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Spittler R, Bahlke F, Hoffmann BA, Marx A, Mollnau H, Quesada-Ocete B, Konrad T, Rostock T. Durable pulmonary vein isolation but not complex substrate ablation determines the type of arrhythmia recurrence after persistent atrial fibrillation ablation. J Interv Card Electrophysiol 2021; 64:417-426. [PMID: 34373981 DOI: 10.1007/s10840-021-01048-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/03/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Complex ablation for persistent atrial fibrillation (AF) aims to modify the arrhythmogenic substrates to become incapable to perpetuate the arrhythmia. Ablation-associated determinants of atrial tachycardia (AT) rather than AF recurrences are unknown. The aim of the study was to evaluate the association between the type of arrhythmia recurrence and electrophysiological findings during redo procedures. METHODS A total number of 384 consecutive patients with persistent AF underwent complex ablation consisting of PV isolation (PVI), biatrial electrogram-guided ablation, and linear ablation with the desired procedural endpoint of AF termination. Electrophysiological findings during redo procedures and its relation to AR type are the subject of this study. RESULTS Overall, 177 (46%) patients underwent a second procedure. Patients with AT recurrences had significantly more often persistent PVI (47 vs. 25%; P = 0.002). Moreover, a higher number of recovered PVs were associated with AF recurrence (3 PVs recovered, AF = 16.1% vs. AT = 5.2%; P = 0.02; 4 PVs recovered, AF = 18.5% vs. AT = 6.3%; P = 0.01), regardless of the extent of substrate ablation during the first procedure. CONCLUSIONS Durable PV isolation but not the extent of atrial substrate ablation determines the type of arrhythmia recurrence. Thus, the PVs may represent dominant perpetuators (and not only triggers) of persistent AF even in the presence of a significantly modified atrial substrate.
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Affiliation(s)
- Raphael Spittler
- Department of Cardiology II - Electrophysiology, University Hospital Mainz, Mainz, Germany.
| | - Fabian Bahlke
- Department of Cardiology II - Electrophysiology, University Hospital Mainz, Mainz, Germany
| | | | - Alexandra Marx
- Department of Cardiology II - Electrophysiology, University Hospital Mainz, Mainz, Germany
| | - Hanke Mollnau
- Department of Cardiology II - Electrophysiology, University Hospital Mainz, Mainz, Germany
| | - Blanca Quesada-Ocete
- Department of Cardiology II - Electrophysiology, University Hospital Mainz, Mainz, Germany
| | - Torsten Konrad
- Department of Cardiology II - Electrophysiology, University Hospital Mainz, Mainz, Germany
| | - Thomas Rostock
- Department of Cardiology II - Electrophysiology, University Hospital Mainz, Mainz, Germany
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2
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Anderson RD, Lee G, Campbell T, Bennett RG, Kizana E, Watts T, Kalman J, Kumar S. Scar nonexcitability using simultaneous pacing for substrate ablation of ventricular tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:1219-1234. [PMID: 32720390 DOI: 10.1111/pace.14025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/21/2020] [Accepted: 07/26/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe an expedited strategy of simultaneous high-output pacing during radiofrequency ablation to achieve scar homogenization and electrical inexcitability as an approach for substrate ablation for scar-related ventricular tachycardia (VT). BACKGROUND Scar homogenization with additional testing for electrical inexcitability is known endpoints for catheter ablation, but achieving both can be time consuming. We describe a strategy of simultaneous pacing during radiofrequency ablation to expedite this approach. METHODS AND RESULTS Ten patients (age 74 ± 6 years; all men, (LV) ejection fraction of 33% ± 8%, ischemic cardiomyopathy, 9; VT storm, 7) underwent scar homogenization with electrical inexcitability to pacing (10 mA, 9 ms pulse width), as well as noninducibility of any VT as an acute procedural endpoint. Thirty-four VTs were inducible in 10 patients with a total of 1127 ablation lesions applied. Median ablation lesions per patient were 97 (interquartile range [IQR]25-75 71-151), and the total ablation time was 49 minutes (IQR25-75 45-56 minutes) with average duration per lesion of 32.2 seconds (IQR25-75 25.8-37.8 seconds). Average power was 33 W (IQR25-75 32-38 W), average contact force was 13 g (IQR25-75 11.9-14.6 g) with a median impedance drop of 9.6 Ω/lesion (IQR25-75 8.1-10.0 Ω). There were no ventricular fibrillation episodes using this strategy. The median procedure time was 246 minutes (IQR25-75 214-293 minutes). Acute procedural success was seen in nine patients with 97% of VTs noninducible. CONCLUSION Simultaneous ablation with high output pacing to achieve scar inexcitability, when combined with scar homogenization and noninducibility of any VT may be an expeditious, safe, and effective technique for catheter ablation.
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Affiliation(s)
- Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Eddy Kizana
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
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Ariyarathna N, Kumar S, Thomas SP, Stevenson WG, Michaud GF. Role of Contact Force Sensing in Catheter Ablation of Cardiac Arrhythmias: Evolution or History Repeating Itself? JACC Clin Electrophysiol 2019; 4:707-723. [PMID: 29929663 DOI: 10.1016/j.jacep.2018.03.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/12/2018] [Accepted: 03/22/2018] [Indexed: 12/28/2022]
Abstract
Adequate catheter-tissue contact facilitates efficient heat energy transfer to target tissue. Tissue contact is thus critical to achieving lesion transmurality and success of radiofrequency (RF) ablation procedures, a fact recognized more than 2 decades ago. The availability of real-time contact force (CF)-sensing catheters has reinvigorated the field of ablation biophysics and optimized lesion formation. The ability to measure and display CF came with the promise of dramatic improvement in safety and efficacy; however, CF quality was noted to have just as important an influence on lesion formation as absolute CF quantity. Multiple other factors have emerged as key elements influencing effective lesion formation, including catheter stability, lesion contiguity and continuity, lesion density, contact homogeneity across a line of ablation, spatiotemporal dynamics of contact governed by cardiac and respiratory motion, contact directionality, and anatomic wall thickness, in addition to traditional ablation indices of power and RF duration. There is greater appreciation of surrogate markers as a guide to lesion formation, such as impedance fall, loss of pace capture, and change in unipolar electrogram morphology. In contrast, other surrogates such as tactile feedback, catheter motion, and electrogram amplitude are notably poor predictors of actual contact and lesion formation. This review aims to contextualize the role of CF sensing in lesion formation with respect of the fundamental principles of biophysics of RF ablation and summarize the state-of-the-art evidence behind the role of CF in optimizing lesion formation.
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Affiliation(s)
- Nilshan Ariyarathna
- Cardiology Department, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Stuart P Thomas
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - William G Stevenson
- Arrhythmia and Electrophysiology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory F Michaud
- Arrhythmia and Electrophysiology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
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Zeng LJ, Shi L, Tian Y, Wang YJ, Yin XD, Liu XQ, Yang XC, Liu XP. Pace capture and adenosine triphosphate provocation are complementary rather than mutually exclusive methods to ensure durable pulmonary vein isolation. J Cardiovasc Electrophysiol 2019; 30:815-823. [PMID: 30891845 DOI: 10.1111/jce.13901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Adenosine triphosphate (ATP)-provoked dormant conduction (DC) and pacing for unexcitability are used to identify conduction gaps along the ablation lines after circumferential pulmonary vein isolation (CPVI). We aim to determine whether ATP provocation and pacing are interchangeable as endpoints for ablation of paroxysmal atrial fibrillation (PAF). METHODS AND RESULTS A total of 107 patients with PAF were randomly divided into two groups after completion of CPVI. In group I (A-P group, n = 53), ATP was administered first. If DC was uncovered, additional ablation was performed until ATP tests were negative. Bipolar pacing along the ablation line was performed subsequently. In group II (P-A group, n = 54), the same protocol was used, but the pacing and the ATP tests were performed in the opposite sequence. The 12-month ablation outcomes of all patients were compared with those of a historical control group of 107 patients with PAF in whom only ATP test was performed. Regardless of which test was performed first, the other modality still identified conduction gaps. In group I, pacing maneuvers identified gaps in 49% (n = 26) of patients who had negative ATP tests. In group II, ATP tests uncovered DC in 18.5% (n = 10) of patients in whom pacing identified no gaps. After 12 months, a higher proportion of patients (91.6%) were free from atrial tachyarrhythmias compared with the historical control group (81.3%; P = 0.031). CONCLUSION Pacing along the ablation lines and ATP provocation are complementary tests for evaluating the durability of CPVI and can lead to better long-term outcomes when used in combination.
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Affiliation(s)
- Li-Jun Zeng
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Liang Shi
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ying Tian
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yan-Jiang Wang
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xian-Dong Yin
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiao-Qing Liu
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin-Chun Yang
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xing-Peng Liu
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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5
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Barbhaiya CR, Aizer A, Knotts R, Bernstein S, Park D, Holmes D, Chinitz LA. Simultaneous pace-ablate during CARTO-guided pulmonary vein isolation with a contact-force sensing radiofrequency ablation catheter. J Interv Card Electrophysiol 2018; 54:119-124. [PMID: 30264289 DOI: 10.1007/s10840-018-0455-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 09/19/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Elimination of pace-capture along pulmonary vein isolation (PVI) lesion sets reduces atrial fibrillation (AF) recurrence in catheter ablation of paroxysmal AF. Pacing from the RF ablation electrode during RF application is prevented within the CARTO electroanatomic mapping system (Biosense Webster, Inc.) due to theoretical safety considerations. We evaluated a method of pacing the distal ablation electrode during RF application in the CARTO system, thus avoiding repeated activation and inactivation of the pacing channel and facilitating immediate recognition of pace-capture loss. We investigated the safety, feasibility, and utility of simultaneous pace-ablate (SPA) during AF ablation with the CARTO-3 system and a contact-force sensing RF ablation catheter. METHODS Safety of feasibility of SPA was evaluated in 250 patients undergoing first-time AF ablation. Frequency and regional distribution of pace-capture following PVI was evaluated in a cohort of 50 consecutive patients undergoing catheter ablation of paroxysmal AF. RESULTS SPA was successfully performed in all 250 patients without adverse event. At least one pace-capture site was noted in 22 of 50 PAF patients (44%), and pace-capture following PVI was most common at anterior and superior left atrial sites. There were 2.0 ± 3.3 RF applications during pacing via the distal ablation electrode per patient, and all lesions sets were successfully rendered unexcitable. CONCLUSIONS Pace-capture along the completed PVI lesion set remains common despite utilization of contact-force sensing RF ablation catheters and automated lesion annotation. Simultaneous pace-ablate in AF ablation using the CARTO system may be safely used to render atrial lesion sets unexcitable.
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Affiliation(s)
- Chirag R Barbhaiya
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA.
| | - Anthony Aizer
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Robert Knotts
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Scott Bernstein
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - David Park
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Douglas Holmes
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Larry A Chinitz
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
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Elsokkari I, Sapp JL, Doucette S, Parkash R, Gray CJ, Gardner MJ, Macintyre C, AbdelWahab AM. Role of contact force in ischemic scar-related ventricular tachycardia ablation; optimal force required and impact of left ventricular access route. J Interv Card Electrophysiol 2018; 53:323-331. [PMID: 29946899 DOI: 10.1007/s10840-018-0396-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Contact force-sensing technology has become a widely used addition to catheter ablation procedures. Neither the optimal contact force required to achieve adequate lesion formation in the ventricle, nor the impact of left ventricular access route on contact force has been fully clarified. PATIENTS AND METHODS Consecutive patients (n = 24) with ischemic cardiomyopathy who underwent ablation for scar-related ventricular tachycardia were included in the study. All ablations (n = 25) were performed using irrigated contact force-sensing catheters (Smart Touch, Biosense Webster). Effective lesion formation was defined as electrical unexcitability post ablation at sites which were electrically excitable prior to ablation (unipolar pacing at 10 mA, 2 ms pulse width). We explored the contact force which achieved effective lesion formation and the impact of left ventricular access route (retrograde aortic or transseptal) on the contact force achieved in various segments of the left ventricle. Scar zone was defined as bipolar signal amplitude < 0.5 mV. RESULTS Among 427 ablation points, effective lesion formation was achieved at 201 points (47.1%). Contact force did not predict effective lesion formation in the overall group. However, within the scar zone, mean contact force ≥ 10 g was significantly associated with effective lesion formation [OR 3.21 (1.43, 7.19) P = 0.005]. In the 12-segment model of the left ventricle, the retrograde approach was associated with higher median contact force in the apical anterior segment (31 vs 19 g; P = 0.045) while transseptal approach had higher median force in the basal inferior segment (25 vs 15 g; P = 0.021). In the 4-segment model, the retrograde approach had higher force in the anterior wall (28 vs 16 g; P = 0.004) while the transseptal approach had higher force in the lateral wall (21 vs 18 g; P = 0.032). There was a trend towards higher force in the inferior wall with the transseptal approach, but this was not statistically significant (20 vs 15 g; P = 0.063). CONCLUSIONS In patients with ischemic cardiomyopathy, a mean contact force of 10 g or more within the scar zone had the best correlation with electrical unexcitability post ablation in our study. The retrograde aortic approach was associated with better contact force over the anterior wall while use of a transseptal approach had better contact force over the lateral wall.
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Affiliation(s)
- Ihab Elsokkari
- Queen Elizabeth II Health Sciences Centre, 1796 Summer street, Room 2501, Halifax, Nova Scotia, B3H 3A7, Canada.
| | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, 1796 Summer street, Room 2501, Halifax, Nova Scotia, B3H 3A7, Canada
| | | | - Ratika Parkash
- Queen Elizabeth II Health Sciences Centre, 1796 Summer street, Room 2501, Halifax, Nova Scotia, B3H 3A7, Canada
| | - Christopher J Gray
- Queen Elizabeth II Health Sciences Centre, 1796 Summer street, Room 2501, Halifax, Nova Scotia, B3H 3A7, Canada
| | - Martin J Gardner
- Queen Elizabeth II Health Sciences Centre, 1796 Summer street, Room 2501, Halifax, Nova Scotia, B3H 3A7, Canada
| | - Ciorsti Macintyre
- Queen Elizabeth II Health Sciences Centre, 1796 Summer street, Room 2501, Halifax, Nova Scotia, B3H 3A7, Canada
| | - Amir M AbdelWahab
- Queen Elizabeth II Health Sciences Centre, 1796 Summer street, Room 2501, Halifax, Nova Scotia, B3H 3A7, Canada
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7
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Pulmonary Vein Isolation With a Pace Capture-Guided Approach: Durable or Debatable? JACC Clin Electrophysiol 2018; 3:1272-1274. [PMID: 29759623 DOI: 10.1016/j.jacep.2017.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/15/2017] [Indexed: 11/20/2022]
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8
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Contact force facilitates the achievement of an unexcitable ablation line during pulmonary vein isolation. Clin Res Cardiol 2018; 107:632-641. [PMID: 29500567 DOI: 10.1007/s00392-018-1228-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/27/2018] [Indexed: 01/13/2023]
Abstract
AIMS Contact force (CF) catheters provide catheter-tissue contact information to improve outcome of pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF). We evaluated different target-CF values for achievement of the additional endpoint of an unexcitable ablation line. METHODS A total of 106 patients undergoing PVI were randomized into three groups (G) (G1: target-CF 15 g, G2: target-CF 10 g, G3: CF concealed from operator). The PVI encircling line was divided into predefined sections. Excitable tissue along the PVI-line identified by high output pacing (10 V, 2 ms) was targeted for further ablation. RESULTS Mean average CF was 17.4 ± 4.7 g (G1) vs. 12.3 ± 6.0 g (G2) vs. 11.1 ± 6.5 g (G 3) (p < 0.001). Primary unexcitable ablation lines were found in 38.6, 19.4 and 5.7% (G1, G2, G3 respectively; G1 vs. G2 p < 0.05, G1 vs. G3 p < 0.001, G2 vs. G3 ns). Additional radiofrequency (RF)-energy to achieve unexcitability was lowest in G1 (3.6 ± 3.1 kJ vs. 8.6 ± 7.2 kJ (G2) and 10.4 ± 6.7 (G3), p ≤ 0.001, G2 vs. G3 ns) with accordingly lowest additional RF applications in G1 (3.0 ± 2.6 vs. 7.0 ± 5.4 in G2 and 8.4 ± 4.0 in G3; G1 vs. G2 and G3, p < 0.001, G 2 vs. G 3 ns). Sections along ablation lines with low initial CF were most likely to reveal excitability. Single procedure success was 81.9 vs. 73.5 vs. 71.4% (G 1, 2 and 3, p = 0.6) during 437 ± 254 day follow-up. CONCLUSION Higher tip-to-tissue CF during PVI facilitates the achievement of an unexcitable ablation line, requiring less additional RF-energy.
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Atrial fibrillation ablation using very short duration 50 W ablations and contact force sensing catheters. J Interv Card Electrophysiol 2018; 52:1-8. [PMID: 29460232 PMCID: PMC5924666 DOI: 10.1007/s10840-018-0322-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/26/2018] [Indexed: 11/29/2022]
Abstract
Purpose The optimal radiofrequency (RF) power and lesion duration using contact force (CF) sensing catheters for atrial fibrillation (AF) ablation are unknown. We evaluate 50 W RF power for very short durations using CF sensing catheters during AF ablation. Methods We evaluated 51 patients with paroxysmal (n = 20) or persistent (n = 31) AF undergoing initial RF ablation. Results A total of 3961 50 W RF lesions were given (average 77.6 ± 19.1/patient) for an average duration of only 11.2 ± 3.7 s. As CF increased from < 10 to > 40 g, the RF application duration decreased from 13.7 ± 4.4 to 8.6 ± 2.5 s (p < 0.0005). Impedance drops occurred in all ablations, and for patients in sinus rhythm, there was loss of pacing capture during RF delivery suggesting lesion creation. Only 3% of the ablation lesions were at < 5 g and 1% at > 40 g of force. As CF increased, the force time integral (FTI) increased from 47 ± 24 to 376 ± 102 gs (p < 0.0005) and the lesion index (LSI) increased from 4.10 ± 0.51 to 7.63 ± 0.50 (p < 0.0005). Both procedure time (101 ± 19.7 min) and total RF energy time (895 ± 258 s) were very short. For paroxysmal AF, the single procedure freedom from AF was 86% at 1 and 2 years. For persistent AF, it was 83% at 1 year and 72% at 2 years. There were no complications. Conclusions Short duration 50 W ablations using CF sensing catheters are safe and result in excellent long-term freedom from AF for both paroxysmal and persistent AF with short procedure times and small amounts of total RF energy delivery.
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Moser J, Sultan A, Lüker J, Servatius H, Salzbrunn T, Altenburg M, Schäffer B, Schreiber D, Akbulak RÖ, Vogler J, Hoffmann BA, Willems S, Steven D. 5-Year Outcome of Pulmonary Vein Isolation by Loss of Pace Capture on the Ablation Line Versus Electrical Circumferential Pulmonary Vein Isolation. JACC Clin Electrophysiol 2017; 3:1262-1271. [DOI: 10.1016/j.jacep.2017.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/12/2017] [Accepted: 04/20/2017] [Indexed: 01/08/2023]
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Chinitz JS, Michaud GF, Stephenson K. Impedance-guided Radiofrequency Ablation: Using Impedance to Improve Ablation Outcomes. J Innov Card Rhythm Manag 2017; 8:2868-2873. [PMID: 32477757 PMCID: PMC7252711 DOI: 10.19102/icrm.2017.081003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/06/2017] [Indexed: 11/06/2022] Open
Abstract
Despite the achievement of acute conduction block during catheter ablation, the recovery of conduction at previously ablated sites remains a primary factor implicated in arrhythmia recurrence after initial ablation. Real-time markers of adequate ablation lesion creation are needed to ensure durable ablation success. However, the assessment of acute lesion formation is challenging, and requires interpretation of surrogate markers of lesion creation that are frequently unreliable. Careful monitoring of impedance changes during radiofrequency catheter ablation has emerged as a highly specific marker of local tissue destruction. Ablation strategies guided by close impedance monitoring during ablation applications have been demonstrated to achieve high levels of success for ablation of atrial fibrillation. Impedance decrease during ablation may therefore be used as an additional endpoint beyond acute conduction block, in order to improve the durability of ablation lesions. In this manuscript, available methods of real-time lesion assessment are reviewed, and the rationale and technique for impedance-guided ablation are described.
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Affiliation(s)
- Jason S Chinitz
- Department of Cardiology, Hofstra Northwell School of Medicine, Northwell Health, Southside Hospital, Bay Shore, NY, USA
| | - Gregory F Michaud
- Arrhythmia Section, Vanderbilt Heart and Vascular Center, Vanderbilt University Medical School, Nashville, TN
| | - Kent Stephenson
- Department of Cardiology, Hofstra Northwell School of Medicine, Northwell Health, Southside Hospital, Bay Shore, NY, USA
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Chamber-Specific Radiofrequency Lesion Dimension Estimation Using Novel Catheter-Based Tissue Interface Temperature Sensing. JACC Clin Electrophysiol 2017; 3:1092-1102. [DOI: 10.1016/j.jacep.2017.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/14/2017] [Accepted: 08/17/2017] [Indexed: 11/18/2022]
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13
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Pambrun T, Combes S, Sousa P, Bloa ML, El Bouazzaoui R, Grand-Larrieu D, Thompson N, Martin R, Combes N, Boveda S, Haïssaguerre M, Albenque JP. Contact-force guided single-catheter approach for pulmonary vein isolation: Feasibility, outcomes, and cost-effectiveness. Heart Rhythm 2017; 14:331-338. [DOI: 10.1016/j.hrthm.2016.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Indexed: 12/31/2022]
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14
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Kogawa R, Watanabe I, Okumura Y, Mano H, Sonoda K, Nagashima K, Sasaki N, Ohkubo K, Takahashi K, Iso K, Kurokawa S, Nakai T, Hirayama A. Usefulness of filtered unipolar electrogram morphology for evaluating transmurality of ablated lesions during pulmonary vein isolation. J Arrhythm 2016; 32:108-11. [PMID: 27092191 PMCID: PMC4823572 DOI: 10.1016/j.joa.2015.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/28/2015] [Accepted: 10/06/2015] [Indexed: 11/05/2022] Open
Abstract
Background Although alteration of the amplitude and morphology of bipolar electrograms is used widely as a guide of the ablation effect, there is little information concerning unipolar electrograms. The amplitude and morphology of filtered bipolar (BP) and filtered unipolar (UP) electrograms were compared during pulmonary vein isolation in patients with atrial fibrillation. Methods BP (30–250 Hz) and UP (30–100 Hz) signals from the ablation catheter were recorded before and after each ablation point at the pulmonary vein antrum in 6 patients with atrial fibrillation. Results In the electrogram group with low-voltage amplitude in BP electrograms before ablation (<0.5 mV), the reduction in amplitude after ablation was significantly greater in the UP than in the BP electrograms, whereas the reduction was similar between the two recording methods in the electrogram group with high-voltage amplitude in BP electrograms (≥0.5 mV). Furthermore, the S wave in the UP electrograms disappeared at the sites of no pace capture after ablation, whereas no characteristic morphologic changes were observed in the BP electrograms. Conclusion Filtered UP electrograms may be useful in assessing the effectiveness of lesion formation.
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Affiliation(s)
- Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Hiroaki Mano
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazumasa Sonoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Naoko Sasaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Keiko Takahashi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazuki Iso
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kami, Itabashi-ku, Tokyo 173-8610, Japan
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15
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Kumar S, Barbhaiya CR, Balindger S, John RM, Epstein LM, Koplan BA, Tedrow UB, Stevenson WG, Michaud GF. Better Lesion Creation And Assessment During Catheter Ablation. J Atr Fibrillation 2015; 8:1189. [PMID: 27957200 DOI: 10.4022/jafib.1189] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 04/03/2015] [Accepted: 07/02/2015] [Indexed: 12/17/2022]
Abstract
Permanent destruction of abnormal cardiac tissue responsible for cardiac arrhythmogenesis whilst avoiding collateral tissue injury forms the cornerstone of catheter ablation therapy. As the acceptance and performance of catheter ablation increases worldwide, limitations in current technology are becoming increasingly apparent in the treatment of complex arrhythmias such as atrial fibrillation. This review will discuss the role of new technologies aimed to improve lesion formation with the ultimate goal of improving arrhythmia-free survival of patients undergoing catheter ablation of atrial arrhythmias.
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Affiliation(s)
- Saurabh Kumar
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
| | - Chirag R Barbhaiya
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
| | - Samuel Balindger
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
| | - Roy M John
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
| | - Laurence M Epstein
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
| | - Bruce A Koplan
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
| | - Usha B Tedrow
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
| | - William G Stevenson
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
| | - Gregory F Michaud
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115
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16
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Keller MW, Schuler S, Wilhelms M, Lenis G, Seemann G, Schmitt C, Dössel O, Luik A. Characterization of radiofrequency ablation lesion development based on simulated and measured intracardiac electrograms. IEEE Trans Biomed Eng 2014; 61:2467-78. [PMID: 24816474 DOI: 10.1109/tbme.2014.2322515] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Radiofrequency ablation (RFA) therapy is the gold standard in interventional treatment of many cardiac arrhythmias. A major obstacle is nontransmural lesions, leading to recurrence of arrhythmias. Recent clinical studies have suggested intracardiac electrogram (EGM) criteria as a promising marker to evaluate lesion development. Seeking for a deeper understanding of underlying mechanisms, we established a simulation approach for acute RFA lesions. Ablation lesions were modeled by a passive necrotic core surrounded by a borderzone with properties of heated myocardium. Herein, conduction velocity and electrophysiological properties were altered. We simulated EGMs during RFA to study the relation between lesion formation and EGM changes using the bidomain model. Simulations were performed on a three-dimensional setup including a geometrically detailed representation of the catheter with highly conductive electrodes. For validation, EGMs recorded during RFA procedures in five patients were analyzed and compared to simulation results. Clinical data showed major changes in the distal unipolar EGM. During RFA, the negative peak amplitude decreased up to 104% and maximum negative deflection was up to 88% smaller at the end of the ablation sequence. These changes mainly occurred in the first 10 s after ablation onset. Simulated unipolar EGMs reproduced the clinical changes, reaching up to 83% negative peak amplitude reduction and 80% decrease in maximum negative deflection for transmural lesions. In future studies, the established model may enable the development of further EGM criteria for transmural lesions even for complex geometries in order to support clinical therapy.
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17
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Kircher S, Sommer P. Electrophysiological Evaluation of Pulmonary Vein Isolation. J Atr Fibrillation 2013; 6:934. [PMID: 28496900 DOI: 10.4022/jafib.934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 08/23/2013] [Accepted: 08/23/2013] [Indexed: 11/10/2022]
Abstract
Since the pulmonary veins (PVs) were identified as a major source of AF triggers, ablation strategies targeting the PVs have evolved from focal ablation inside the PVs to wide area circumferential PV isolation (PVI) which at this juncture is the standard approach. Despite the widespread popularity of PVI, a universal definition is lacking. While "entrance block" is a generally accepted endpoint for PVI, the role of "exit block" has yet to be determined. Inexcitability of the circular ablation line has been introduced as a promising additional endpoint for PVI and was associated with an improved clinical outcome in a randomized trial. Correct interpretation of PV electrograms during an ablation procedure is critical in terms of efficacy and safety. A variety of electrophysiological techniques help to correctly differentiate components of complex PV electrograms. Resumption of PV conduction after initially successful PVI leading to AF recurrence remains a major problem and confirmation of bi-directional conduction block does not exclude reversible tissue damage along the ablation line. Prolongation of post-PVI monitoring and application of provocative procedures such as the administration of adenosine after initial PVI to unmask dormant PV conduction may improve clinical outcome although there is lack of valid data supporting these strategies. This article aims on clarifying the electrophysiological criteria for complete pulmonary vein isolation and the explain the importance of this cornerstone in almost all atrial fibrillation ablation procedures.
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Affiliation(s)
- S Kircher
- Heart Center, University of Leipzig, Department of Electrophysiology, Leipzig, Germany
| | - P Sommer
- Heart Center, University of Leipzig, Department of Electrophysiology, Leipzig, Germany
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18
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Steven D, Sultan A, Reddy V, Luker J, Altenburg M, Hoffmann B, Rostock T, Servatius H, Stevenson WG, Willems S, Michaud GF. Benefit of pulmonary vein isolation guided by loss of pace capture on the ablation line: results from a prospective 2-center randomized trial. J Am Coll Cardiol 2013; 62:44-50. [PMID: 23644091 DOI: 10.1016/j.jacc.2013.03.059] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Revised: 03/09/2013] [Accepted: 03/26/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study was conducted to determine if an additional procedural endpoint of unexcitability (UE) to pacing along the ablation line reduces recurrence of atrial fibrillation (AF) or atrial tachycardia (AT) after radiofrequency catheter ablation. BACKGROUND AF/AT recurrence is common after pulmonary vein isolation (PVI). METHODS We included 102 patients from 2 centers (age 63 ± 10 years; 33 women; left atrium 38 ± 7 mm; left ventricular ejection fraction 61 ± 6%) with symptomatic paroxysmal AF. A 3-dimensional mapping system and circumferential mapping catheter were used in all patients for PVI. In group 1 (n = 50), the procedural endpoint was bidirectional block across the ablation line. In group 2 (n = 52), additional UE to bipolar pacing at an output of 10 mA and 2-ms pulse width was required. The primary endpoint was freedom from any AF/AT (>30 s) after discontinuation of antiarrhythmic drugs. RESULTS Procedural endpoints were successfully achieved in all patients. Procedure duration was significantly longer in group 2 (185 ± 58 min vs. 139 ± 57 min; p < 0.001); however, fluoroscopy times were not different (23 ± 9 min vs. 23 ± 9 min; p = 0.49). After a follow-up of 12 months in all patients, 26 patients (52%) in group 1 versus 43 (82.7%) in group 2 were free from any AF/AT (p = 0.001) after a single procedure. No major complications occurred. CONCLUSIONS The use of pacing to ensure UE along the PVI line markedly improved near-term single-procedure success, compared with demonstration of bidirectional block alone. This additional endpoint significantly improved patient outcomes after PVI. (Unexcitability Along the Ablation as an Endpoint for Atrial Fibrillation Ablation; NCT01724437).
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Affiliation(s)
- Daniel Steven
- Department for Cardiac Electrophysiology, University Heart Center, Hamburg, Germany.
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