Novel tailored very-high-power short-duration radiofrequency ablation around the esophagus guided by left atrial voltage

BACKGROUND

Very-high-power short-duration (vHPSD) radiofrequency (RF) ablation is expected to make shallow lesions and reduce collateral damage. This study investigated the power setting and quality of acute lesions performed by a modified vHPSD RF ablation guided by left atrial (LA) voltage around the esophagus.

METHODS

A voltage map was obtained by an OCTARAY catheter (3-mm spacing) during pacing from the high right atrium. The power setting of the vHPSD was modified according to the LA voltage around the esophagus: 65 W for <1.8 mV, 75 W for <2.7 mV, and 90 W for ≥2.7 mV. The incidence of gaps after the 1st pass and spontaneous, isoproterenol-induced, and adenosine-induced reconnections were evaluated. The limit of esophagus temperature rise was set at 40 °C. Gastric hypomotility was assessed.

RESULTS

A modified vHPSD RF ablation guided by the LA voltage was performed for 450 lesions in 32 patients (median age 73 years, 15 females). The RF setting was 65 W for 221 lesions (49 %), 75 W for 104 lesions (23 %), and 90 W for 125 lesions (28 %). Gaps after the 1st pass were observed in 3 patients (9.4 %). Any reconnections were observed in 6 patients (19 %). Esophageal temperature rises of >40 °C were observed at 39 lesions. RF ablation at the areas modified to 65 W more frequently resulted in esophageal temperature rise of >40 °C than the areas modified to 75 W or 90 W (12 % vs. 5.2 %, p = 0.017). No-gap-no-reconnection lesions were more frequently achieved for lesions ablated with 65 W (216/221 lesions, 98 %) than for lesions ablated with 90 W (113/125 lesions, 90 %, p = 0.004). No gastric hypomotility and atrio-esophageal fistulae were observed.

CONCLUSIONS

The modified vHPSD RF ablation guided by the LA voltage was a reasonable option for reducing the power setting without compromising the acute pulmonary vein isolation quality.

Proactive esophageal cooling during radiofrequency cardiac ablation: data update including applications in very high-power short duration ablation

INTRODUCTION

Proactive esophageal cooling reduces injury during radiofrequency (RF) ablation of the left atrium (LA) for the treatment of atrial fibrillation (AF). New catheters are capable of higher wattage settings up to 90 W (very high-power short duration, vHPSD) for 4 s. Varying power and duration, however, does not eliminate the risk of thermal injury. Furthermore, alternative energy sources such as pulsed field ablation (PFA) also exhibit thermal effects, with clinical data showing esophageal temperatures up to 40.3°C. The ensoETM esophageal cooling device (Attune Medical, now a part of Haemonetics, Boston, MA, U.S.A.) is commercially available and FDA-cleared to reduce thermal injury to the esophagus during RF ablation for AF and is recommended in the 2024 expert consensus statement on catheter and surgical ablation of AF.

AREAS COVERED

This review summarizes growing evidence of esophageal cooling during high power RF ablation for AF treatment, including data relating to procedural efficacy, safety, and efficiency, and techniques to enhance operator success while providing directions for further research.

EXPERT OPINION

Proactive esophageal cooling reduces injury to the esophagus during high power RF ablation, and utilizing this approach may result in increased success in first-pass isolation, procedural efficiency, and long-term efficacy.

Efficacy and safety of high-power short-duration ablation for atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

High-power short-duration (HPSD) ablation has emerged as an alternative to conventional standard-power long-duration (SPLD) ablation. We aim to assess the efficacy and safety of HPSD versus SPLD for atrial fibrillation (AF) ablation.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL were performed through August 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI).

PROSPERO ID

CRD42023471797.

RESULTS

We included six RCTs with a total of 694 patients. HPSD was significantly associated with a decreased total procedure time (MD: -22.88 with 95% CI [-36.13, -9.63], P = 0.0007), pulmonary vein isolation (PVI) time (MD: -19.73 with 95% CI [-23.93, -15.53], P < 0.00001), radiofrequency time (MD: -10.53 with 95% CI [-12.87, -8.19], P < 0.00001). However, there was no significant difference between HPSD and SPLD ablation with respect to the fluoroscopy time (MD: -0.69 with 95% CI [-2.00, 0.62], P = 0.30), the incidence of esophageal lesions (RR: 1.15 with 95% CI [0.43, 3.07], P = 0.77), and the incidence of first pass isolation (RR: 0.98 with 95% CI [0.88, 1.08], P = 0.65).

CONCLUSION

HPSD ablation was significantly associated with decreased total procedure time, PVI time, and radiofrequency time compared with SPLD ablation. On the contrary, SPLD ablation was significantly associated with low maximum temperature.

Incidence and predictors of thermal oesophageal and vagus nerve injuries in Ablation Index-guided high-power-short-duration ablation of atrial fibrillation: a prospective study

AIMS

High-power-short-duration (HPSD) ablation is an effective treatment for atrial fibrillation but poses risks of thermal injuries to the oesophagus and vagus nerve. This study aims to investigate incidence and predictors of thermal injuries, employing machine learning.

METHODS AND RESULTS

A prospective observational study was conducted at Leipzig Heart Centre, Germany, excluding patients with multiple prior ablations. All patients received Ablation Index-guided HPSD ablation and subsequent oesophagogastroduodenoscopy. A machine learning algorithm categorized ablation points by atrial location and analysed ablation data, including Ablation Index, focusing on the posterior wall. The study is registered in clinicaltrials.gov (NCT05709756). Between February 2021 and August 2023, 238 patients were enrolled, of whom 18 (7.6%; nine oesophagus, eight vagus nerve, one both) developed thermal injuries, including eight oesophageal erythemata, two ulcers, and no fistula. Higher mean force (15.8 ± 3.9 g vs. 13.6 ± 3.9 g, P = 0.022), ablation point quantity (61.50 ± 20.45 vs. 48.16 ± 19.60, P = 0.007), and total and maximum Ablation Index (24 114 ± 8765 vs. 18 894 ± 7863, P = 0.008; 499 ± 95 vs. 473 ± 44, P = 0.04, respectively) at the posterior wall, but not oesophagus location, correlated significantly with thermal injury occurrence. Patients with thermal injuries had significantly lower distances between left atrium and oesophagus (3.0 ± 1.5 mm vs. 4.4 ± 2.1 mm, P = 0.012) and smaller atrial surface areas (24.9 ± 6.5 cm2 vs. 29.5 ± 7.5 cm2, P = 0.032).

CONCLUSION

The low thermal lesion's rate (7.6%) during Ablation Index-guided HPSD ablation for atrial fibrillation is noteworthy. Machine learning based ablation data analysis identified several potential predictors of thermal injuries. The correlation between machine learning output and injury development suggests the potential for a clinical tool to enhance procedural safety.

Impedance-guided modified CLOSE protocol ablation can reduce ablation index necessary for pulmonary vein isolation in patients with atrial fibrillation

BACKGROUND

Real-time monitoring of generator impedance drop is not considered in CLOSE protocol pulmonary vein (PV) isolation (PVI) in patients with atrial fibrillation (AF). We verified whether additional information of impedance drop could minimize ablation index required for PVI using modified CLOSE protocol (target ablation index ≥ 500 on anterior wall and ≥400 on posterior wall along with inter-lesion distance of 3-6 mm and maximum power of 35 W) without any adverse effect of procedural data and efficacy.

METHODS

Sixty consecutive Japanese AF patients [paroxysmal AF: 43 (72 %) patients] underwent first-time PVI with modified CLOSE protocol with real-time monitoring of impedance drop (impedance-guided modified CLOSE protocol). Ablation tags were colored according to impedance drop and ablation was immediately terminated before reaching target ablation index if impedance drop of ≥10 Ω was confirmed. Ablation index needed for PVI, first-pass PVI rate, other procedural data, and atrial tachyarrhythmia recurrence were evaluated.

RESULTS

Mean ablation index and impedance drop on anterior and posterior walls were 437.6 ± 43.5 Ω and 10.2 ± 2.6 Ω and 393.3 ± 27.4 Ω and 9.3 ± 2.2 Ω, respectively. First-pass PVI per PV pair was accomplished in 90/120 (75 %). No complications occurred. PV gaps after first-pass ablation were locationally most often found on right posterior wall than on the other parts (p < 0.001). There were no differences in mean contact force, impedance drop, and ablation index between walls with and without PV gaps after first-pass PV ablation. During a mean follow-up of 24 ± 9 months, survival from atrial tachyarrhythmia recurrence was 51/60 (85 %) patients.

CONCLUSIONS

Using additional generator impedance drop information may be useful to minimize radiofrequency current application to accomplish PVI with modified CLOSE protocol while maintaining efficacy and safety in Japanese AF population.

Characteristics of tissue temperature during ablation with THERMOCOOL SMARTTOUCH SF versus TactiCath versus QDOT MICRO catheters (Qmode and Qmode+): An in vivo porcine study

INTRODUCTION

High-power short-duration (HPSD) ablation at 50 W, guided by ablation index (AI) or lesion size index (LSI), and a 90 W/4 s very HSPD (vHPSD) setting are available for atrial fibrillation (AF) treatment. Yet, tissue temperatures during ablation with different catheters around venoatrial junction and collateral tissues remain unclear.

METHODS

In this porcine study, we surgically implanted thermocouples on the epicardium near the superior vena cava (SVC), right pulmonary vein, and esophagus close to the inferior vena cava. We then compared tissue temperatures during 50W-HPSD guided by AI 400 or LSI 5.0, and 90 W/4 s-vHPSD ablation using THERMOCOOL SMARTTOUCH SF (STSF), TactiCath ablation catheter, sensor enabled (TacthCath), and QDOT MICRO (Qmode and Qmode+ settings) catheters.

RESULTS

STSF produced the highest maximum tissue temperature (Tmax ), followed by TactiCath, and QDOT MICRO in Qmode and Qmode+ (62.7 ± 12.5°C, 58.0 ± 10.1°C, 50.0 ± 12.1°C, and 49.2 ± 8.4°C, respectively; p = .005), achieving effective transmural lesions. Time to lethal tissue temperature ≥50°C (t-T ≥ 50°C) was fastest in Qmode+, followed by TacthCath, STSF, and Qmode (4.3 ± 2.5, 6.4 ± 1.9, 7.1 ± 2.8, and 7.7 ± 3.1 s, respectively; p < .001). The catheter tip-to-thermocouple distance for lethal temperature (indicating lesion depth) from receiver operating characteristic curve analysis was deepest in STSF at 5.2 mm, followed by Qmode at 4.3 mm, Qmode+ at 3.1 mm, and TactiCath at 2.8 mm. Ablation at the SVC near the phrenic nerve led to sudden injury at t-T ≥ 50°C in all four settings. The esophageal adventitia injury was least deep with Qmode+ ablation (0.4 ± 0.1 vs. 0.8 ± 0.4 mm for Qmode, 0.9 ± 0.3 mm for TactiCath, and 1.1 ± 0.5 mm for STSF, respectively; p = .005), correlating with Tmax .

CONCLUSION

This study revealed distinct tissue temperature patterns during HSPD and vHPSD ablations with the three catheters, affecting lesion effectiveness and collateral damage based on Tmax and/or t-T ≥ 50°C. These findings provide key insights into the safety and efficacy of AF ablation with these four settings.

Atrioesophageal Fistula Rates Before and After Adoption of Active Esophageal Cooling During Atrial Fibrillation Ablation

BACKGROUND

Active esophageal cooling reduces the incidence of endoscopically identified severe esophageal lesions during radiofrequency (RF) catheter ablation of the left atrium for the treatment of atrial fibrillation. A formal analysis of the atrioesophageal fistula (AEF) rate with active esophageal cooling has not previously been performed.

OBJECTIVES

The authors aimed to compare AEF rates before and after the adoption of active esophageal cooling.

METHODS

This institutional review board (IRB)-approved study was a prospective analysis of retrospective data, designed before collecting and analyzing the real-world data. The number of AEFs occurring in equivalent time frames before and after adoption of cooling using a dedicated esophageal cooling device (ensoETM, Attune Medical) were quantified across 25 prespecified hospital systems. AEF rates were then compared using generalized estimating equations robust to cluster correlation.

RESULTS

A total of 14,224 patients received active esophageal cooling during RF ablation across the 25 hospital systems, which included a total of 30 separate hospitals. In the time frames before adoption of active cooling, a total of 10,962 patients received primarily luminal esophageal temperature (LET) monitoring during their RF ablations. In the preadoption cohort, a total of 16 AEFs occurred, for an AEF rate of 0.146%, in line with other published estimates for procedures using LET monitoring. In the postadoption cohort, no AEFs were found in the prespecified sites, yielding an AEF rate of 0% (P < 0.0001).

CONCLUSIONS

Adoption of active esophageal cooling during RF ablation of the left atrium for the treatment of atrial fibrillation was associated with a significant reduction in AEF rate.

Impact of high-power short-duration atrial fibrillation ablation technique on the incidence of silent cerebral embolism: a prospective randomized controlled study

BACKGROUND

High-power short-duration (HPSD) ablation strategy has emerged as a popular approach for treating atrial fibrillation (AF), with shorter ablation time. The utilized Smart Touch Surround Flow (STSF) catheter, with 56 holes around the electrode, lowers electrode-tissue temperature and thrombus risk. Thus, we conducted this prospective, randomized study to investigate if the HPSD strategy with STSF catheter in AF ablation procedures reduces the silent cerebral embolism (SCE) risk compared to the conventional approach with the Smart Touch (ST) catheter.

METHODS

From June 2020 to September 2021, 100 AF patients were randomized 1:1 to the HPSD group using the STSF catheter (power set at 50 W) or the conventional group using the ST catheter (power set at 30 to 35 W). Pulmonary vein isolation was performed in all patients, with additional lesions at operator's discretion. High-resolution cerebral diffusion-weighted magnetic resonance imaging (hDWI) with slice thickness of 1 mm was performed before and 24-72 h after ablation. The incidence of new periprocedural SCE was defined as the primary outcome. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA) test.

RESULTS

All enrolled AF patients (median age 63, 60% male, 59% paroxysmal AF) underwent successful ablation. Post-procedural hDWI identified 106 lesions in 42 enrolled patients (42%), with 55 lesions in 22 patients (44%) in the HPSD group and 51 lesions in 20 patients (40%) in the conventional group (p = 0.685). No significant differences were observed between two groups regarding the average number of lesions (p = 0.751), maximum lesion diameter (p = 0.405), and total lesion volume per patient (p = 0.669). Persistent AF and CHA2DS2-VASc score were identified as SCE determinants during AF ablation procedure by multivariable regression analysis. No significant differences in MoCA scores were observed between patients with SCE and those without, both immediately post-procedure (p = 0.572) and at the 3-month follow-up (p = 0.743).

CONCLUSIONS

Involving a small sample size of 100 AF patients, this study reveals a similar incidence of SCE in AF ablation procedures, comparing the HPSD strategy using the STSF catheter to the conventional approach with the ST catheter.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04408716. AF = Atrial fibrillation, DWI = Diffusion-weighted magnetic resonance imaging, HPSD = High-power short-duration, ST = Smart Touch, STSF = Smart Touch Surround Flow.

Recurrent Atrial Fibrillation Ablation after Initial Successful Pulmonary Vein Isolation

BACKGROUND

Pulmonary vein isolation (PVI) is an effective treatment option for patients with symptomatic atrial fibrillation (AF). However, the electrical recovery of pulmonary veins (PVs) is the main trigger for AF recurrences. This study investigates the characteristics of patients admitted for redo AF ablation, the PV reconnection rates depending on previous ablation modalities and the impact of different ablation strategies for redo procedures.

METHODS

Consecutive patients undergoing first redo AF ablation were included. Patients were grouped according to the electrical recovery of at least one PV. The impacts of the technique for first AF ablation on PV reconnection rates and patients with and without PV reconnection were compared. Different ablation strategies for redo procedures were compared and its recurrence rates after a mean follow-up of 25 ± 20 months were investigated.

RESULTS

A total of 389 patients (68 ± 10 years; 57% male; 39% paroxysmal AF) underwent a first redo. The median time between the first and redo procedure was 40 ± 39 months. Radiofrequency was used in 278 patients, cryoballoon was used in 85 patients and surgical AF ablation was performed on 26 patients. In total, 325 patients (84%) had at least one PV reconnected, and the mean number of reconnected PVs was 2.0 ± 1.3, with significant differences between ablation approaches (p for all = 0.002); this was mainly due to differences in the left inferior PV and right superior PV reconnections. The presence of PV reconnection during redo was not associated with better long-term success compared to completely isolated PVs (67% vs. 67%; log-rank p = 0.997). Overall, the different ablation strategies for redos were comparable regarding AF recurrences during follow-up (p = 0.079), with the ablation approach having no impact in the case of left atrial low voltage or without.

CONCLUSIONS

PV reconnections after initial successful PVI are common among all techniques of AF ablation. Long-term rhythm control off antiarrhythmic drugs was possible in 2/3 of all patients after the redo procedure; however, different ablation strategies with extra-PV trigger ablation did not improve long-term success. Patients with recurrent AF after PVI constitute a challenging group of patients.

Higher power short duration vs. lower power longer duration posterior wall ablation for atrial fibrillation and oesophageal injury outcomes: a prospective multi-centre randomized controlled study (Hi-Lo HEAT trial)

AIMS

Radiofrequency (RF) ablation for pulmonary vein isolation (PVI) in atrial fibrillation (AF) is associated with the risk of oesophageal thermal injury (ETI). Higher power short duration (HPSD) ablation results in preferential local resistive heating over distal conductive heating. Although HPSD has become increasingly common, no randomized study has compared ETI risk with conventional lower power longer duration (LPLD) ablation. This study aims to compare HPSD vs. LPLD ablation on ETI risk.

METHODS AND RESULTS

Eighty-eight patients were randomized 1:1 to HPSD or LPLD posterior wall (PW) ablation. Posterior wall ablation was 40 W (HPSD group) or 25 W (LPLD group), with target AI (ablation index) 400/LSI (lesion size index) 4. Anterior wall ablation was 40-50 W, with a target AI 500-550/LSI 5-5.5. Endoscopy was performed on Day 1. The primary endpoint was ETI incidence. The mean age was 61 ± 9 years (31% females). The incidence of ETI (superficial ulcers n = 4) was 4.5%, with equal occurrence in HPSD and LPLD (P = 1.0). There was no difference in the median value of maximal oesophageal temperature (HPSD 38.6°C vs. LPLD 38.7°C, P = 0.43), or the median number of lesions per patient with temperature rise above 39°C (HPSD 1.5 vs. LPLD 2, P = 0.93). Radiofrequency ablation time (23.8 vs. 29.7 min, P < 0.01), PVI duration (46.5 vs. 59 min, P = 0.01), and procedure duration (133 vs. 150 min, P = 0.05) were reduced in HPSD. After a median follow-up of 12 months, AF recurrence was lower in HPSD (15.9% vs. LPLD 34.1%; hazard ratio 0.42, log-rank P = 0.04).

CONCLUSION

Higher power short duration ablation was associated with similarly low rates of ETI and shorter total/PVI RF ablation times when compared with LPLD ablation. Higher power short duration ablation is a safe and efficacious approach to PVI.

Radiofrequency ablation of atrial fibrillation-50 W or 90 W?

BACKGROUND

This study sought to evaluate the short and midterm efficacy and safety of the novel very high power very short duration (vHPvSD) 90 W approach compared to HPSD 50 W for atrial fibrillation (AF) ablation as well as reconnection patterns of 90 W ablations.

METHODS AND RESULTS

Consecutive patients undergoing first AF ablation with vHPvSD (90 W; predefined ablation time of 3 s for posterior wall ablation and 4 s for anterior wall ablation) were compared to patients using HPSD (50 W; ablation index-guided; AI 350 for posterior wall ablation, AI 450 for anterior wall ablation) retrospectively. A total of 84 patients (67.1 ± 9.8 years; 58% male; 47% paroxysmal AF) were included (42 with 90 W, 42 with 50 W) out of a propensity score-matched cohort. 90 W ablations revealed shorter ablation times (10.5 ± 6.7 min vs. 17.4 ± 9.9 min; p = .001). No major complication occurred. 90 W ablations revealed lower first pass PVI rates (40% vs. 62%; p = .049) and higher AF recurrences during blanking period (38% vs. 12%; p = .007). After 12 months, both ablation approaches revealed comparable midterm outcomes (62% vs. 70%; log-rank p = .452). In a multivariable Cox regression model, persistent AF (hazard ratio [HR]: 1.442, 95% confidence interval [CI]: 1.035-2.010, p = .031) and increased procedural duration (HR: 1.011, 95% CI: 1.005-1.017, p = .001) were identified as independent predictors of AF recurrence during follow-up.

CONCLUSIONS

AF ablation using 90 W vHPvSD reveals a similar safety profile compared to 50 W ablation with shorter ablation times. However, vHPvSD ablation was associated with lower rates of first-pass isolations and increased AF recurrences during the blanking period. After 12 months, 90 W revealed comparable efficacy results to 50 W ablations in a nonrandomized, propensity-matched comparison.

Radiofrequency Pulmonary Vein Isolation without Esophageal Temperature Monitoring: Contact-Force Characteristics and Incidence of Esophageal Thermal Damage

Esophageal thermal lesions following pulmonary vein isolation (PVI) for atrial fibrillation (AF) potentially harbor lethal complications. Radiofrequency (RF)-PVI using contact force-technology can reduce collateral damage. We evaluated the incidence of endoscopically detected esophageal lesions (EDEL) and the contribution of contact force to esophageal lesion formation without esophageal temperature monitoring. One hundred and thirty-one AF patients underwent contact force-guided RF-PVI. Contact force, energy, force-time-integral, and force-power-time-integral were adopted. During PVI at the posterior segment of the wide antral circumferential line, limits were set for energy (30 W), duration (30 s) and contact force (40 g). Ablations were analyzed postero-superior and -inferior around PVs. Endoscopy within 120 h identified EDEL in six patients (4.6%). In EDEL(+), obesity was less frequent (17% vs. 68%, p = 0.018), creatinine was higher (1.55 ± 1.18 vs. 1.07 ± 0.42 mg/dL, p = 0.016), and exclusively at the left postero-inferior site, force-time-integral and force-power-time-integral were greater (2973 ± 3267 vs. 1757 ± 1262 g·s, p = 0.042 and 83,547 ± 105,940 vs. 43,556 ± 35,255 g·J, p = 0.022, respectively) as compared to EDEL(-) patients. No major complications occurred. At 12 months, arrhythmia-free survival was 74%. The incidence of EDEL was low after contact force-guided RF-PVI. Implementing combined contact force-indices on the postero-inferior site of left-sided PVs may reduce EDEL.

Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives

Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.

Mitigating Esophageal Injury after Atrial Fibrillation Ablation Guided by Ablation Index; CLOSEr to goal

In the ongoing quest to optimize outcomes for atrial fibrillation ablation, efforts continue to balance the reliable creation of durable transmural ablation lesions, while minimizing risk to neighboring sensitive structures. This article is protected by copyright. All rights reserved.

Esophageal safety in CLOSE-guided 50W high-power-short-duration pulmonary vein isolation - The PREHEAT-PVI-Registry

AIMS

Pulmonary vein isolation (PVI) using high-power-short-duration (HPSD) radiofrequency ablation (RF) is emerging as the standard of care for treatment of atrial fibrillation (AF). While procedural short-term to mid-term efficacy and efficiency are very promising, this registry aims to investigate esopahgeal safety using an optimized ablation approach.

METHODS

In a single-centre experience, 388 consecutive standardized first-time AF ablation were performed using a CLOSE-guided-fixed-50W-circumferential PVI and substrate modification without intraprocedural oesophageal temperature measurement. 300 patients underwent post-procedural esophageal endoscopy to diagnose and grade endoscopically detected esophageal lesions (EDEL) and were included in the analysis.

RESULTS

EDEL were detected in 35 of 300 patients (11.6%), 25 of 35 were low-grade KCC 1 lesions with fast healing tendencies. 6 patients suffered KCC 2a lesions, 4 patients had KCC 2b lesions (1.3% of all patients). No esophageal perforation or fistula formation was observed. Patient baseline characteristics, especially patients age, gender and body-mass-index did not influence EDEL incidence. Additional posterior box isolation did not increase the incidence of EDEL. In patients diagnosed with EDEL, mean catheter contact force during posterior wall ablation was higher (11.9 ± 1.8 vs. 14.7 ± 3 grams, p<0.001), mean RF duration was shorter (11.9 ± 1 vs. 10.7 ± 1.2 sec., p<0.001), while achieved AI was not different between groups (434 ± 4.9 vs. 433 ± 9.5, n.s.).

CONCLUSIONS

Incidence of EDEL after CLOSE-guided-50W-HPSD PVI is lower compared to historical cohorts using standard-power RF settings. Catheter contact force during posterior HPSD ablation should not exceed 15 grams. This article is protected by copyright. All rights reserved.

Efficacy and safety of high-power short duration atrial fibrillation ablation in elderly patients

INTRODUCTION

Data about atrial fibrillation (AF) ablation using high-power short duration (HPSD) radiofrequency ablation in the elderly population is still scarce. The aim of our study was to investigate the efficacy and safety of HPSD ablation in patients over 75 years compared to younger patients.

METHODS

Consecutive patients older than 75 years with paroxysmal or persistent AF undergoing a first-time AF ablation using 50 W HPSD ablation approach were analyzed in this retrospective observational analysis and compared to a control group <75 years. Short-term endpoints included intraprocedural reconnection of at least one pulmonary vein (PV) and intrahospital and AF recurrence during 3 months blanking period, as well as a long-term endpoint of freedom from atrial arrhythmias of antiarrhythmic drugs after 12 months.

RESULTS

A total of 540 patients underwent a first AF ablation with HPSD (66 ± 10 years; 58% male; 47% paroxysmal AF). Mean age was 78 ± 2.4 and 63 ± 6.3 years (p < .001), respectively. Elderly patients were significantly more often women (p < .001). The procedure, fluoroscopy, and ablation were comparable. Elderly patients revealed significantly more often extra-PV low-voltage areas requiring additional left atrial ablations (p < .001). Overall complication rates were low; however, elderly patients revealed higher major complication rates mainly due to unmasking sick sinus syndrome (p = .003). Freedom from arrhythmia recurrences was comparable (68% vs. 76%, log-rank p = .087). Only in the subgroup of paroxysmal AF, AF recurrences were more common after 12 months (69% vs. 82%; log-rank p = .040; hazard ratio: 1.462, p = .044) in the elderly patients. In multivariable Cox regression analysis of the whole cohort persistent AF, female gender, diabetes mellitus and presence of left atrium low-voltage areas, but not age >75 years were associated with AF recurrences.

CONCLUSION

HPSD AF ablation of patients >75 years in experienced centers is safe and effective. Therefore, age alone should not be the reason to withhold AF ablation from vital elderly patients due to only a slightly worse outcome and safety profile. In paroxysmal AF, elderly patients have more recurrences compared to the younger control group.