/euae072] [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: 01/20/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024] Open
Abstract
AIMS Catheter ablation (CA) of post-ablation left atrial tachycardias (LATs) can be challenging. So far, pulsed field ablation (PFA) has not been compared to standard point-by-point radiofrequency current (RFC) energy for LAT ablation. To compare efficacy of PFA vs. RFC in patients undergoing CA for LAT. METHODS AND RESULTS Consecutive patients undergoing LAT-CA were prospectively enrolled (09/2021-02/2023). After electro-anatomical high-density mapping, ablation with either a pentaspline PFA catheter or RFC was performed. Patients were matched 1:1. Ablation was performed at the assumed critical isthmus site with additional ablation, if necessary. Right atrial tachycardia (RAT) was ablated with RFC. Acute and chronic success were assessed. Fifty-six patients (n = 28 each group, age 70 ± 9 years, 75% male) were enrolled.A total of 77 AT (n = 67 LAT, n = 10 RAT; 77% macroreentries) occurred with n = 32 LAT in the PFA group and n = 35 LAT in the RFC group. Of all LAT, 94% (PFA group) vs. 91% (RFC group) successfully terminated to sinus rhythm or another AT during ablation (P = 1.0). Procedure times were shorter (PFA: 121 ± 41 vs. RFC: 190 ± 44 min, P < 0.0001) and fluoroscopy times longer in the PFA group (PFA: 15 ± 9 vs. RFC: 11 ± 6 min, P = 0.04). There were no major complications. After one-year follow-up, estimated arrhythmia free survival was 63% (PFA group) and 87% (RFC group), [hazard ratio 2.91 (95% CI: 1.11-7.65), P = 0.0473]. CONCLUSION Pulsed field ablation of post-ablation LAT using a pentaspline catheter is feasible, safe, and faster but less effective compared to standard RFC ablation after one year of follow-up. Future catheter designs and optimization of the electrical field may further improve practicability and efficacy of PFA for LAT.
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Affiliation(s)
- Melanie A Gunawardene
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Tim Harloff
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Mario Jularic
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Jannis Dickow
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Rahin Wahedi
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Omar Anwar
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Peter Wohlmuth
- Asklepios Proresearch Research Insitute, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
| | - Nele Gessler
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
- Asklepios Proresearch Research Insitute, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
| | - Jens Hartmann
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Stephan Willems
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
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21
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Chollet L, Iqbal SUR, Wittmer S, Thalmann G, Madaffari A, Kozhuharov N, Galuszka O, Küffer T, Gräni C, Brugger N, Servatius H, Noti F, Haeberlin A, Roten L, Tanner H, Reichlin T. Impact of atrial fibrillation phenotype and left atrial volume on outcome after pulmonary vein isolation. Europace 2024; 26:euae071. [PMID: 38597211 PMCID: PMC11004789 DOI: 10.1093/europace/euae071] [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: 01/10/2024] [Accepted: 03/12/2024] [Indexed: 04/11/2024] Open
Abstract
AIMS Pulmonary vein isolation (PVI) is increasingly performed in patients with atrial fibrillation (AF). Both AF phenotype and left atrial (LA) volume have been shown to influence ablation outcome. The inter-relationship of the two is incompletely understood. We aimed to investigate the impact of AF phenotype vs. LA volume on outcome after PVI. METHODS AND RESULTS In a retrospective analysis of a prospective registry of patients undergoing a first PVI, the association of AF phenotype and LA volume index (LAVI) was assessed as well as their impact on AF recurrence during follow-up. Overall, 476 patients were enrolled (median age 63 years, 29% females, 65.8% paroxysmal AF). Obesity, hypertension, chronic kidney disease, and heart failure were all significantly more frequent in persistent AF. After 1 year, single-procedure, freedom from arrhythmia recurrence was 61.5%. Patients with paroxysmal AF had better outcomes compared with patients with persistent AF (65.6 vs. 52.7%, P = 0.003), as had patients with no/mild vs. moderate/severe LA dilation (LAVI <42 mL/m2 67.1% vs. LAVI ≥42 mL/m2 53%, P < 0.001). The combination of both parameters refined prediction of 1-year recurrence (P < 0.001). After adjustment for additional clinical risk factors in multivariable Cox proportional hazard analysis, both AF phenotype and LAVI ≥42 mL/m2 contributed significantly towards the prediction of 1-year recurrence. CONCLUSION Atrial fibrillation phenotype and LA volume are independent predictors of outcome after PVI. Persistent AF with no/mild LA dilation has a similar risk of recurrence as paroxysmal AF with a moderate/severe LA dilation and should be given similar priority for ablation.
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Affiliation(s)
- Laurève Chollet
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Salik ur Rehman Iqbal
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Severin Wittmer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Gregor Thalmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Antonio Madaffari
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Nikola Kozhuharov
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Oskar Galuszka
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Thomas Küffer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
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22
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [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: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Brešković T, Lisica L, Jurišić Z, Petrović D, Sikirić I, Metličić V, Anić A. Ablation of accessory pathways in different anatomic locations using focal pulsed field ablation. Heart Rhythm 2024:S1547-5271(24)00275-3. [PMID: 38499129 DOI: 10.1016/j.hrthm.2024.03.030] [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: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Ablation of accessory pathways (APs) is the cornerstone for treatment of patients with Wolff-Parkinson-White syndrome and manifestation of atrioventricular reentrant tachycardia. Pulsed field ablation (PFA) is a new type of nonthermal energy source delivered to the underlying tissue via the ablation catheter and used for ablation of arrhythmic substrates. OBJECTIVE The purpose of this study was to determine the efficiency and long-term outcome of ablation of APs of different localizations using a focal pulsed electrical field. METHODS Electrophysiological study was performed in patients with indication for AP ablation. An ablation catheter was used to map the position of AP insertion. Pulsed electric field was delivered through a standard ablation catheter. In left-sided APs, the first ablation attempt was within the coronary sinus (CS). Patient follow-up was scheduled 1-3 months after the ablation. Additional check-up was performed after 6 and 12 months. RESULTS Fourteen 14 patients (3 pediatric) were treated. Termination of AP conduction was achieved in all procedures. The cohort consisted of 3 right free wall, 3 posteroseptal, and 8 left-sided APs. Ablation through CS was successfully used in 7 of 8 patients with left-sided APs. No complications were reported. Median follow-up was 5.5 months. Conduction recurrence through AP was documented in 1 patient. CONCLUSION Focal PFA for AP shows promising results in terms of efficacy and safety. A high rate of successful termination of left-sided APs by ablation within CS may represent a new standard approach. The safety and efficacy profile of PFA seems to be transferable to the pediatric population.
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Affiliation(s)
- Toni Brešković
- Department of Cardiology, University Hospital Center Split, Split, Croatia.
| | - Lucija Lisica
- Department of Cardiology, University Hospital Center Split, Split, Croatia
| | - Zrinka Jurišić
- Department of Cardiology, University Hospital Center Split, Split, Croatia
| | - Davor Petrović
- Division of Cardiology, Department of Pediatrics, University Hospital Center Split, Split, Croatia
| | - Ivan Sikirić
- Department of Cardiology, University Hospital Center Split, Split, Croatia
| | - Vitomir Metličić
- Division of Cardiology, Department of Pediatrics, University Hospital Center Split, Split, Croatia
| | - Ante Anić
- Department of Cardiology, University Hospital Center Split, Split, Croatia
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24
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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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25
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Peng W, Polajžer T, Yao C, Miklavčič D. Dynamics of Cell Death Due to Electroporation Using Different Pulse Parameters as Revealed by Different Viability Assays. Ann Biomed Eng 2024; 52:22-35. [PMID: 37704904 PMCID: PMC10761553 DOI: 10.1007/s10439-023-03309-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/02/2023] [Indexed: 09/15/2023]
Abstract
The mechanisms of cell death due to electroporation are still not well understood. Recent studies suggest that cell death due to electroporation is not an immediate all-or-nothing response but rather a dynamic process that occurs over a prolonged period of time. To investigate whether the dynamics of cell death depends on the pulse parameters or cell lines, we exposed different cell lines to different pulses [monopolar millisecond, microsecond, nanosecond, and high-frequency bipolar (HFIRE)] and then assessed viability at different times using different viability assays. The dynamics of cell death was observed by changes in metabolic activity and membrane integrity. In addition, regardless of pulse or cell line, the dynamics of cell death was observed only at high electroporation intensities, i.e., high pulse amplitudes and/or pulse number. Considering the dynamics of cell death, the clonogenic assay should remain the preferred viability assay for assessing viability after electroporation.
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Affiliation(s)
- Wencheng Peng
- The State Key Laboratory of Power Transmission Equipment and System Security and New Technology, School of Electrical Engineering, Chongqing University, Chongqing, 400044, China
| | - Tamara Polajžer
- Faculty of Electrical Engineering, University of Ljubljana, Tržaška 25, 1000, Ljubljana, Slovenia
| | - Chenguo Yao
- The State Key Laboratory of Power Transmission Equipment and System Security and New Technology, School of Electrical Engineering, Chongqing University, Chongqing, 400044, China
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, University of Ljubljana, Tržaška 25, 1000, Ljubljana, Slovenia.
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26
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Aryana A, Hata C, de la Rama A, Nguyen K, Panescu D. A novel pulsed field ablation system using linear and spiral ablation catheters can create large and durable endocardial and epicardial ventricular lesions in vivo. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01714-6. [PMID: 38157151 DOI: 10.1007/s10840-023-01714-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/26/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND We investigated the preclinical safety and efficacy of ventricular pulsed field ablation (PFA) using a family of novel, 6-/8-Fr, linear, and spiral PFA/mapping catheters (CRC EP, Inc). METHODS QRS-gated, bipolar PFA (>2.0 kV) was performed in 10 healthy swine. Altogether, 20 endocardial and epicardial right and left ventricular applications were delivered. The catheters were inserted through an 8.5-Fr steerable introducer. The intensity of skeletal muscle activation was quantified using an accelerometer. Lesions were assessed by pre- versus post-PFA electrogram analysis, pacing threshold, 3D voltage mapping, necropsy, and histology. The swine rete mirabile, liver and kidneys were examined for embolic events. RESULTS All applications were single-shot (56 ± 18 s) without catheter repositioning. Minimal microbubbling was observed without significant skeletal muscle stimulation (mean acceleration 0.05 m/s2) or ventricular tachyarrhythmias. There was significant reduction in post- versus pre-PFA electrogram amplitude (0.5 ± 0.2 mV versus 3.2 ± 0.9 mV, P < 0.001) with a marked increase in pacing threshold (>20 mA versus 7.5 ± 2.9 mA, P < 0.001). All lesions were large and durable up to 28 days, measuring 32 ± 5 mm (length), 27 ± 8 mm (width), and 8 ± 3 mm (depth) using the spiral catheters and 43 ± 1 mm (length), 7 ± 1 mm (width), and 8 ± 1 mm (depth) using the linear catheters. Despite higher waveform voltages and prolonged applications, no thermal effects were detected at necropsy/histology. Moreover, gross and microscopic examinations revealed no evidence of thromboembolism, vascular or collateral injury. CONCLUSIONS A novel, QRS-gated PFA system using linear and spiral PFA catheters is capable of creating large and durable ventricular lesions in vivo without significant microbubbling, ventricular arrhythmias or thromboembolism.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, 3941 J Street, Suite #350, Sacramento, CA, 95819, USA.
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27
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Rottner L, Metzner A. Atrial Fibrillation Ablation: Current Practice and Future Perspectives. J Clin Med 2023; 12:7556. [PMID: 38137626 PMCID: PMC10743921 DOI: 10.3390/jcm12247556] [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: 11/14/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Catheter ablation to perform pulmonary vein isolation (PVI) is established as a mainstay in rhythm control of atrial fibrillation (AF). The aim of this review is to provide an overview of current practice and future perspectives in AF ablation. The main clinical benefit of AF ablation is the reduction of arrhythmia-related symptoms and improvement of quality of life. Catheter ablation of AF is recommended, in general, as a second-line therapy for patients with symptomatic paroxysmal or persistent AF, who have failed or are intolerant to pharmacological therapy. In selected patients with heart failure and reduced left-ventricular fraction, catheter ablation was proven to reduce all-cause mortality. Also, optimal management of comorbidities can reduce AF recurrence after AF ablation; therefore, multimodal risk assessment and therapy are mandatory. To date, the primary ablation tool in widespread use is still single-tip catheter radiofrequency (RF) based ablation. Additionally, balloon-based pulmonary vein isolation (PVI) has gained prominence, especially due to its user-friendly nature and established safety and efficacy profile. So far, the cryoballoon (CB) is the most studied single-shot device. CB-based PVI is characterized by high efficiency, convincing success rates, and a beneficial safety profile. Recently, CB-PVI as a first-line therapy for AF was shown to be superior to pharmacological treatment in terms of efficacy and was shown to reduce progression from paroxysmal to persistent AF. In this context, CB-based PVI gains more and more importance as a first-line treatment choice. Non-thermal energy sources, namely pulsed-field ablation (PFA), have garnered attention due to their cardioselectivity. Although initially applied via a basket-like ablation tool, recent developments allow for point-by-point ablation, particularly with the advent of a novel lattice tip catheter.
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Affiliation(s)
- Laura Rottner
- University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Andreas Metzner
- University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, 20251 Hamburg, Germany
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28
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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: 109] [Impact Index Per Article: 109.0] [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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Schipper JH, Steven D, Lüker J, Wörmann J, van den Bruck JH, Filipovic K, Dittrich S, Scheurlen C, Erlhöfer S, Pavel F, Sultan A. Comparison of pulsed field ablation and cryoballoon ablation for pulmonary vein isolation. J Cardiovasc Electrophysiol 2023; 34:2019-2026. [PMID: 37682001 DOI: 10.1111/jce.16056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/18/2023] [Accepted: 08/28/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Pulmonary vein isolation (PVI) remains the cornerstone in the treatment of atrial fibrillation (AF). PVI using cryoballoon (CB) technology has emerged as a standard procedure in many centers. Recently, pulsed field ablation (PFA) has been introduced and used to achieve PVI. First data show high acute and favorable long-term outcomes. So far, data comparing these new "single shot" devices are sparse. We sought to compare procedural and outcome data for first time PFA users versus CB in patients undergoing de novo PVI. Furthermore, potentially postprocedural discomfort and affection of autonomic ganglia were assessed. METHODS AND RESULTS A retrospective analysis and comparison of all de novo PVIs with PFA and CB was performed. Furthermore, PFA PVI learning curve was evaluated. During follow-up, repeat outpatient visits and Holter electrocardiogram were performed to analyze arrhythmia-free survival. Discomfort analysis was obtained by prescribed analgesic medication within first 48 h after PVI. Potential changes in heart rate (HR) between baseline and at 3-month follow-up were evaluated. A total of 108 patients (54 PFA and 54 CB; PFA; 33 (30%) female) with paroxysmal and persistent AF were analyzed. Type of AF was comparable (Patients suffering from PAF: PFA: 16 (30%), CB: 17 (31%), p = 1.0). In 107 (99%) patients, successful PVI was achieved. Transient phrenic palsy omitted complete PVI in one CB patient. A trend for a shorter overall procedure duration was observed in the PFA group (PFA: 64.5 ± 17.5 min; CB: 73.0 ± 24.8 min; p = 0.07). Excluding LA mapping time (first 14 cases), procedure time was significantly shorter using PFA (PFA: 58.0 ± 12.5 min, CB: 73.0 ± 24.8 min, p = 0.0001). Fluoroscopy time was significantly longer for PFA (PFA: 15.3 ± 4.7 min, CB: 12.3 ± 5.3 min; p = 0.001), but significantly less contrast medium was used (PFA: 12 ± 6 mL; CB: 51 ± 29 mL, p < 0.0001). Subgroup analysis of the PFA group revealed a significant shortening of procedure duration over time (first tertile: 72.7 ± 13.5 min, second tertile: 67.3 ± 21.7 min, third tertile: 53.4 ± 9.8 min, first vs. third tertile p < 0.0001). Two cardiac tamponades occurred in the PFA group (p = 0.495), of which one was most likely related to complex transseptal puncture. In the first 48 h after PVI, the number of prescribed analgesics due to postprocedural pain was equal between both groups (PFA: 7 (13%) patients, CB: 10 (19%) patients, p = 0.598). After a FU of 273 ± 129 days, 35 of 47 patients (74%) after PFA and 36 of 50 patients (72%) after CB PVI were free of any atrial arrhythmia (HR: 0.98, p = 0.88). Only in the PFA group, a significant increase in HR 3 months after PVI was observed (pre-PVI: 61 ± 8 beats/min, post-PVI: 65 ± 9 beats/min, p = 0.008). CONCLUSION The new PFA technology is equally effective and safe as compared to CB for complete PVI with potentially shorter procedure time and significantly less contrast medium. However, AF recurrence rates after PFA PVI seem to be comparable to CB PVI.
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Affiliation(s)
- Jan-Hendrik Schipper
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | - Daniel Steven
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | - Jakob Lüker
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | - Jonas Wörmann
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | | | - Karlo Filipovic
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | - Sebastian Dittrich
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | - Cornelia Scheurlen
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | - Susanne Erlhöfer
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | - Friederike Pavel
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
| | - Arian Sultan
- Department of Electrophysiology, Heart Center, University of Cologne, Köln, Germany
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Affiliation(s)
- Jacob S Koruth
- Helmsely Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Iwanari Kawamura
- Helmsely Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY
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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: 1] [Impact Index Per Article: 1.0] [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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