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Brasca FM, Curti E, Perego GB. Thermal and Non-Thermal Energies for Atrial Fibrillation Ablation. J Clin Med 2025; 14:2071. [PMID: 40142878 PMCID: PMC11943438 DOI: 10.3390/jcm14062071] [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: 12/19/2024] [Revised: 01/23/2025] [Accepted: 03/11/2025] [Indexed: 03/28/2025] Open
Abstract
The cornerstone of ablative therapy for atrial fibrillation (AF) is pulmonary vein isolation (PVI). Whether PVI should be added with additional lesions in persistent atrial fibrillation (PerAF) or for any post-ablative recurrent AF is a matter of debate. Whatever the ablative strategy, it must determine the choice of energy source to achieve the most durable lesion sets with the least likelihood of complications. Radiofrequency (RF) is the most studied thermal ablation technique. It can be combined with high-density electroanatomic mapping and can be used for both pulmonary and extrapulmonary atrial ablation. Cryoenergy is at least as effective as radiofrequency for PVI; it is rapid, relatively safe, and has a steep learning curve. Therefore, it has been proposed as a first-line approach for PVI-only procedures. More recently, a non-thermal technique based on the application of pulsed direct current (Pulsed Field Ablation-PFA) has been introduced. PFA causes cell death by opening cell membrane pores (electroporation) without a significant increase in tissue temperature. It is fast and does not alter the extracellular matrix as thermal techniques do, although it ends up causing long-lasting, transmural lesions. Most importantly, it is relatively selective on cardiac myocytes and therefore potentially safer than thermal techniques. Some PFA systems can be combined with electroanatomic mapping systems. However, as of now, it appears that these ablation technologies should be considered complementary rather than alternative for a number of practical and theoretical reasons.
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Affiliation(s)
| | | | - Giovanni B. Perego
- Istituto Auxologico, IRCCS Ospedale S. Luca, 20149 Milan, Italy; (F.M.B.)
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Weyand S, Adam V, Biehler P, Hägele P, Hanger S, Löbig S, Pinchuk A, Ausbuettel F, Waechter C, Seizer P. Impact of Tricuspid Regurgitation on Atrial Fibrillation Recurrence After Pulmonary Vein Isolation. J Cardiovasc Electrophysiol 2025. [PMID: 39980096 DOI: 10.1111/jce.16615] [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: 11/16/2024] [Revised: 01/28/2025] [Accepted: 02/09/2025] [Indexed: 02/22/2025]
Abstract
BACKGROUND The impact of tricuspid regurgitation (TR) on the outcomes of pulmonary vein isolation (PVI) for atrial fibrillation (AF) remains unclear. While the effects of mitral regurgitation (MR) on PVI outcomes are well-documented, there are limited data on how moderate or greater TR influences PVI efficacy and recurrence rates. OBJECTIVES The aim of this study was to assess the impact of moderate or greater TR on the outcomes of PVI, particularly focusing on AF recurrence rates within the first year post-PVI. METHODS We conducted an observational cohort study involving 421 patients undergoing their first PVI. 96 patients with moderate or greater TR were propensity score-matched with 96 controls based on age, sex, body mass index, and MR severity. Procedural parameters, complication rates, and AF recurrence within 1-year post-PVI were analyzed. RESULTS Despite comparable procedural parameters and low overall complication rates between the groups, patients with moderate or greater TR experienced significantly higher AF recurrence rates within the first year after PVI. Right atrium (RA) area was notably larger in these patients, suggesting a potential link between RA remodeling and increased AF recurrence. CONCLUSIONS Our findings indicate that moderate or greater TR is associated with higher recurrence rates of AF after PVI, potentially due to RA enlargement and remodeling. This highlights the need for tailored ablation strategies that consider the RA substrate and/or TR treatment in patients with significant TR and AF. Further multicenter, prospective studies are required to validate these results and explore long-term outcomes.
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Affiliation(s)
- Sebastian Weyand
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Viola Adam
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Paloma Biehler
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Patricia Hägele
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Simon Hanger
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Stephanie Löbig
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Andrei Pinchuk
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Felix Ausbuettel
- Department of Cardiology, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Christian Waechter
- Department of Cardiology, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Peter Seizer
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Aalen, Germany
- University of Ulm, Ulm, Germany
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Sim I, Lemus JAS, O'Shea C, Razeghi O, Whitaker J, Mukherjee R, O'Hare D, Fitzpatrick N, Harrison J, Gharaviri A, O'Neill L, Kotadia I, Roney CH, Grubb N, Newby DE, Dweck MR, Masci P, Wright M, Chiribiri A, Niederer S, O'Neill M, Williams SE. Quantification of atrial cardiomyopathy disease severity by electroanatomic voltage mapping and cardiac magnetic resonance imaging. J Cardiovasc Electrophysiol 2025; 36:467-479. [PMID: 39739521 PMCID: PMC11837893 DOI: 10.1111/jce.16462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/04/2024] [Accepted: 10/03/2024] [Indexed: 01/02/2025]
Abstract
INTRODUCTION Atrial late gadolinium enhancement (Atrial-LGE) and electroanatomic voltage mapping (Atrial-EAVM) quantify the anatomical and functional extent of atrial cardiomyopathy. We aimed to explore the relationships between, and outcomes from, these modalities in patients with atrial fibrillation undergoing ablation. METHODS Patients undergoing first-time ablation had disease severities quantified using both Atrial-LGE and Atrial-EAVM. Correlations between modalities and their relationships with clinical features and arrhythmia recurrence were assessed. RESULTS In 123 atrial fibrillation patients (60 ± 10 years), Atrial-EAVM was moderately correlated with Atrial-LGE (r = .34, p < .001), with a mean fibrosis burden of 47.2% ± 14.91%. Agreement was strongest in the highest tertile of fibrosis burden (mean of differences 16.8% (95% CI = -24.4% to 57.9%, p = .433). Fibrosis burden was greater for Atrial-LGE than Atrial-EAVM (50.7% ± 10.7% vs. 13.7% ± 7.13%, p < .005) for patients in the lowest tertile who were younger, had smaller atria and a greater frequency of paroxysmal atrial fibrillation. Both Atrial EAVM and Atrial LGE were associated with recurrence of arrhythmia following ablation (Atrial-LGE HR = 1.02 (95% CI = 1.01-1.04), p = .047; Atrial-EAVM HR = 1.02 (95% CI = 1.005-1.03), p = .007). A low fibrosis burden (<15%) by Atrial-EAVM identified patients with very low arrhythmia recurrence. In contrast, a much higher fibrosis burden (>66%) by Atrial-LGE identified patients failing to respond to ablation. CONCLUSIONS We demonstrate for the first time that the level of agreement between Atrial-EAVM and Atrial-LGE is dependent on the level of atrial cardiomyopathy disease severity. The functional consequences of atrial cardiomyopathy are most evident in patients with the highest anatomical extent of disease.
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Affiliation(s)
- Iain Sim
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | | | - Christopher O'Shea
- Department of Cardiovascular ScienesUniversity of BirminghamBirminghamUK
| | - Orod Razeghi
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - John Whitaker
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Rahul Mukherjee
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Daniel O'Hare
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Noel Fitzpatrick
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - James Harrison
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Ali Gharaviri
- Centre for Cardiovascular ScienceThe University of EdinburghEdinburghUK
| | - Louisa O'Neill
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Irum Kotadia
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Caroline H. Roney
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Neil Grubb
- Centre for Cardiovascular ScienceThe University of EdinburghEdinburghUK
| | - David E. Newby
- Centre for Cardiovascular ScienceThe University of EdinburghEdinburghUK
| | - Marc R. Dweck
- Centre for Cardiovascular ScienceThe University of EdinburghEdinburghUK
| | - Pier‐Giorgio Masci
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Matthew Wright
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Steven Niederer
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Mark O'Neill
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
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Singh S, Garg L, Kanjwal MY, Bliden K, Tantry US, Gurbel PA, Alraies MC, Damluji AA. Catheter Ablation in Atrial Fibrillation: Recent Advances. J Clin Med 2024; 13:7700. [PMID: 39768622 PMCID: PMC11679530 DOI: 10.3390/jcm13247700] [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: 11/15/2024] [Revised: 12/08/2024] [Accepted: 12/16/2024] [Indexed: 01/11/2025] Open
Abstract
Atrial fibrillation (AF) is the leading cause of arrhythmia-related morbidity and mortality. Recurrent symptoms, hospitalizations, and cost burden to patients have necessitated treatments beyond antiarrhythmic drugs (AADs) for patients with AF. Catheter ablation has proven to be effective over medical therapy alone; however the recurrence rates for atrial tachyarrhythmias post-ablation remain significant, particularly in patients with persistent and long-standing persistent AF. Hence, new techniques for catheter ablation have arisen, such as non-thermal energy sources, novel catheters, electroanatomical mapping, and ablation of additional targets. In this review, we discuss the recent advances in the field of catheter ablation, including newer modalities for the prevention of adverse events and future perspectives.
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Affiliation(s)
- Sahib Singh
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Lohit Garg
- Division of Cardiology, University of Colorado, Aurora, CO 80045, USA;
| | - Mohammed Y. Kanjwal
- Division of Cardiology, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA; (M.Y.K.); (P.A.G.)
| | - Kevin Bliden
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA; (K.B.); (U.S.T.)
| | - Udaya S. Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA; (K.B.); (U.S.T.)
| | - Paul A. Gurbel
- Division of Cardiology, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA; (M.Y.K.); (P.A.G.)
| | - M. Chadi Alraies
- Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, MI 48201, USA;
| | - Abdulla A. Damluji
- Division of Cardiology, Inova Center of Outcomes Research, Falls Church, VA 22042, USA;
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Valcher S, Villaschi A, Falasconi G, Chiarito M, Giunti F, Novelli L, Addeo L, Taormina A, Panico C, Francia P, Saglietto A, Del Monaco G, Latini AC, Carli S, Frittella S, Giaj Levra A, Antonelli G, Preda A, Guarracini F, Mazzone P, Berruezo A, Tritto M, Condorelli G, Penela D. Low-Voltage Area Ablation in Addition to Pulmonary Vein Isolation in Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:4541. [PMID: 39124807 PMCID: PMC11313645 DOI: 10.3390/jcm13154541] [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: 07/06/2024] [Revised: 07/26/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Low-voltage area (LVA) ablation, in addition to pulmonary vein isolation (PVI), has been proposed as a new strategy in patients with atrial fibrillation (AF), but clinical trials have shown conflicting results. We performed a systematic review and meta-analysis to assess the impact of LVA ablation in patient undergoing AF ablation (PROSPERO-registered CRD42024537696). Methods: Randomized clinical trials investigating the role of LVA ablation in addition to PVI in patients with AF were searched on PubMed, Embase, and the Cochrane Library from inception to 22 April 2024. Primary outcome was atrial arrhythmia recurrence after the first AF ablation procedure. Secondary endpoints included procedure time, fluoroscopy time, and procedure-related complication rate. Sensitivity analysis including only patients with LVA demonstration at mapping and multiple subgroups analyses were also performed. Results: 1547 patients from 7 studies were included. LVA ablation in addition to PVI reduced atrial arrhythmia recurrence (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.52-0.81, p < 0.001) with a number needed to treat to prevent recurrence of 10. No difference in procedure time (mean difference [MD] -5.32 min, 95% CI -19.01-8.46 min, p = 0.45), fluoroscopy time (MD -1.10 min, 95% CI -2.48-0.28 min, p = 0.12) and complication rate (OR 0.81, 95% CI 0.40-1.61, p = 0.54) was observed. Consistent results were demonstrated when considering only patients with LVA during mapping and in prespecified subgroups for AF type (paroxysmal vs. persistent), multicentric vs. monocentric trial, and ablation strategy in control group. Conclusions: In patients with AF, ablation of LVAs in addition to PVI reduces atrial arrhythmia recurrence without a significant increase in procedure time, fluoroscopy time, or complication rate.
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Affiliation(s)
- Stefano Valcher
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- Olv Hospital, 9300 Aalst, Belgium;
| | - Alessandro Villaschi
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- Department of Medicine, Karolinska Institutet, 17177 Solna, Sweden
| | - Giulio Falasconi
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
- Teknon Medical Center, 08022 Barcelona, Spain; (P.F.); (A.B.)
- Campus Clínic, University of Barcelona, 08036 Barcelona, Spain
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Filippo Giunti
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Laura Novelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Lucio Addeo
- Olv Hospital, 9300 Aalst, Belgium;
- Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
| | - Antonio Taormina
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Cristina Panico
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Pietro Francia
- Teknon Medical Center, 08022 Barcelona, Spain; (P.F.); (A.B.)
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Andrea Saglietto
- Teknon Medical Center, 08022 Barcelona, Spain; (P.F.); (A.B.)
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
| | - Guido Del Monaco
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Alessia Chiara Latini
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Sebastiano Carli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Stefano Frittella
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Alessandro Giaj Levra
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Giulia Antonelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Alberto Preda
- Electrophysiology Unit, De Gasperis Cardio Center, ASST Great Metropolitan Niguarda, 20162 Milan, Italy; (A.P.); (F.G.); (P.M.)
| | - Fabrizio Guarracini
- Electrophysiology Unit, De Gasperis Cardio Center, ASST Great Metropolitan Niguarda, 20162 Milan, Italy; (A.P.); (F.G.); (P.M.)
| | - Patrizio Mazzone
- Electrophysiology Unit, De Gasperis Cardio Center, ASST Great Metropolitan Niguarda, 20162 Milan, Italy; (A.P.); (F.G.); (P.M.)
| | | | - Massimo Tritto
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Diego Penela
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
- Teknon Medical Center, 08022 Barcelona, Spain; (P.F.); (A.B.)
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