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Whitaker J, Hunter TD, Carsey J, Thatcher WH, Yungher D, Goldberg S, Kaneko C, Amit M, Kreidieh O, Thurber C, Steiger N, Chang D, Batnyam U, Sharma E, McClennen S, Kapur S, Tadros T, Sauer WH, Koplan B, Tedrow U, Zei PC. Consistency of ablations with trainee and increasing independence during fellowship training-Analysis of ablation data by CARTONET. J Cardiovasc Electrophysiol 2024; 35:1645-1655. [PMID: 38924224 DOI: 10.1111/jce.16349] [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: 01/15/2024] [Revised: 06/06/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Training in clinical cardiac electrophysiology (CCEP) involves the development of catheter handling skills to safely deliver effective treatment. Objective data from analysis of ablation data for evaluating trainee of CCEP procedures has not previously been possible. Using the artificial intelligence cloud-based system (CARTONET), we assessed the impact of trainee progress through ablation procedural quality. METHODS Lesion- and procedure-level data from all de novo atrial fibrillation (AF) and cavotricuspid isthmus (CTI) ablations involving first-year (Y1) or second-year (Y2) fellows across a full year of fellowship was curated within Cartonet. Lesions were automatically assigned to anatomic locations. RESULTS Lesion characteristics, including contact force, catheter stability, impedance drop, ablation index value, and interlesion time/distance were similar over each training year. Anatomic location and supervising operator significantly affected catheter stability. The proportion of lesion sets delivered independently and of lesions delivered by the trainee increased steadily from the first quartile of Y1 to the last quartile of Y2. Trainee perception of difficult regions did not correspond to objective measures. CONCLUSION Objective ablation data from Cartonet showed that the progression of trainees through CCEP training does not impact lesion-level measures of treatment efficacy (i.e., catheter stability, impedance drop). Data demonstrates increasing independence over a training fellowship. Analyses like these could be useful to inform individualized training programs and to track trainee's progress. It may also be a useful quality assurance tool for ensuring ongoing consistency of treatment delivered within training institutions.
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Affiliation(s)
- John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - Tina D Hunter
- CTI Clinical Trial & Consulting, Covington, Kentucky, USA
| | - Jane Carsey
- CTI Clinical Trial & Consulting, Covington, Kentucky, USA
| | | | | | | | | | - Mati Amit
- Biosense Webster, Irvine, California, USA
| | - Omar Kreidieh
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Clinton Thurber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nathaniel Steiger
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Chang
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Uyanga Batnyam
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Esseim Sharma
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Seth McClennen
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sunil Kapur
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Tadros
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - William H Sauer
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Koplan
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Usha Tedrow
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Paul C Zei
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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De Smet MAJ, Wielandts JY, El Haddad M, De Becker B, François C, Tavernier R, le Polain de Waroux JB, Duytschaever M, Knecht S. Risk assessment of esophageal ulceration following left atrial radiofrequency linear ablation. J Cardiovasc Electrophysiol 2024; 35:1561-1569. [PMID: 38818534 DOI: 10.1111/jce.16330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/10/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Esophageal safety following radiofrequency (RF) left atrial (LA) linear ablation has not been established. To determine the esophageal safety profile of LA linear RF lesions, we performed systematic esophagogastroduodenoscopy in all patients with intraesophageal temperature rise (ITR) ≥ 38.5°C. METHODS AND RESULTS Between December 2021 and July 2023, a total of 200 consecutive patients with atrial tachyarrhythmia (ATA) underwent linear ablation with posterior dome (roof or floor) or posterior mitral isthmus line transection. Patients with ITR ≥ 38.5°C were scheduled for esophageal endoscopy ~3 weeks after ablation. Patient and ATA characteristics, procedural parameters, endoscopy findings and ablation lesion data were collected and analyzed. One hundred thirty-three out of 200 (67%) patients showed ITR ≥ 38.5°C during LA linear ablation. ITR (with maximal temperature of 45.7°C) was more frequently observed during floor line ablation (82% of cases). ITR was less observed during roof line ablation (34%) and posterior mitral isthmus ablation (4%). Endoscopy, performed in 115 patients after 24 ± 10 days, showed esophageal ulceration in four patients (two patients Kansas City classification [KCC] 2a and two patients KCC 2b). No patient showed esophageal perforation or fistula. CONCLUSION Temperature rise during LA linear ablation is frequent and ulceration risk exists, particularly when floor line is performed. Safety measures are needed to avoid potential severe complications like esophageal perforation and fistula.
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Affiliation(s)
| | | | - Milad El Haddad
- Department of Cardiology, AZ Sint-Jan Hospital Bruges, Bruges, Belgium
| | | | - Clara François
- Department of Cardiology, AZ Sint-Jan Hospital Bruges, Bruges, Belgium
| | - Rene Tavernier
- Department of Cardiology, AZ Sint-Jan Hospital Bruges, Bruges, Belgium
| | | | | | - Sébastien Knecht
- Department of Cardiology, AZ Sint-Jan Hospital Bruges, Bruges, Belgium
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024; 67:921-1072. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Takigawa M, Yamaguchi J, Goya M, Iwakawa H, Yamamoto T, Amemiya M, Ikenouchi T, Negishi M, Kawamura I, Goto K, Shigeta T, Nishimura T, Takamiya T, Tao S, Ohuchi K, Suzuki S, Miyazaki S, Sasano T. An optimized approach for increasing lesion size in temperature-controled setting using a catheter with a surface thermocouple and efficient irrigation. J Arrhythm 2024; 40:536-551. [PMID: 38939786 PMCID: PMC11199823 DOI: 10.1002/joa3.13040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/15/2024] [Accepted: 04/07/2024] [Indexed: 06/29/2024] Open
Abstract
Background We explore an optimized approach for increasing lesion size using a novel ablation catheter with a surface thermocouple and efficient irrigation in a temperature-control setting. Methods We conducted radiofrequency applications at various power levels (35 W, 40 W, and 45 W), contact forces (CFs, 10 g/20 g), and durations (60 s/120 s/180 s) in perpendicular/parallel catheter orientations, with normal saline irrigation (NS-irrigation) and Half NS-irrigation (HNS-irrigation) in an ex-vivo model (Step 1). In addition, we performed applications (35 W/40 W/45 W for 60 s/120 s/180 s in NS-irrigation and 35 W/40 W for 60 s/120 s/180 s in HNS-irrigation) in four swine (Step 2), evaluating lesion characteristics and the occurrence of steam pops. Results In Step 1, out of 288 lesions, we observed 47 (16.3%) steam pops, with 13 in NS-irrigation and 34 in HNS-irrigation (p = .001). Although steam pops were mostly observed with the most aggressive setting (45 W/180 s, 54%) with NS-irrigation, they happened in less aggressive settings with HNS irrigation. Lesion size significantly increased with longer-duration ablation but not with HNS-irrigation. The optimal %impedance-drop cutoff to predict steam pops was 20% with a negative-predictive-value (NPV) = 95.1% including NS- and HNS-irrigation groups, and 22% with an NPV = 96.1% in NS-irrigation group. In Step 2, similar to the ex-vivo model, lesion size significantly increased with longer-duration ablation but not with HNS-irrigation. Steam pops were absent with NS-irrigation (0/35) even with the largest %impedance-drop reaching 31% at 45 W/180 s. All steam pops were observed with HNS-irrigation (6/21, 29%). The optimal %impedance-drop cutoff predicting steam pops was 24% with an NPV = 96.3% including both NS- and HNS-irrigation groups. Conclusions Rather than using HNS-irrigation, very long-duration of radiofrequency applications up to 45 W/180 s may be recommended to safely and effectively increase lesion dimensions using this catheter with NS-irrigation.
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Affiliation(s)
- Masateru Takigawa
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Division of Advanced Arrhythmia ResearchTokyo Medical and Dental University HospitalTokyoJapan
| | - Junji Yamaguchi
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Masahiko Goya
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Hidehiro Iwakawa
- Department of Cardiovascular MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Tasuku Yamamoto
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Miki Amemiya
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Takashi Ikenouchi
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Miho Negishi
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Iwanari Kawamura
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Kentaro Goto
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Division of Advanced Arrhythmia ResearchTokyo Medical and Dental University HospitalTokyoJapan
| | - Takatoshi Shigeta
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Takuro Nishimura
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Tomomasa Takamiya
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Susumu Tao
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
| | - Katsuhiro Ohuchi
- Center for Experimental AnimalsTokyo Medical and Dental UniversityTokyoJapan
| | | | - Shinsuke Miyazaki
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Division of Advanced Arrhythmia ResearchTokyo Medical and Dental University HospitalTokyoJapan
| | - Tetsuo Sasano
- Department of Cardiovascular MedicineTokyo Medical and Dental University HospitalTokyoJapan
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Valeriano C, Buytaert D, Fabbricatore D, De Schouwer K, Addeo L, De Braekeleer L, Geelen P, De Potter T. High efficiency single-catheter workflow for radiofrequency atrial fibrillation ablation in the QDOT catheter era. J Interv Card Electrophysiol 2024; 67:817-826. [PMID: 38092999 DOI: 10.1007/s10840-023-01709-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/22/2023] [Indexed: 06/12/2024]
Abstract
BACKGROUND High-power short-duration (HPSD) ablation may improve the consistency and efficiency of pulmonary vein isolation (PVI). The novel QDOT Micro™ catheter (Biosense Webster, Inc.) with temperature feedback and microelectrodes aims to enhance PVI efficiency and safety. This study wants to evaluate the feasibility, safety, and efficiency of a standardized single-catheter workflow for PVI using QDOT (Q-FLOW). METHODS The Q-FLOW includes single transeptal access, radiofrequency encircling of the PVs using a power of 50 W in a temperature/flow-controlled mode, and validation of the circles with microelectrodes. A 1:1 propensity-matched cohort of patients treated with conventional power-controlled ablation using a circular mapping catheter (CMC-FLOW) was used to compare procedural and clinical outcomes. RESULTS A total of 150 consecutive atrial fibrillation patients (paroxysmal 67%, persistent 33%) were included. First-pass isolation rate was 86%. Procedural time, X-ray time, and dose were significantly lower for the Q-FLOW vs the CMC-FLOW (67.2 ± 17.9 vs 88.3 ± 19.2 min, P < 0.001; 3.0 ± 1.9 vs 5.0 ± 2.4 min, P < 0.001; 4.3 ± 1.9 vs 6.4 ± 2.3 Gycm2, P < 0.001). Complications were numerically but not significantly lower in the Q-FLOW group (2 [1.3%] vs 7 [4.7%], P = 0.091). There was no difference in arrhythmia recurrence at 12 months (atrial arrhythmia-free survival rate, 87.5% vs 84.4%, P = 0.565). CONCLUSION A streamlined single-catheter workflow for PVI using QDOT was feasible and safe, resulting in a high rate of first-pass isolation and a low complication rate. The Q-FLOW further improved the efficiency of PVI compared to the standard CMC-FLOW, without difference in the 12-month outcome.
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Affiliation(s)
- Chiara Valeriano
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Dimitri Buytaert
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
| | - Davide Fabbricatore
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Koen De Schouwer
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
| | - Lucio Addeo
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Lisa De Braekeleer
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
| | - Peter Geelen
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
| | - Tom De Potter
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium.
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6
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Brahier MS, Piccini JP. Pulmonary Vein Isolation in Persistent Atrial Fibrillation: Not Necessarily Durable, Nor Sufficient. JACC Clin Electrophysiol 2024; 10:1101-1103. [PMID: 38925720 DOI: 10.1016/j.jacep.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Mark S Brahier
- Electrophysiology Section, Duke Heart Center, Duke University Hospital and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Electrophysiology Section, Duke Heart Center, Duke University Hospital and Duke Clinical Research Institute, Durham, North Carolina, USA.
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7
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De Potter TJR, De Becker B, Duytschaever M. Durable pulmonary vein isolation with optimized high-power and very high-power short-duration temperature-controlled ablation: A step-by-step guide. J Cardiovasc Electrophysiol 2024; 35:886-894. [PMID: 38433316 DOI: 10.1111/jce.16217] [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: 11/09/2023] [Revised: 01/24/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Through systematic scientific rigor, the CLOSE guided workflow was developed and has been shown to improve pulmonary vein isolation durability. However, this technique was developed at a time when using power-controlled ablation catheters with conventional power ranges was the norm. There has been increased adoption of a high-power and very high-power short-duration ablation practice propelled by the availability of the temperature-controlled radiofrequency QDOT MICRO catheter. METHODS There are fundamental differences in biophysics between very high-powered temperature guided ablation and conventional ablation strategy that may impact patient outcomes. The catheter's design and ablation modes offer flexibility in technique while accommodating the individual operator's clinical discretion and preference to deliver a durable, transmural, and contiguous lesion set. RESULTS Here, we provide recommendations for 3 different workflows using the QDOT MICRO catheter in a step-by-step manner for pulmonary vein isolation based on our cumulative experience as early adopters of the technology and the data available in the scientific literature. CONCLUSIONS With standardization, temperature-controlled ablation with the QDOT MICRO catheter provides operators the flexibility of implementing different ablation strategies to ensure durable contiguous pulmonary vein isolation depending on patient characteristics.
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Affiliation(s)
- Tom J R De Potter
- Cardiovascular Center, Division of Cardiology, Onze Lieve Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Benjamin De Becker
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove, Brugge, Belgium
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8
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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9
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Cheung JW. Applying ablation index to catheter ablation of ventricular tachycardia: The search for the more perfect ablation lesion continues. J Cardiovasc Electrophysiol 2024; 35:639-640. [PMID: 38424451 DOI: 10.1111/jce.16230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Jim W Cheung
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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10
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Falasconi G, Penela D, Soto-Iglesias D, Francia P, Saglietto A, Turturiello D, Viveros D, Bellido A, Alderete J, Zaraket F, Franco-Ocaña P, Huguet M, Cámara Ó, Vătășescu R, Ortiz-Pérez JT, Martí-Almor J, Berruezo A. Personalized pulmonary vein isolation with very high-power short-duration lesions guided by left atrial wall thickness: the QDOT-by-LAWT randomized trial. Europace 2024; 26:euae087. [PMID: 38652090 PMCID: PMC11036893 DOI: 10.1093/europace/euae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using very high-power short-duration (vHPSD) radiofrequency (RF) ablation proved to be safe and effective. However, vHPSD applications result in shallower lesions that might not be always transmural. Multidetector computed tomography-derived left atrial wall thickness (LAWT) maps could enable a thickness-guided switching from vHPSD to the standard-power ablation mode. The aim of this randomized trial was to compare the safety, the efficacy, and the efficiency of a LAWT-guided vHPSD PVI approach with those of the CLOSE protocol for PAF ablation (NCT04298177). METHODS AND RESULTS Consecutive patients referred for first-time PAF ablation were randomized on a 1:1 basis. In the QDOT-by-LAWT arm, for LAWT ≤2.5 mm, vHPSD ablation was performed; for points with LAWT > 2.5 mm, standard-power RF ablation titrating ablation index (AI) according to the local LAWT was performed. In the CLOSE arm, LAWT information was not available to the operator; ablation was performed according to the CLOSE study settings: AI ≥400 at the posterior wall and ≥550 at the anterior wall. A total of 162 patients were included. In the QDOT-by-LAWT group, a significant reduction in procedure time (40 vs. 70 min; P < 0.001) and RF time (6.6 vs. 25.7 min; P < 0.001) was observed. No difference was observed between the groups regarding complication rate (P = 0.99) and first-pass isolation (P = 0.99). At 12-month follow-up, no significant differences occurred in atrial arrhythmia-free survival between groups (P = 0.88). CONCLUSION LAWT-guided PVI combining vHPSD and standard-power ablation is not inferior to the CLOSE protocol in terms of 1-year atrial arrhythmia-free survival and demonstrated a reduction in procedural and RF times.
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Affiliation(s)
- Giulio Falasconi
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
- Arrhythmology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Diego Penela
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Arrhythmology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - David Soto-Iglesias
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Pietro Francia
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Division of Cardiology, Department of Clinical and Molecular Medicine, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Andrea Saglietto
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Dario Turturiello
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Open Heart Foundation, Barcelona, Spain
| | - Daniel Viveros
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
| | - Aldo Bellido
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Jose Alderete
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
- Open Heart Foundation, Barcelona, Spain
| | - Fatima Zaraket
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Paula Franco-Ocaña
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Marina Huguet
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | | | - Radu Vătășescu
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | | | - Julio Martí-Almor
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Antonio Berruezo
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
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11
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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12
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Boga M, Orbán G, Perge P, Salló Z, Tanai E, Ferencz AB, Tóth P, Komlósi F, Osztheimer I, Nagy KV, Merkely B, Gellér L, Szegedi N. Adherence to the CLOSE Protocol and Low Baseline Generator Impedance Are Independent Predictors of Durable Pulmonary Vein Isolation. J Clin Med 2024; 13:1960. [PMID: 38610727 PMCID: PMC11012634 DOI: 10.3390/jcm13071960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) is predominantly attributed to pulmonary vein reconnection (PVR). Predictors of AF recurrence have been widely studied; however, data are scarce on procedural parameters that predict chronic PVR. We aimed to study PVR rates and predictors of PVR. Methods: We retrospectively included 100 patients who underwent repeated ablation due to AF recurrence after initial PVI with the CARTO system. PVR was determined during the repeated procedure by electrophysiological evaluation, and initial procedural characteristics predicting PVR were studied, including adherence to the CLOSE protocol, use of high power, first-pass isolation (FPI), and baseline generator impedance (BGI). Results: Thirty-eight patients underwent initial CLOSE-guided PVI, and sixty-two underwent initial non-CLOSE PVI. A repeat procedure was performed 23 ± 16 months after the initial procedure. In total, PVR was found in 192 of 373 PVs (51.5%), and all PVs were isolated in 17/100 (17%) patients. Factors associated with all PVs being isolated were adherence to the CLOSE protocol, a higher power setting, the presence of bilateral FPI, and lower BGI (88% vs. 28%, p < 0.0001; 37.5 W vs. 30 W, p = 0.0276; 88.2% vs. 40.4%, p = 0.0007; and 127.6 Ω vs. 136.6 Ω, p = 0.0027, respectively). In initial procedures with adherence to the CLOSE protocol, the FPI rate was significantly higher (73.7% vs. 25%, p < 0.0001), while there were no significant differences in terms of procedure time and left atrial dwell time (81 vs. 85 min, p = 0.83; and 60 vs. 58 min, p = 0.08, respectively). BGI ≥ 130 Ω (AUC = 0.7403, sensitivity: 77.1%, specificity: 68.8%, p = 0.0032) was associated with a significantly higher probability of PVR (OR = 6.757; p < 0.0001). In multivariable analysis, independent predictors for PVR were non-adherence to the CLOSE protocol and BGI ≥ 130 Ω. Conclusions: Our findings indicate that adherence to the CLOSE protocol and baseline generator impedance < 130 Ω during AF ablation are independent predictors of PVI durability.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Nándor Szegedi
- Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary; (M.B.); (G.O.)
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13
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Zeng L, Chen S, Zeng R, Hu H, Yang Q, Cui K, Chen Q, Fu H, Pu X. CLOSE protocol versus lower ablation index value for paroxysmal atrial fibrillation: A randomized noninferior clinical trial. J Cardiovasc Electrophysiol 2024; 35:469-477. [PMID: 38282257 DOI: 10.1111/jce.16194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/02/2024] [Accepted: 01/14/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION The optimized ablation index (AI) value for catheter ablation of atrial fibrillation (AF) remains to be defined. We aimed to compare the efficacy and safety of CLOSE protocol and lower AI protocol in paroxysmal AF. METHODS AND RESULTS Patients with symptomatic, drug-resistant paroxysmal AF for first ablation were prospectively enrolled from September 2020 to January 2022. The patients were randomly divided into CLOSE group (AI ≥ 550 for anterior/roof segments and ≥400 for posterior/inferior segments) and lower AI group (AI ≥ 450 for anterior/roof segments and ≥350 for posterior/inferior segments). First-pass isolation, acute pulmonary vein (PV) reconnections, 1-year arrhythmia recurrence, and major complications were assessed. Of the 270 enrolled patients, 238 completed 1-year follow-up (118 in CLOSE group and 120 in lower AI group). First-pass isolation in left PVs was higher in CLOSE group (71.2% vs. 53.3%, p = .005). Acute PV reconnections were comparable between groups (9.3% vs. 14.2%, p = .246). At 1 year, 86.4% in CLOSE group versus 81.7% in lower AI group were free from atrial arrhythmia (log rank p = .334). The proportion difference was -4.8% (95% CI: -14.1% to 4.6%), and p = .475 for noninferiority. Stroke occurred in four patients of lower AI group, and no cardiac tamponade, atrioesophageal fistula, major bleeding or death occurred post procedure. CONCLUSION For patients with paroxysmal AF and treated by AI-guided PV ablation, lower AI is not noninferior to CLOSE protocol.
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Affiliation(s)
- Lijun Zeng
- Laboratory of Heart Valve Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Shi Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Zeng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hongde Hu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qingyong Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hua Fu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaobo Pu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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14
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Gu W, Liu W, Li J, Shen J, Liu R, Liang W, Luo X, Xiong N. Acute epicardial pulmonary vein reconnection: Nondurable transmural lesion or late manifestation of conduction through intercaval bundle. J Cardiovasc Electrophysiol 2024; 35:422-432. [PMID: 38205929 DOI: 10.1111/jce.16182] [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: 10/03/2023] [Revised: 12/20/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Acute pulmonary vein reconnection (PVR) via epicardial fibers can be found during observation period after PV isolation, the characteristics and related factors have not been fully studied. We aimed to investigate the prevalence, locations, electrogram characteristics, and ablation parameters related to acute epicardial pulmonary vein reconnection (AEPVR). METHODS Acute PVR was monitored during observation period after PV isolation. AEPVRs were mapped and distinguished from endocardial conduction gaps. The clinical, electrophysiological characteristics and lesion set parameters were compared between patients with and without PVR. They were also compared among AEPVR, gap-related reconnection, and epicardial PVR in repeat procedures. RESULTS A total of 56.1% acute PVR were AEPVR, which required a longer waiting period (p < .001) than endocardial gap. The majority of AEPVR were connections from the posterior PV carina to the left atrial posterior wall, followed by late manifestation of intercaval bundle conduction from the right anterior carina to right atrium. AEPVR was similar to epicardial PVR in redo procedures in distribution and electrogram characteristics. Smaller atrium (p < .001), lower impedance drop (p = .039), and ablation index (p = .028) on the posterior wall were independently associated with presence of AEPVR, while lower interlesion distance (p = .043) was the only predictor for AEPVR in acute PVR. An integrated model containing multiple lesion set parameters had the highest predictive ability for AEPVR in receiver operating characteristics analysis. CONCLUSIONS Epicardial reconduction accounted for the majority of acute PVR. AEPVR was associated with anatomic characteristics and multiple ablation-related parameters, which could be explained by nondurable transmural lesion or late manifestation of conduction through intercaval bundle.
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Affiliation(s)
- Wentao Gu
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Weizhuo Liu
- Centre for Cardiopulmonary Translational Medicine, Shanghai Chest Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jian Li
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Shen
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Rongchen Liu
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Weiguo Liang
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xinping Luo
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Nanqing Xiong
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
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15
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Robaye B, Deceuninck O, Blommaert D, Godeaux V, Dormal F, Collet B, Ballant E, Huys F, Purnode P, Xhaët O. Method, safety, and outcomes of persistent AF ablation without a circular mapping catheter: 3 years experience of a Belgian Tertiary Centre. Acta Cardiol 2024:1-8. [PMID: 38334112 DOI: 10.1080/00015385.2022.2135240] [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: 08/06/2021] [Accepted: 10/06/2022] [Indexed: 02/10/2024]
Abstract
BACKGROUND We aimed to share our methods and experience of persistent AF ablation without a circular mapping catheter (CMC), thereby avoiding femoral venous and transseptal punctures, decreasing the cost of the procedure, and possibly reducing the duration of the procedure and fluoroscopy time. METHODS We report our experience with 261 persistent AF ablations performed without a CMC over the past 3 years. RESULTS The procedures were performed with no apparent loss of efficacy or safety. Freedom from recurrence was defined as a 1-year absence of AF/atrial flutter (AFL) episodes >30 s, beyond the 3-month blanking period. At 1 year, 72% of the patients were free from arrythmias. CONCLUSIONS Persistent AF ablation is feasible without a CMC, reducing the need for venous and transseptal punctures and the cost of the procedure. We suggest that prospective studies should aim to characterise the reduction in procedure and fluoroscopy times as a result of this technique.
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Affiliation(s)
- Benoit Robaye
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Olivier Deceuninck
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
- Department of Cardiology, CHR Namur, Namur, Belgium
| | - Dominique Blommaert
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Veronique Godeaux
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Fabien Dormal
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Benoit Collet
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Elisabeth Ballant
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Florence Huys
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Philippe Purnode
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Olivier Xhaët
- Service de Cardiologie, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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16
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Nomura T, Maeda M, Kumazawa D, Mizuno Y, Onodera K, Toyoda S, Yamashita K. The effect of ablation settings on lesion characteristics with DiamondTemp ablation system: An ex vivo experiment. J Arrhythm 2024; 40:109-117. [PMID: 38333399 PMCID: PMC10848608 DOI: 10.1002/joa3.12970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction Creating large lesion in ablations using the DiamondTemp (DTA) ablation system may reduce the frequency of arrhythmia recurrence and allow the treatment of ventricular arrhythmias. Therefore, this study aimed to investigate whether power, application time, contact force (CF), and contact angle affect lesion formation in the ventricles. Methods Ablations were delivered to porcine myocardial preps to evaluate the lesion characteristics. Ablations were conducted with a maximum power of 50 W, target temperature of 58°C, CF of 10, 20, or 30 g, and contact angle between the catheter tip and tissue. The ablation durations were 15, 30, 60 s, 15 s × 2, or 30 s × 2. Results Steam pops occurred only in cases with perpendicular contact. The lesion depth was larger in all settings in the perpendicular orientation than in the parallel orientation. The temperatures were lower in all settings in the perpendicular orientation than in the parallel orientation. The lesions became larger as CF increased with perpendicular contact and duration of ≥30 s. The longer application time resulted in larger surface area, depth, and volume of the lesion. Lesion depth was greater with single application of 30 and 60 s than with 15 s × 2 and 30 s × 2, respectively. Conclusion It is important to perform a single prolonged application as much as possible to create deeper lesions. Parallel contact with the tissue should be maintained to take advantage of the temperature sensor's capabilities to avoid pop phenomenon.
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Affiliation(s)
- Takehiro Nomura
- Heart Rhythm Center, Department of Cardiovascular MedicineSendai Kosei HospitalSendai‐shiMiyagiJapan
| | - Manabu Maeda
- Heart Rhythm Center, Department of Cardiovascular MedicineSendai Kosei HospitalSendai‐shiMiyagiJapan
| | - Daiki Kumazawa
- Heart Rhythm Center, Department of Cardiovascular MedicineSendai Kosei HospitalSendai‐shiMiyagiJapan
| | - Yosuke Mizuno
- Heart Rhythm Center, Department of Cardiovascular MedicineSendai Kosei HospitalSendai‐shiMiyagiJapan
| | - Kosuke Onodera
- Heart Rhythm Center, Department of Cardiovascular MedicineSendai Kosei HospitalSendai‐shiMiyagiJapan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, School of MedicineDokkyo Medical UniversityMibuTochigiJapan
| | - Kennosuke Yamashita
- Heart Rhythm Center, Department of Cardiovascular MedicineSendai Kosei HospitalSendai‐shiMiyagiJapan
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17
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Iwakawa H, Takigawa M, Yamaguchi J, Martin CA, Goya M, Yamamoto T, Amemiya M, Ikenouchi T, Negishi M, Kawamura I, Goto K, Shigeta T, Nishimura T, Takamiya T, Tao S, Miyazaki S, Watanabe H, Sasano T. Superiority of the Combination of Input and Output Parameters to the Single Parameter for Lesion Size Estimation. Circ J 2023; 87:1757-1764. [PMID: 37899173 DOI: 10.1253/circj.cj-23-0574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND For lesion size prediction, each input parameter, including ablation energy (AE), and output parameter, such as impedance, is individually used. We hypothesize that using both parameters simultaneously may be more optimal.Methods and Results: Radiofrequency applications at a range of power (30-50 W), contact force (10 g and 20 g), duration (10-60 s), and catheter orientation with normal saline (NS)- or half-normal saline (HNS)-irrigation were performed in excised porcine hearts. The correlations, with lesion size of AE, absolute impedance drop (∆Imp-drop), relative impedance drop (%Imp-drop), and AE*%Imp-drop were examined. Lesion size was analyzed in 283 of 288 lesions (NS-irrigation, n=142; HNS-irrigation, n=141) without steam pops. AE*%Imp-drop consistently showed the strongest correlations with lesion maximum depth (NS-irrigation, ρ=0.91; HNS-irrigation, ρ=0.94), surface area (NS-irrigation, ρ=0.87; HNS-irrigation, ρ=0.86), and volume (NS-irrigation, ρ=0.94; HNS-irrigation, ρ=0.94) compared with the other parameters. Moreover, compared with AE alone, AE*%Imp-drop significantly improved the strength of correlation with lesion maximum depth (AE vs. AE*%Imp-drop, ρ=0.83 vs. 0.91, P<0.01), surface area (ρ=0.73 vs. 0.87, P<0.01), and volume (ρ=0.84 vs. 0.94, P<0.01) with NS-irrigation. This tendency was also observed with HNS-irrigation. Parallel catheter orientation showed a better correlation with lesion depth and volume using ∆Imp-drop, %Imp-drop, and AE*%Imp-drop than perpendicular orientation. CONCLUSIONS The combination of input and output parameters is more optimal than each single parameter for lesion prediction.
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Affiliation(s)
- Hidehiro Iwakawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine
| | - Masateru Takigawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Junji Yamaguchi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Tasuku Yamamoto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Miki Amemiya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Takashi Ikenouchi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Miho Negishi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Iwanari Kawamura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Kentaro Goto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Takatoshi Shigeta
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Takuro Nishimura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Tomomasa Takamiya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Susumu Tao
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Hiroyuki Watanabe
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
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18
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Tonko JB, Silberbauer J, Mann I. How to ablate the septo-pulmonary bundle: a case-based review of percutaneous ablation strategies to achieve roof line block. Europace 2023; 25:euad283. [PMID: 37713215 PMCID: PMC10558061 DOI: 10.1093/europace/euad283] [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: 06/27/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
Electrical conduction through cardiac muscle fibres separated from the main myocardial wall by layers of interposed adipose tissue are notoriously difficult to target by endocardial ablation alone. They are a recognised important cause for procedural failure due to the difficulties of delivering sufficient energy via the endocardial radiofrequency catheter to reach the outer epicardial layer without risking adverse events of the otherwise thin walled atria. Left atrial ablations for atrial fibrillation (AF) and tachycardia are commonly affected by the presence of several epicardial structures, with the septo-pulmonary bundle (SPB), Bachmann's bundle, and the ligament of Marshall all posing substantial challenges for endocardial procedures. Delivery of a transmural lesion set is essential for sustained pulmonary vein isolation and for conduction block across linear atrial lines which in turn has been described to translate into a reduced AF/atrial tachycardia recurrence rate. To overcome the limitations of endocardial-only approaches, surgical ablation techniques for epicardial or combined hybrid endo-epicardial ablations have been described to successfully target these connections. Yet, these techniques confer an increase in procedure complexity, duration, cost, and morbidity. Alternatively, coronary venous system ethanol ablation has been successfully employed by sub-selecting the vein of Marshall to facilitate mitral isthmus line block, although this approach is naturally limited to this area by the coronary venous anatomy. Increased awareness of the pathophysiological relevance of these epicardial structures and their intracardiac conduction patterns in the era of high-resolution 3D electro-anatomical mapping technology has allowed greater understanding of their contribution to the persistence of AF as well as failure to achieve transmural block by traditional ablation approaches. This might translate into novel catheter ablation strategies with procedural success rates comparable to surgical 'cut-and-sew' techniques. This review aims to give an overview of percutaneous catheter ablation strategies to target the SPB, an important cause of failed block across the roof line and isolation of the left atrial posterior wall and/or the pulmonary veins. Existing and investigational technologies will be discussed and an outlook of future approaches provided.
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Affiliation(s)
- Johanna Bérénice Tonko
- Institute for Cardiovascular Science, University College London, 5 University Street, WC1E 6JF London, UK
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
| | - John Silberbauer
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
| | - Ian Mann
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
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19
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Okumura K, Inoue K, Goya M, Origasa H, Yamazaki M, Nogami A. Acute and mid-term outcomes of ablation for atrial fibrillation with VISITAG SURPOINT: the Japan MIYABI registry. Europace 2023; 25:euad221. [PMID: 37490850 PMCID: PMC10492225 DOI: 10.1093/europace/euad221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023] Open
Abstract
AIMS The effectiveness of pulmonary vein isolation (PVI) guided by VISITAG SURPOINT (VS) has been demonstrated in Western populations. However, data for Asian populations are limited. VS settings may differ for Asians, given their smaller body size. This study aimed to describe outcomes of radiofrequency atrial fibrillation (AF) ablation guided by VS in a large Asian population. METHODS AND RESULTS The prospective, observational, multicentre MIYABI registry collected real-world data from patients undergoing VS-guided AF ablation using ThermoCool SmartTouch and ThermoCool SmartTouch SF catheters from 50 Japanese centres. All patients had paroxysmal AF or persistent AF for <6 months. Primary adverse events (PAEs) were evaluated for safety. The primary efficacy endpoint was the proportion of patients with PVI at the end of the procedure. Mid-term effectiveness (up to 12 months) was evaluated by freedom from documented atrial arrhythmias. Of the 1011 patients enrolled, 1002 completed AF ablation. The mean number of VS values per procedure was 428.8 on the anterior wall and 400.4 on the posterior wall. Nine patients (0.9%) experienced PAEs. Upon procedure completion, 99.7% of patients had PVI. Twelve-month freedom from atrial arrhythmia recurrence was 88.5%; 5.7% of patients were re-ablated. At repeat ablation, 54% of RSPV, 73% of RIPV, 70% of LSPV, and 86% of LIPV evaluated remained durably isolated. CONCLUSION Despite lower anterior wall VS values compared with the CLOSE protocol (≥550), the present study demonstrated comparable efficacy outcomes, indicating that a VS of ≥550 for the anterior wall may not be necessary for Asian patients.
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Affiliation(s)
- Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto 861-4193, Japan
| | - Koichi Inoue
- Division of Cardiology, National Hospital Organization Osaka National Hospital, 2-1-14 Houenzaka, Chuo-ku, Osaka 540-0006, Japan
- Cardiovascular Center, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Hideki Origasa
- The Institute of Statistical Mathematics, 10-3 Midori-cho, Tachikawa, Tokyo 190-8562, Japan
| | - Makiho Yamazaki
- Department of Clinical Research, Johnson & Johnson K.K. Medical Company,Chiyoda First Building West Tower, 3-5-2 Nishi-Kanda, Chiyoda-ku, Tokyo 101-0065, Japan
| | - Akihiko Nogami
- Department of Cardiology, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
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20
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Ding L, Weng S, Zhang H, Sun Y, Jiang Z, Mi L, Yu F, Qi Y, Zhang S, Hua W, Yao Y, Tang M. The predictive value of tissue response viewer for lesion transmurality in a porcine model. Hellenic J Cardiol 2023; 72:34-42. [PMID: 36750164 DOI: 10.1016/j.hjc.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/25/2023] [Accepted: 02/02/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The tissue response viewer (TRV) is a multiparametric index that incorporates time, power, tissue pressure, impedance, and wall thickness data during radiofrequency catheter ablation (RFCA) and is used to predict the transmurality of lesions. This study aimed to evaluate the feasibility and accuracy of the TRV in a porcine model. METHODS Twelve pigs underwent preablation high-density voltage and activation mapping of two atria, and both were repeated after linear RFCA. Intentional gaps were kept in the left atrium (LA) and were touched up in the right atrium (RA). Standard and high powers were, respectively, performed in the LA ablation. Six pigs were immediately sacrificed for pathological examination after the mapping and ablation procedure (acute study). Another six pigs were kept for 4 weeks before remapping and pathological examination (chronic study). RESULTS All animals completed the planned procedure. The TRV function showed a sensitivity of 97.1% and a specificity of 76.9% in the acute study, and a sensitivity of 95.9% and a specificity of 72.5% in the chronic study to predict the transmural lesion. All positive and negative predictive values were over 80%. In addition, the TRV achieved higher sensitivity (92.3% vs. 85.0%) and specificity (88.2% vs. 78.9%) to predict the transmural lesion in LA ablation with high power compared with standard ablation. CONCLUSIONS This study presents the histopathological validation of TRV to predict transmural lesions. The use of TRV may guide a more individual ablation and a more precise touch-up of gaps for atrial arrhythmias.
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Affiliation(s)
- Lei Ding
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Sixian Weng
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China; National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital, National Center of Gerontology, Beijing
| | - Hongda Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Yang Sun
- Department of Pathology, Diagnostic Laboratory Service, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Zihan Jiang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Lijie Mi
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Fengyuan Yu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Yingjie Qi
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Shu Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Wei Hua
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Yan Yao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China
| | - Min Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing 100037, China.
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21
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Miller J, Sewani A, Rezazada J, Alawneh Y, Kazemian P, Terricabras M, Wright G, Tavallaei MA. Quantification of Mechanical Characteristics of Conventional Steerable Ablation Catheters for Treatment of Atrial Fibrillation Using a Heart Phantom. Cardiovasc Eng Technol 2023; 14:419-427. [PMID: 36828976 DOI: 10.1007/s13239-023-00662-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/06/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Accurate and reliable catheter navigation is important in formation of adequate lesions during radiofrequency cardiac catheter ablation. To inform future device design efforts and to characterize the limitations of conventional devices, the focus of this study is to assess and quantify the mechanical performance of manual ablation catheters for pulmonary vein isolation procedures within a phantom heart model. METHODS We measured three important metrics: accuracy of catheter tip navigation to target anatomical landmarks at the pulmonary veins (PVs), orientation of the catheter relative to the tissue at the targets, and the delivered force values and their stability and variations at those targets. A stereovision system was used for navigational guidance and to measure the catheter's tip position and orientation relative to the targets. To measure force, piezoelectric sensors were used which were integrated at the targets, whereby operators were instructed to stabilize the catheter to achieve a chosen reference force value. RESULTS An overall positioning accuracy of 1.57 ± 1.71 mm was achieved for all targets. No statistical significance was observed in position accuracy between the right and left PVs (p = 0.5138). The orientation of the catheter relative to tissue surface was 41° ± 21° with no statistical significance between targets. The overall force stability was 41 ± 6 g with higher difficulty in force stabilization in the right compared to the left PV (40 ± 8 vs. 43 ± 2 g, p < 0.0001). CONCLUSION Based on our results, future improvements to manual catheter navigation for ablation should focus on improving device performance in orientation control and improved force stability.
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Affiliation(s)
- Jacob Miller
- Toronto Metropolitan University, Toronto, ON, Canada.
- Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Alykhan Sewani
- Toronto Metropolitan University, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Jeffrey Rezazada
- Toronto Metropolitan University, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Yara Alawneh
- Toronto Metropolitan University, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | | | | | | | - M Ali Tavallaei
- Toronto Metropolitan University, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
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22
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Falasconi G, Penela D, Soto-Iglesias D, Francia P, Teres C, Saglietto A, Jauregui B, Viveros D, Bellido A, Alderete J, Meca-Santamaria J, Franco P, Gaspardone C, San Antonio R, Huguet M, Cámara Ó, Ortiz-Pérez JT, Martí-Almor J, Berruezo A. Personalized pulmonary vein antrum isolation guided by left atrial wall thickness for persistent atrial fibrillation. Europace 2023; 25:euad118. [PMID: 37125968 PMCID: PMC10228614 DOI: 10.1093/europace/euad118] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/07/2023] [Indexed: 05/02/2023] Open
Abstract
AIMS Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF. METHODS AND RESULTS Consecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50-67), fluoroscopy time was 43 s (IQR 20-71), and radiofrequency (RF) time was 16.5 min (IQR 14.3-18.4). The median AI tailored to the local LAWT was 387 (IQR 360-410) for the anterior wall and 335 (IQR 300-375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up. CONCLUSION In this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).
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Affiliation(s)
- Giulio Falasconi
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, C/Villarroel 170, 08024 Barcelona, Spain
| | - Diego Penela
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - David Soto-Iglesias
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Pietro Francia
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
- Cardiology, Department of Clinical and Molecular Medicine, St. Andrea Hospital, Sapienza University, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Cheryl Teres
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Andrea Saglietto
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - Beatriz Jauregui
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Daniel Viveros
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, C/Villarroel 170, 08024 Barcelona, Spain
| | - Aldo Bellido
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Jose Alderete
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, C/Villarroel 170, 08024 Barcelona, Spain
| | - Julia Meca-Santamaria
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Paula Franco
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Carlo Gaspardone
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Rodolfo San Antonio
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Marina Huguet
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Óscar Cámara
- Department of Information and Communication Technologies, Pompeu Fabra University, C/Tànger 122-140, 08018 Barcelona, Spain
| | - José-Tomás Ortiz-Pérez
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Julio Martí-Almor
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
| | - Antonio Berruezo
- Arrhythmia Department, Heart Institute, Teknon Medical Centre, C/Vilana 12, 08022 Barcelona, Spain
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23
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Nair GM, Birnie DH, Nery PB, Redpath CJ, Sarrazin JF, Roux JF, Parkash R, Bernier M, Sterns LD, Sapp J, Novak P, Veenhuyzen G, Morillo CA, Singh SM, Sadek MM, Golian M, Klein A, Sturmer M, Chauhan VS, Angaran P, Green MS, Bernick J, Wells GA, Essebag V. Standard vs Augmented Ablation of Paroxysmal Atrial Fibrillation for Reduction of Atrial Fibrillation Recurrence: The AWARE Randomized Clinical Trial. JAMA Cardiol 2023; 8:475-483. [PMID: 36947030 PMCID: PMC10034661 DOI: 10.1001/jamacardio.2023.0212] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/24/2023] [Indexed: 03/23/2023]
Abstract
Importance Recurrent atrial fibrillation (AF) commonly occurs after catheter ablation and is associated with patient morbidity and health care costs. Objective To evaluate the superiority of an augmented double wide-area circumferential ablation (WACA) compared with a standard single WACA in preventing recurrent atrial arrhythmias (AA) (atrial tachycardia, atrial flutter, or atrial fibrillation [AF]) in patients with paroxysmal AF. Design, Setting, and Participants This was a pragmatic, multicenter, prospective, randomized, open, blinded end point superiority clinical trial conducted at 10 university-affiliated centers in Canada. The trial enrolled patients 18 years and older with symptomatic paroxysmal AF from March 2015 to May 2017. Analysis took place between January and April 2022. Analyses were intention to treat. Interventions Patients were randomized (1:1) to receive radiofrequency catheter ablation for pulmonary vein isolation with either a standard single WACA or an augmented double WACA. Main Outcomes and Measures The primary outcome was AA recurrence between 91 and 365 days postablation. Patients underwent 42 days of ambulatory electrocardiography monitoring after ablation. Secondary outcomes included need for repeated catheter ablation and procedural and safety variables. Results Of 398 patients, 195 were randomized to the single WACA (control) arm (mean [SD] age, 60.6 [9.3] years; 65 [33.3%] female) and 203 to the double WACA (experimental) arm (mean [SD] age, 61.5 [9.3] years; 66 [32.5%] female). Overall, 52 patients (26.7%) in the single WACA arm and 50 patients (24.6%) in the double WACA arm had recurrent AA at 1 year (relative risk, 0.92; 95% CI, 0.66-1.29; P = .64). Twenty patients (10.3%) in the single WACA arm and 15 patients (7.4%) in the double WACA arm underwent repeated catheter ablation (relative risk, 0.72; 95% CI, 0.38-1.36). Adjudicated serious adverse events occurred in 13 patients (6.7%) in the single WACA arm and 14 patients (6.9%) in the double WACA arm. Conclusions and Relevance In this randomized clinical trial of patients with paroxysmal AF, additional ablation by performing a double ablation lesion set did not result in improved freedom from recurrent AA compared with a standard single ablation set. Trial Registration ClinicalTrials.gov Identifier: NCT02150902.
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Affiliation(s)
- Girish M. Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H. Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pablo B. Nery
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | - Ratika Parkash
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | - Martin Bernier
- McGill University Health Center, Montreal, Québec, Canada
| | | | - John Sapp
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | - Paul Novak
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | - George Veenhuyzen
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carlos A. Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Mehrdad Golian
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andres Klein
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marcio Sturmer
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Vijay S. Chauhan
- University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul Angaran
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Martin S. Green
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jordan Bernick
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A. Wells
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Québec, Canada
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
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Cai C, Wang J, Niu HX, Chu JM, Hua W, Zhang S, Yao Y. Clinical outcome of lesion size index-guided high-power radiofrequency catheter ablation for pulmonary vein isolation in patients with atrial fibrillation: 2-year follow-up. J Cardiovasc Electrophysiol 2023; 34:546-555. [PMID: 36640429 DOI: 10.1111/jce.15809] [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: 08/31/2022] [Revised: 12/03/2022] [Accepted: 01/04/2023] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The long-term efficacy of high-power (50 W) ablation guided by lesion size index (LSI-guided HP) for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) remains undetermined. Our study sought to assess the clinical efficacy of LSI-guided HP ablation for PVI in patients with AF and explore the potential predictors associated with clinical outcomes. METHODS We consecutively included 186 patients with AF who underwent LSI-guided HP (50 W) ablation at Fuwai Hospital from June 2019 to October 2021. The target LSI values of 4.5-5.5 and 4.0-4.5 at the anterior and posterior walls, respectively, were used in our study. The baseline clinical characteristics, procedural and ablation data, and clinical outcomes were evaluated. The independent potential predictors associated with AF recurrence were further evaluated. RESULTS The incidence rate of first-pass PVI was 83.9% (156/186). A total of 11 883 lesions were analyzed, and compared with posterior walls of pulmonary veins, anterior walls had significantly lower mean contact force (8.2 ± 3.0 vs. 8.3 ± 2.3 g, p = .015), longer mean radiofrequency duration (16.9 ± 7.2 vs. 12.9 ± 4.5 s, p < .001) and higher mean LSI (4.8 ± 0.2 vs. 4.4 ± 0.2, p < .001). The overall incidence of periprocedural complications was 3.7%, and steam pops without pericardial effusion occurred in three patients (1.6%). During a mean follow-up of 24.0 ± 8.4 months, the overall AF recurrence-free survival was 87.1% after a single procedure. Patients with paroxysmal AF had a higher incidence of freedom from AF recurrence than those with persistent AF (91.2% vs. 80.8%, log-rank p = .034). Higher LSI (HR 0.50, p < .001) and paroxysmal AF (HR 0.39, p = .029) were significantly associated with decreased AF recurrence. By receiver operating characteristic analysis, the LSI of 4.7 and 4.3 for the anterior and posterior walls of the PVs had the highest predictive value for AF recurrence, respectively. CONCLUSION LSI-guided HP (50 W) ablation for PVI was an efficient and safe strategy and led to favorable single-procedure 2-year AF recurrence-free survival in patients with AF. Higher LSI and paroxysmal AF were independent predictors of decreased 2-year AF recurrence. The LSI of 4.7 for the anterior wall and 4.3 for the posterior wall of the PVs were the best cutoff values for predicting AF recurrence after LSI-guided HP ablation.
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Affiliation(s)
- Chi Cai
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Wang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong-Xia Niu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Min Chu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Hua
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Mujović NM, Marinković MM, Marković N, Kocijančić A, Kovačević V, Vučićević V, Mujović NM, Potpara TS. Risk factors for late reconnections after circumferential pulmonary vein isolation guided by lesion size index - Data from repeat invasive electrophysiology procedure. Front Cardiovasc Med 2023; 9:986207. [PMID: 36776941 PMCID: PMC9908948 DOI: 10.3389/fcvm.2022.986207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 12/29/2022] [Indexed: 01/27/2023] Open
Abstract
Background Late reconnections (LR) of pulmonary veins (PVs) after wide antral circumferential ablation (WACA) using point-to-point radiofrequency (RF) ablation are common. Lesion size index (LSI) is a novel marker of lesion quality proposed by Ensite Precision mapping system, expected to improve PV isolation durability. This study aimed to assess the durability of LSI-guided PVI and the risk factors for LR of PVs. Methods The prospective study included 33 patients with paroxysmal atrial fibrillation (PAF) who underwent (1) the index LSI-guided WACA procedure (with target LSI of 5.5-6.0 for anterior and 5.0-5.5 for posterior WACA segments) and (2) the 3-month protocol-mandated re-mapping procedure in all patients, irrespective of AF recurrence after the index procedure. Ablation parameters reported by Ensite mapping system were collected retrospectively. The inter-lesion distance (ILD) between all adjacent WACA lesions was calculated off-line. Association between index ablation parameters and the LRs of PVs at 3 months was analyzed. Results The median patient age was 61 (IQR: 53-64) years and 55% of them were males. At index procedure, the first-pass WACA isolation rate was higher for the left PVs than the right PVs (64 vs. 33%, p = 0.014). In addition, a low acute reconnection rates were observed, as follows: in 12.1% of patients, in 6.1% of WACA circles, in 3.8% of WACA segments and in 4.5% of PVs. However, the 3-month remapping study revealed LR of PV in 63.6% of patients, 37.9% of WACA circles, 20.5% of WACA segments and 26.5% of PVs. The LRs were identified mostly along the left anterior WACA segment. Independent risk factors for the LR of WACA were left-sided WACA location (OR 3.216 [95%CI: 1.065-9.716], p = 0.038) and longer ILD (OR 1.256 [95%CI: 1.035-1.523] for each 1-mm increase, p = 0.021). The ILD of > 8.0 mm showed a predictive value for the LR of WACA, with the sensitivity of 84% and specificity of 46%. A single case of cardiac tamponade occurred following the re-mapping invasive procedure. No other complications were encountered. Conclusion Although the LSI-guided PVI ensures a consistent PVI during the index procedure, LRs of PVs are still common. Besides the LSI, the PVI durability requires an optimal ILD between adjacent lesions, especially along the anterior lateral ridge.
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Affiliation(s)
- Nebojša M. Mujović
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia,Faculty of Medicine, University of Belgrade, Belgrade, Serbia,*Correspondence: Nebojša M. Mujović,
| | - Milan M. Marinković
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nebojša Marković
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia,Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Aleksandar Kocijančić
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladan Kovačević
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Vera Vučićević
- Center for Anesthesiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nataša M. Mujović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia,Center for Physical Medicine and Rehabilitation, University Clinical Center of Serbia, Belgrade, Serbia
| | - Tatjana S. Potpara
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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High-power short-duration versus low-power long-duration ablation guided by the ablation index. Int J Cardiol 2023; 370:209-214. [PMID: 36228764 DOI: 10.1016/j.ijcard.2022.10.013] [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: 06/10/2022] [Revised: 09/21/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
AIMS To compare the two different ablation strategies, both guided by the Ablation Index (AI), in the setting of atrial fibrillation (AF) ablation: high-power short-duration (HPSD) ablation using 40 W on the posterior wall and 50 W elsewhere versus low-power long-duration (LPLD) using 25 W posteriorly and 35 W elsewhere. METHODS Prospective, multicenter nonrandomized, noninferiority study of consecutive patients referred for paroxysmal AF ablation from January 2018 to July 2019. Ablation was guided by the AI (≥500 for anterior segments, ≥450 for the roof and inferior segments and 400 posteriorly) and an interlesion distance (ILD) ≤ 6 mm. Patients were separated into two groups: HPSD vs LPLD. Acute reconnection (after adenosine trial) and 2-year outcomes were assessed. RESULTS 160 patients (61% males, median age of 62 [IQR 51-69] years), fulfilled the study inclusion criteria - 80 patients (316 pulmonary veins [PV]) in the HPSD group and 80 patients (314 PV) in the LPLD. The probability of acute PV reconnection was similar between both groups: 2.2% in HPSD, 95%CI 0.6% to 3.8% vs. 3.4% in LPLD, 95%CI 1.4% to 5.4%; p < 0.001 for noninferiority. Median PV ablation time (20 min vs 30 min, p < 0.01) and procedure duration (80 min vs 100 min, p < 0.001) were shorter in the HPSD group. After a median follow-up of 26 months, arrhythmia recurrence was similar between groups (17.5% in HPSD group vs. 18.8% in LPLD group, p = 0.79). CONCLUSIONS In paroxysmal AF patients treated with the Ablation Index, a HPSD strategy is noninferior to the more standard LPLD ablation, while allowing for quicker procedures with shorter ablation times.
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Sohns C, Bergau L, El-Hamriti M, Fox H, Molatta S, Braun M, Khalaph M, Imnadze G, Sommer P. Posterior wall substrate modification using optimized and contiguous lesions in patients with atrial fibrillation. Cardiol J 2022; 29:917-926. [PMID: 33346368 PMCID: PMC9788747 DOI: 10.5603/cj.a2020.0180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/13/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Radiofrequency (RF) linear ablation at the left atrial (LA) roof and bottom to isolate the LA posterior wall using contiguous and optimized RF lesions was evaluated. Achieving isolation of the LA posterior wall is challenging as two continuous linear lesion sets are necessary. METHODS Forty consecutive patients with symptomatic atrial fibrillation (AF) and arrhythmia substrates affecting the LA posterior wall underwent posterior wall isolation by linear lesions across the roof and bottom. The cohort was divided into two groups: group 1 (20 patients) linear ablation guided by contact force (CF) only; group 2 (20 patients) guided by ablation index (AI) and interlesion distance. RESULTS Bidirectional block across the LA roof and bottom was achieved in 40/40 patients. Additional endocardial RF applications in 5 patients from group 1 vs. 3 patients from group 2 resulted in posterior wall isolation in all patients. Procedure duration was almost equal in both groups. CF and AI were significantly higher in group 2 for the roof line, whereas no statistical difference was found for the bottom line. AI-guided LA posterior wall isolation led to a significantly lower maximum temperature increase. The mean AI value as well as the mean value for catheter-to-tissue CF for the roof line were significantly higher when AI-guided ablation was performed. Standard deviation in group 2 showed a remarkably lower dispersion. CONCLUSIONS Ablation index guided posterior wall isolation for substrate modification is safe and effective. AI guided application of the posterior box lesion allows improved lesion formation.
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Affiliation(s)
- Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Leonard Bergau
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Mustapha El-Hamriti
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery and Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Stephan Molatta
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Martin Braun
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Moneeb Khalaph
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Guram Imnadze
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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Nakagawa H, Ikeda A, Yokoyama K, An Y, Hussein AA, Saliba WI, Wazni OM, Castellvi Q. Improvement in Lesion Formation with Radiofrequency Energy and Utilization of Alternate Energy Sources (Cryoablation and Pulsed Field Ablation) for Ventricular Arrhythmia Ablation. Card Electrophysiol Clin 2022; 14:757-767. [PMID: 36396191 DOI: 10.1016/j.ccep.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Current ablation systems rely on thermal energy to produce ablation lesions (heating: RF, laser and ultrasound, and cooling: cryo-thermia). While thermal ablation has been proven to be effective, there are several limitations: 1) relatively long procedural times; 2) high recurrence rate of ventricular arrhythmias; and 3) excessive heating potentially leading to serious complications, including steam pop (perforation), coronary arterial injury and thrombo-embolism. Pulsed field ablation (PFA)/irreversible electroporation (IRE) offers a unique non-thermal ablation strategy which has the potential to overcome these limitations. Recent pre-clinical studies suggest that PFA/IRE might be effective and safe for the treatment of cardiac arrhythmias.
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Affiliation(s)
- Hiroshi Nakagawa
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA.
| | - Atsushi Ikeda
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Katsuaki Yokoyama
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshimori An
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ayman A Hussein
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Walid I Saliba
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Oussama M Wazni
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Quim Castellvi
- Department of Information and Communications Technologies, Pompeu Fabra University, Barcelona, Spain
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High-power short-duration ablation index-guided pulmonary vein isolation protocol using a single catheter. J Interv Card Electrophysiol 2022; 65:633-642. [PMID: 35596105 PMCID: PMC9726791 DOI: 10.1007/s10840-022-01226-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/13/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Catheter ablation for atrial fibrillation (AF) is the most commonly performed electrophysiological procedure. To improve healthcare utilization, we aimed to compare the efficacy, efficiency, and safety of a minimalistic, streamlined single catheter ablation approach using a high-power short-duration ablation index-guided protocol (HPSD) vs. a control single-catheter protocol (SP). METHODS Pulmonary vein isolation (PVI) with a single transseptal puncture without a multipolar mapping catheter was performed in 91 patients. Left atrial mapping was performed with the ablation catheter, only. Pacing maneuvers were used to confirm exit block. Procedural characteristics and success rates were compared using HPSD (n = 34) vs. a control (n = 57) ablation protocol. Freedom from recurrence was defined as a 1-year absence of AF episodes > 30 s, beyond the 3-month blanking period. RESULTS Using the HPSD protocol the median procedure and RF ablation time were significantly shorter compared to the SP, 84 (IQR 76-100) vs. 118 min (IQR 104-141) and 1036 (898-1184) vs. 1949s (IQR 1693-2261), respectively, p < .001 for all. First-pass PVI was achieved using the HPSD protocol in 88% and using the SP in 87% of patients, p = 1.0. No procedural complications were observed. High-sensitivity cardiac troponin levels were significantly higher in patients using the HPSD protocol compared to the SP. At 12 months follow-up, 87% patients remained free from AF with no differences between groups. CONCLUSIONS A minimalistic, HPSD ablation index-guided PVI with a single-catheter approach is very efficient, safe, and associated with excellent clinical outcomes at 1 year.
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30
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Gabriels JK, Ying X, Purkayastha S, Braunstein E, Liu CF, Markowitz SM, Mountantonakis S, Thomas G, Goldner B, Willner J, Goyal R, Ip JE, Lerman BB, Carter J, Bereanda N, Fitzgerald MM, Anca D, Patel A, Cheung JW. Safety and Efficacy of a Novel Approach to Pulmonary Vein Isolation Using Prolonged Apneic Oxygenation. JACC Clin Electrophysiol 2022; 9:497-507. [PMID: 36752460 DOI: 10.1016/j.jacep.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/11/2022] [Accepted: 10/19/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Improved ablation catheter-tissue contact results in more effective ablation lesions. Respiratory motion causes catheter instability, which impacts durable pulmonary vein isolation (PVI). OBJECTIVES This study sought to evaluate the safety and efficacy of a novel ablation strategy involving prolonged periods of apneic oxygenation during PVI. METHODS We conducted a multicenter, prospective controlled study of 128 patients (mean age 63 ± 11 years; 37% women) with paroxysmal atrial fibrillation undergoing PVI. Patients underwent PVI under general anesthesia using serial 4-minute runs of apneic oxygenation (apnea group; n = 64) or using standard ventilation settings (control group; n = 64). Procedural data, arterial blood gas samples, catheter position coordinates, and ablation lesion characteristics were collected. RESULTS Baseline characteristics between the 2 groups were similar. Catheter stability was significantly improved in the apnea group, as reflected by a decreased mean catheter displacement (1.55 ± 0.97 mm vs 2.25 ± 1.13 mm; P < 0.001) and contact force SD (4.9 ± 1.1 g vs 5.2 ± 1.5 g; P = 0.046). The percentage of lesions with a mean catheter displacement >2 mm was significantly lower in the apnea group (22% vs 44%; P < 0.001). Compared with the control group, the total ablation time to achieve PVI was reduced in the apnea group (18.8 ± 6.9 minutes vs 23.4 ± 7.8 minutes; P = 0.001). There were similar rates of first-pass PVI, acute PV reconnections and dormant PV reconnections between the two groups. CONCLUSIONS A novel strategy of performing complete PVI during apneic oxygenation results in improved catheter stability and decreased ablation times without adverse events. (Radiofrequency Ablation of Atrial Fibrillation Under Apnea; NCT04170894).
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Affiliation(s)
- James K Gabriels
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Xiaohan Ying
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Subhanik Purkayastha
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Eric Braunstein
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Christopher F Liu
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Steven M Markowitz
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Stavros Mountantonakis
- Division of Electrophysiology, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - George Thomas
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Bruce Goldner
- Division of Electrophysiology, Long Island Jewish Hospital, Northwell Health, Queens, New York, USA
| | - Jonathan Willner
- Division of Electrophysiology, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Rajat Goyal
- Division of Electrophysiology, Southside Hospital, Northwell Health, Bay Shore, New York, USA
| | - James E Ip
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Bruce B Lerman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Jane Carter
- Department of Anesthesia, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Nicola Bereanda
- Department of Anesthesia, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Meghann M Fitzgerald
- Department of Anesthesia, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Diana Anca
- Department of Anesthesia, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Apoor Patel
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA.
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA.
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Effectiveness and Safety of High-Power Radiofrequency Ablation Guided by Ablation Index for the Treatment of Atrial Fibrillation. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5609764. [PMID: 35991126 PMCID: PMC9391153 DOI: 10.1155/2022/5609764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/09/2022] [Accepted: 07/21/2022] [Indexed: 11/25/2022]
Abstract
Background To investigate the efficacy and safety of ablation index- (AI-) guided high-power radiofrequency ablation in the treatment of atrial fibrillation (AF). Methods Outcomes of radiofrequency (RF) applications were compared in a swine ventricular endocardial model (n = 10 each for 50 W, 40 W, and 30 W; AI = 500). And a total of 100 consecutive patients with paroxysmal AF undergoing pulmonary vein isolation (PVI) were included. The patients were divided into two groups (n = 50 for each) as follows: control group, treated with conventional power (30 W) ablation mode; and study group, treated with high power (40 W) radiofrequency ablation mode. All groups were treated with the same AI value guided the ablation (target AI = 400/500 on posterior/anterior wall, respectively). Acute pulmonary vein (PV) reconnection was assessed post adenosine administration 20 minutes after ablation. Subsequently, pathological observation of porcine heart lesions and necrotic tissue was performed. Additionally, statistical analyses were carried out on patients' baseline clinical characteristics, surgical data, and total RF energy. Results In swine ventricular endocardial RF applications, compared with 40 W and 30 W, the use of 50 W was associated with shallower tissue lesion depth (p < 0.001) and greater lesion maximum diameter (p < 0.001). Compared with 40 W and 30 W, tissue necrosis caused by 50 W was the deepest and largest (p < 0.001). In pulmonary vein isolation (PVI), there was no significant difference in baseline data between the study group and control group (p > 0.05). In patients with paroxysmal atrial fibrillation, the procedure time in the high-power group was significantly shortened (p < 0.001). The ablation time was significantly shorter (p < 0.001). Compared with control group, RF energy per point and acute pulmonary vein (PV) reconnection were lower (p < 0.001), and first-pass PVI was higher (p < 0.01) in study group. There were no significant differences in complications and sinus rhythm maintenance at 12 months between the two groups (p > 0.05). Conclusions Compared with conventional (30 W) PVI, AI-guided high-power (40 W) was safe and associated with shorter procedure time and reduced acute PV reconnection.
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Makihara Y, Miyazaki S, Harama T, Obunai K, Watanabe H, Tada H. Ablation Index Guided Left Atrial Posterior Wall Isolation. Int Heart J 2022; 63:708-715. [PMID: 35908854 DOI: 10.1536/ihj.22-091] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Ablation index (AI)-guided linear ablation is reported to be feasible.We assessed the feasibility of AI-guided left atrial (LA) posterior wall isolations (PWIs) using different target AI values.Seventy-one persistent atrial fibrillation patients who underwent AI-guided PWIs following pulmonary vein isolation were included. LA linear lesions were created with strict contiguity (inter-lesion distance < 4 mm) and different predetermined AI target values (Group-1: 430, Group-2: 450). The data was analyzed retrospectively.The total radiofrequency application time of the roof and bottom-line ablation was a median of 2.8 (2.0, 3.8) and 3.6 (2.8, 4.3) minutes. The first-pass PWI success rate (26/35 [74.3%] versus 16/36 [44.4%], P = 0.011) and a first-pass roof line block (28/35 [80.0%] versus 21/36 [58.3%], P = 0.048) were significantly higher in Group-2 than Group-1, but that for the first-pass bottom line block was similar between Group-1 and Group-2 (29/36 [80.6%] versus 29/35 [82.9%], P = 0.80). Successful PWIs were achieved by additional applications in all. The significant parameter associated with a successful first-pass LA roof line block was a greater RF power, and that for the LA bottom were a higher radiofrequency power and shorter inter-lesion distance. Conduction gaps were mostly located at the middle of both lines. Among 22 roof line gaps, 12 were closed on the line whereas 10 (45.4%) required ablation inside the posterior wall for PWIs. On the contrary, all 11 gaps on bottom lines were closed on the line.Successful first-pass PWIs were obtained in 74% of patients using a target AI value of 450 and strict criteria for the lesion contiguity.
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Affiliation(s)
- Yu Makihara
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shinsuke Miyazaki
- Department of Cardiovascular medicine, Faculty of Medical Sciences, University of Fukui
| | - Tomoko Harama
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kotaro Obunai
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | - Hiroshi Tada
- Department of Cardiovascular medicine, Faculty of Medical Sciences, University of Fukui
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Di Biase L, Monir G, Melby D, Tabereaux P, Natale A, Manyam H, Athill C, Delaughter C, Patel A, Gentlesk P, Liu C, Arkles J, McElderry HT, Osorio J. Composite Index Tagging for PVI in Paroxysmal AF. JACC Clin Electrophysiol 2022; 8:1077-1089. [DOI: 10.1016/j.jacep.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/16/2022] [Accepted: 06/06/2022] [Indexed: 11/27/2022]
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Unipolar Electrogram-Guided versus Lesion Size Index-Guided Catheter Ablation in Patients with Paroxysmal Atrial Fibrillation. J Cardiovasc Dev Dis 2022; 9:jcdd9070229. [PMID: 35877591 PMCID: PMC9320701 DOI: 10.3390/jcdd9070229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 11/17/2022] Open
Abstract
Background: This research explores the relationship between the unipolar electrogram (UP-EGM) and lesion size index (LSI) in different regions of continuous circular lesions (CCLs) and to assess the safety and efficacy of UP-EGM-guided versus LSI-guided radiofrequency catheter ablation (RFCA) in patients with paroxysmal atrial fibrillation (PAF). Methods: A total of 120 patients with drug-refractory PAF who underwent index RFCA were scheduled to be consecutively included from March 2020 to April 2021. All the patients were randomly divided 1:1 into two groups: the UP-EGM group and the LSI group. The first-pass PVI rate, acute PVI rate, and the sinus rhythm maintenance rate were compared. Results: A total of 120 patients with PAF were included in the study: the UP-EGM group (n = 60) and the LSI group (n = 60). All the LSI values in the UP-EGM group were less than those in the corresponding regions in the LSI group (all p < 0.001). There were no significant differences in the first-pass PVI rate and acute PVI rate between the two groups. After a mean follow-up period of 11.31 ± 1.70 months, the sinus rhythm maintenance rate in the UP-EGM group was comparable to that in the LSI group (90% vs. 91.7%, p = 0.752). Conclusion: UP-EGM-guided and LSI-guided RFCA are both effective and safe in patients with PAF. However, UP-EGM may be more suitable than LSI for guiding individual RFCA.
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Xiong Q, Liao J, Chen W, Xiao P, Du H, He Q, Yin Y, Ling Z, Chen S. Tailored Target Ablation Index Guided Pulmonary Vein Isolation in Treating Paroxysmal Atrial Fibrillation: A Single Center Randomized Study in Asian Population (AI-Asian-I). Front Cardiovasc Med 2022; 9:937913. [PMID: 35872904 PMCID: PMC9300915 DOI: 10.3389/fcvm.2022.937913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/20/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the efficacy and safety of lower ablation indexes (AI) guided pulmonary vein isolation (PVI) in treating paroxysmal atrial fibrillation (AF). Methods Ninety patients with paroxysmal AF scheduled for radiofrequency ablation were randomly divided into three groups. The AI targets for PVI were as follows: In group A/B/C, 550/500/450 for roof and anterior wall, and 400/350/300 for posterior/inferior wall. The first-pass PVI rate, ablation time, complications and recurrence of atrial tachyarrhythmia (ATa) were compared. Results The mean age was 62.5 years (male: 63.0%), mean body mass index (BMI): 24.35 ± 3.66 kg/m2. The baseline characteristics were comparable. There was no significant difference in the first-pass PVI rate among the three groups (left-sided-PV: 66.7% vs. 80% vs. 73.3%, P = 0.51; right-sided-PV: 70% vs. 83.3% vs. 73.3%, P = 0.64), also with similar gap rate during the procedural waiting time. At 1-year follow-up there was no significant difference in the recurrence rate of ATa among the three groups (10% vs. 13.3% vs. 13.3%, P = 1.00). The ablation time in the Group C was significantly less than that in the other two groups (47.8 min. vs. 47.0 min. vs. 36.6 min, P < 0.001). Higher AI seemed to link a non-significant trend toward higher rate of pericardial effusion (group A + B vs. group C:6.7% vs. 0%, P = 0.30), although the rate of overall complications was not different among the three groups. Conclusion This randomized study shows that, a relatively lower target AI guided ablation may be similarly effective to achieve PVI with significantly reduced ablation time and obtain similar clinical outcome in treating paroxysmal AF in Asian population. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [NCT:04549714].
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Boussoussou M, Szilveszter B, Vattay B, Kolossváry M, Vecsey-Nagy M, Salló Z, Orbán G, Péter P, Katalin P, Vivien NK, István O, Maurovich-Horvat P, Merkely B, Gellér L, Szegedi N. The effect of left atrial wall thickness and pulmonary vein sizes on the acute procedural success of atrial fibrillation ablation. Int J Cardiovasc Imaging 2022; 38:1601-1611. [PMID: 35138472 PMCID: PMC11142952 DOI: 10.1007/s10554-022-02533-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/20/2022] [Indexed: 11/05/2022]
Abstract
Nowadays, a novel contact-force guided ablation technique is used for enclosing pulmonary veins in patients with atrial fibrillation (AF). We sought to determine whether left atrial (LA) wall thickness (LAWT) and pulmonary vein (PV) dimensions, as assessed by cardiac CT, could influence the success rate of first-pass pulmonary vein isolation (PVI). In a single-center, prospective study, we enrolled consecutive patients with symptomatic, drug-refractory AF who underwent initial radiofrequency catheter ablation using a modified CLOSE protocol. Pre-procedural CT was performed in all cases. Additionally, the diameter and area of the PV orifices were obtained. A total of 1034 LAWT measurements and 376 PV area measurements were performed in 94 patients (mean CHA2DS2-VASc score 2.1 ± 1.5, mean age 62.4 ± 12.6 years, 39.5% female, 38.3% persistent AF). Mean procedure time was 81.2 ± 19.3 min. Complete isolation of all PVs was achieved in 100% of patients. First-pass isolation rate was 76% and 71% for the right-sided PVs and the left-sided PVs, respectively. No difference was found regarding comorbidities and imaging parameters between those with and without first-pass isolation. LAWT (mean of 11 regions or separately) had no effect on the acute procedural outcome on logistic regression analysis (all p ≥ 0.05). Out of all assessed parameters, only RSPV diameter was associated with a higher rate of successful right-sided first pass isolation (OR 1.01, p = 0.04). Left atrial wall thickness does not have an influence on the acute procedural success of PVI using ablation index and a standardized ablation protocol. RSPV diameter could influence the probability of right sided first-pass isolation.
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Affiliation(s)
- Melinda Boussoussou
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary.
| | - Bálint Szilveszter
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Borbála Vattay
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Márton Kolossváry
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Milán Vecsey-Nagy
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Zoltán Salló
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Gábor Orbán
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Perge Péter
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Piros Katalin
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Nagy Klaudia Vivien
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Osztheimer István
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | | | - Béla Merkely
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - László Gellér
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
| | - Nándor Szegedi
- Semmelweis University Heart and Vascular Center, Városmajor utca 68., Budapest, 1122, Hungary
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Cai C, Wang J, Niu HX, Chu JM, Hua W, Zhang S, Yao Y. Optimal Lesion Size Index for Pulmonary Vein Isolation in High-Power Radiofrequency Catheter Ablation of Atrial Fibrillation. Front Cardiovasc Med 2022; 9:869254. [PMID: 35463774 PMCID: PMC9021528 DOI: 10.3389/fcvm.2022.869254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Although both high-power (HP) ablation and lesion size index (LSI) are novel approaches to make effective lesions during pulmonary vein isolation (PVI) for atrial fibrillation (AF), the optimal LSI in HP ablation for PVI is still unclear. Our study sought to explore the association between LSI and acute conduction gap formation and investigate the optimal LSI in HP ablation for PVI. Methods A total of 105 consecutive patients with AF who underwent HP ablation guided by LSI (LSI-guided HP) for PVI in our institute between June 2019 and July 2020 were retrospectively enrolled. Each ipsilateral PV circle was subdivided into four segments, and ablation power was set to 50 W with target LSI values at 5.0 and 4.0 for anterior and posterior walls, respectively. We compared the LSI values with and without acute conduction gaps after the initial first-pass PVI. Results PVI was achieved in all patients, and the incidence of first-pass PVI was 78.1% (82/105). A total of 6,842 lesion sites were analyzed, and the acute conduction gaps were observed in 23 patients (21.9%) with 45 (0.7%) lesion points. The gap formation was significantly associated with lower LSI (3.9 ± 0.4 vs. 4.6 ± 0.4, p < 0.001), lower force-time integral (82.6 ± 24.6 vs. 120.9 ± 40.4 gs, p < 0.001), lower mean contact force (5.7 ± 2.4 vs. 8.5 ± 2.8 g, p < 0.001), shorter ablation duration (10.5 ± 3.6 vs. 15.4 ± 6.4 s, p < 0.001), lower mean temperature (34.4 ± 1.4 vs. 35.6 ± 2.6°C, p < 0.001), and longer interlesion distance (4.4 ± 0.3 vs. 4.3 ± 0.4 mm, p = 0.031). As per the receiver operating characteristic analysis, the LSI had the highest predictive value for gap formation in all PVs segments, with a cutoff of 4.35 for effective ablation (sensitivity 80.0%; specificity 75.4%, areas under the curve: 0.87). The LSI of 4.55 and 3.95 had the highest predictive value for gap formation for the anterior and posterior segments of PVs, respectively. Conclusion Using LSI-guided HP ablation for PVI, more than 4.35 of LSI for all PVs segments showed the best predictive value to avoid gap formation for achieving effective first-pass PVI. The LSI of 4.55 for the anterior wall and 3.95 for the posterior wall were the best cutoff values for predicting gap formation, respectively.
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Affiliation(s)
- Chi Cai
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jing Wang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Hong-Xia Niu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jian-Min Chu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wei Hua
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shu Zhang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yan Yao
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Sousa PA, Puga L, Barra S, Campos D, António N, Elvas L, Gonçalves L. High-sensitivity Troponin I and Ablation Effectiveness Quotient after Ablation Index-guided pulmonary vein isolation-markers of arrhythmia recurrence? J Interv Card Electrophysiol 2022; 65:115-121. [PMID: 35469051 DOI: 10.1007/s10840-022-01229-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND There are conflicting data regarding the relationship between high-sensitivity cardiac Troponin I (Hs-cTnI) and the ablation effectiveness quotient (AEQ) with arrhythmia recurrence following atrial fibrillation (AF) ablation. Our goals were to evaluate the impact of the Ablation Index (AI) software on Hs-cTnI and AEQ levels and to assess whether these markers are predictors of arrhythmia recurrence. METHODS Prospective single-center study of 75 consecutive patients referred for paroxysmal AF ablation from October 2017 to January 2019. Procedural endpoints and 2-year outcomes were assessed and compared to those of 75 propensity score-matched patients submitted to non-AI-guided pulmonary vein isolation (PVI) [control group]. RESULTS Compared to the control group, patients having AI-guided PVI had lower Hs-cTnI values (1580 [IQR 1180-2140] ng/L vs. 2600 [IQR 1840 - 3900], p < 0.001) and a lower AEQ (0.9 [IQR 0.6-1.2] ng/L/s vs. 1.4 [0.8-1.6] ng/L/s, p < 0.001). After a median follow-up of 26 (IQR 20-32) months, there was a significant reduction in arrhythmia recurrence in the AI group (15% vs. 31%, HR 0.67 [95% CI, 0.32-1.40], p = 0.02). However, neither Hs-cTnI nor AEQ was predictors of arrhythmia recurrence in AI-guided PVI. CONCLUSIONS The use of the AI software led to reduced levels of Hs-cTnI and lower AEQ in AF patients submitted to PVI. However, none of these markers predicted arrhythmia recurrence.
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Affiliation(s)
- Pedro A Sousa
- Pacing & Electrophysiology Unit, Cardiology Department, Coimbra's Hospital and University Center, Morada: Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal.
| | - Luís Puga
- Pacing & Electrophysiology Unit, Cardiology Department, Coimbra's Hospital and University Center, Morada: Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal
| | - Sérgio Barra
- Cardiology Department, Hospital da Luz Arrábida, V. N. Gaia, Portugal
| | - Diana Campos
- Pacing & Electrophysiology Unit, Cardiology Department, Coimbra's Hospital and University Center, Morada: Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal
| | - Natália António
- Pacing & Electrophysiology Unit, Cardiology Department, Coimbra's Hospital and University Center, Morada: Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal.,Faculty of Medicine, ICBR, University of Coimbra, Coimbra, Portugal
| | - Luís Elvas
- Pacing & Electrophysiology Unit, Cardiology Department, Coimbra's Hospital and University Center, Morada: Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal
| | - Lino Gonçalves
- Pacing & Electrophysiology Unit, Cardiology Department, Coimbra's Hospital and University Center, Morada: Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal.,Faculty of Medicine, ICBR, University of Coimbra, Coimbra, Portugal
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Impact of tip design and thermocouple location on the efficacy and safety of radiofrequency application. J Interv Card Electrophysiol 2022; 66:885-896. [PMID: 35451737 DOI: 10.1007/s10840-022-01219-8] [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: 12/04/2021] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The FlexAbility™ SE catheter has a laser-cut 8Fr 4-mm flexible tip irrigated through laser-cut kerfs with a thermocouple 0.3 mm from the distal end. The TactiCath™ SE catheter has an 8Fr 3.5-mm tip and 6-irrigation port with a thermocouple 2.67 mm proximal to the tip. We investigated the impact of these differences on the efficacy and safety of radiofrequency (RF) applications. METHODS RF applications at a range of powers (20 W, 30 W, and 40 W), contact forces (5 g, 15 g, and 25 g), and durations (10-60 s) using perpendicular/parallel catheter orientation were performed in excised porcine hearts. Lesion characteristics and incidence of steam pops were compared. RESULTS A total of 540 lesions were examined. The FlexAbility™ SE catheter produced smaller lesion depths (4.0 mm vs. 4.4 mm, p = 0.014 at 20 W; 4.6 mm vs. 5.6 mm, p = 0.015 at 30 W), surface areas (22.7mm2 vs. 29.2mm2 at 20 W, p = 0.005; 23.2mm2 vs. 28.7mm2, p = 0.009 at 30 W), and volumes (126.1mm3 vs. 175.1mm3, p = 0.018 at 20 W; 183.2mm3 vs. 304.3mm3, p = 0.002 at 30 W) with perpendicular catheter placement. However, no differences were observed with parallel catheter placement. Steam-pops were significantly less frequently observed with the FlexAbility™ SE catheter (4% vs. 22%, p < 0.001) irrespective of catheter direction to the tissue. Multivariate analysis showed that use of the TactiCath™ SE catheter, power ≥ 40 W, contact force ≥ 25 g, RF duration > 30 s, parallel angle, and impedance drop ≥ 20Ω were significantly associated with occurrence of steam-pops. CONCLUSIONS The FlexAbility™ SE catheter reduced the risk of steam-pops but produced smaller lesions with perpendicular catheter placement compared to the TactiCath™ SE catheter.
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40
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Comparison of two catheters measuring local impedance: local impedance variation vs lesion characteristics and steam pops. J Interv Card Electrophysiol 2022; 65:419-428. [PMID: 35438394 DOI: 10.1007/s10840-022-01214-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The size of the distal electrode and the method of measuring local impedance (LI) are different between the IntellaNav MiFi-OI™ (MiFi-OI) and IntellaNav STABLE POINT™ (SP) catheters. We investigated the impact of these differences on LI, efficacy, and safety of radiofrequency (RF) applications. METHODS RF applications at a range of powers (30 W, 40 W, and 50 W), contact forces (10 g and 20 g), and durations (10-120 s) were performed in excised porcine hearts (N = 48). LI variation was defined by δLI-drop (= initial LI - post-RF LI) and %LI-drop (= δLI-drop/initial LI) × 100, and the relationship between lesion characteristics and LI variation was compared. RESULTS A total of 576 lesions were examined. Although absolute δLI-drop during RF applications was significantly larger for the SP than MiFi-OI catheter (47[31-65]ohm for SP vs 37[24-51]ohm for MiFi-OI, p < 0.0001), %LI-drop was similar (23.3 [15.5-30.6]% in SP vs 24.9[17.3-32.5]% in MiFi-OI, p = 0.10). Although lesions produced by both catheters were similarly correlated with LI variation, the SP catheter produced generally larger lesions (depth; 5.0 [3.7-6.1]mm vs 4.7 [3.3-6.0]mm, p = 0.06; surface areas, 46.9 [36.8-58.8]mm2 vs 44.7 [34.3-55.5]mm2, p = 0.02; volume, 321 [165-533]mm3 vs 265[141-471]mm3, p = 0.02). Steam pops were similarly observed with both catheters. In both catheters, %LI-drop was superior to δLI-drop in correlation to lesion size (p < 0.0001) and in predicting steam pops (p < 0.01). CONCLUSIONS Although no difference in safety profile is observed between MiFi-OI and SP catheters, the SP catheter produces larger lesions. %LI-drop is superior to δLI-drop in correlation to lesion size and in predicting steam pops as well as in normalizing the difference between catheters.
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Kreidieh O, Varley AL, Romero J, Singh D, Silverstein J, Thosani A, Varosy P, Hebsur S, Godfrey BE, Schrappe G, Justice L, Zei PC, Osorio J. Practice Patterns of Operators Participating in the Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) Registry. J Interv Card Electrophysiol 2022; 65:429-440. [PMID: 35438393 DOI: 10.1007/s10840-022-01205-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) is a multicenter prospective registry of atrial fibrillation (AF) ablation. We sought to describe the baseline workflows of REAL-AF operators. METHODS REAL-AF enrolls high volume minimum fluoroscopy radiofrequency ablators. A 150 item questionnaire was administered to participating operators. Responses were analyzed using standard methods. RESULTS Forty-two respondents had a mean 178.2 ± 89.2 yearly AF ablations, with 42.4 ± 11.9% being paroxysmal (PAF). Most operators performed ablation with uninterrupted or minimally interrupted anticoagulation (66.7% and 28.6%). Left atrial appendage (LAA) thrombus was most commonly ruled out with transesophageal echocardiography (33.3% and 42.9% for PAF and persistent AF). Consistent with registry design, radiofrequency energy (92.1% ± 18.8% of cases) and zero fluoroscopy ablation (73.8% goal 0 fluoroscopy) were common. The majority of operators relied on index-guided ablation (90.5%); Mean Visitag surpoint targets were higher anteriorly vs posteriorly (508.3 ± 49.8 vs 392.3 ± 37.0, p < 0.01), but power was similar. There was considerable heterogeneity related to gaps in current knowledge, such as lesion delivery targets and sites of extra-pulmonary vein ablation (most common was the posterior wall followed by the roof). Peri-procedural risk factor management of obesity, hypertension, and sleep apnea was common. There was a mean of 3.0 ± 1.2 follow-up visits at 12 months. CONCLUSIONS REAL-AF operators were high volume low fluoroscopy "real world" operators with good follow-up and adherence to known best-practices. There was disagreement related to knowledge gaps in guidelines.
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Affiliation(s)
- Omar Kreidieh
- Brigham And Women's Hospital, Harvard Medical School, 44 Washington Street, Boston, MA, 02115, USA.
| | - Allyson L Varley
- Heart Rhythm Clinical and Research Solutions, Birmingham, AL, USA
| | - Jorge Romero
- Brigham And Women's Hospital, Harvard Medical School, 44 Washington Street, Boston, MA, 02115, USA
| | - David Singh
- Division of Cardiology, Queen's Medical Center, Honolulu, HI, USA
| | | | | | - Paul Varosy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Shrinivas Hebsur
- Michigan Heart and Vascular Institute, St Mary Mercy Hospital, Livonia, MI, USA
| | | | - Gunther Schrappe
- Heart Rhythm Clinical and Research Solutions, Birmingham, AL, USA
| | - Linda Justice
- Heart Rhythm Clinical and Research Solutions, Birmingham, AL, USA
| | - Paul C Zei
- Brigham And Women's Hospital, Harvard Medical School, 44 Washington Street, Boston, MA, 02115, USA
| | - Jose Osorio
- Arrhythmia Institute at Grandview Health, Birmingham, AL, USA
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Weng W, Birnie DH, Ramirez FD, Van Stiphout C, Golian M, Nery PB, Hansom SP, Redpath CJ, Klein A, Nair GM, Alqarawi W, Green MS, Davis DR, Santangelli P, Schaller RD, Marchlinski FE, Sadek MM. Outcomes of a comprehensive strategy during repeat atrial fibrillation ablation. J Interv Card Electrophysiol 2022; 65:391-399. [DOI: 10.1007/s10840-022-01190-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/20/2022] [Indexed: 11/28/2022]
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Aksan G, Yanık A, Yontar OC, Boyacı F, Uçar M, Şahin MK, Soylu K. The predictive value of galectin‐3 levels on left atrial low voltage areas assessed by high‐density mapping in patients with paroxysmal atrial fibrillation. J Arrhythm 2022; 38:353-362. [PMID: 35785368 PMCID: PMC9237302 DOI: 10.1002/joa3.12703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/20/2022] [Accepted: 03/13/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Gökhan Aksan
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Ahmet Yanık
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Osman Can Yontar
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Faruk Boyacı
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Melisa Uçar
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Mustafa Kürşat Şahin
- Department of Family Medicine Faculty of Medicine Ondokuz Mayıs University Samsun Turkey
| | - Korhan Soylu
- Department of Cardiology, Faculty of Medicine Ondokuz Mayis University Samsun Turkey
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Park SY, Yang H, Marboe C, Ziv O, Laurita K, Rollins A, Saluja D, Hendon CP. Cardiac endocardial left atrial substrate and lesion depth mapping using near-infrared spectroscopy. BIOMEDICAL OPTICS EXPRESS 2022; 13:1801-1819. [PMID: 35519253 PMCID: PMC9045901 DOI: 10.1364/boe.451547] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 06/14/2023]
Abstract
Atrial fibrillation (AF) is a rapid irregular electrical activity in the upper chamber and the most common sustained cardiac arrhythmia. Many patients require radiofrequency ablation (RFA) therapy to restore sinus rhythm. Pulmonary vein isolation requires distinguishing normal atrial wall from the pulmonary vein tissue, and atrial substrate ablation requires differentiating scar tissue, fibrosis, and adipose tissue. However, current anatomical mapping methods for strategically locating ablation sites by identifying structural substrates in real-time are limited. An intraoperative tool that accurately provides detailed structural information and classifies endocardial substrates could help improve RF guidance during RF ablation therapy. In this work, we propose a 7F NIRS integrated ablation catheter and demonstrate endocardial mapping on ex vivo swine (n = 12) and human (n = 5) left atrium (LA). First, pulmonary vein (PV) sleeve, fibrosis and ablation lesions were identified with NIRS-derived contrast indices. Based on these key spectral features, classification algorithms identified endocardial substrates with high accuracy (<11% error). Then, a predictive model for lesion depth was evaluated on classified lesions. Model predictions correlated well with histological measurements of lesion dimensions (R = 0.984). Classified endocardial substrates and lesion depth were represented in 2D spatial maps. These results suggest NIRS integrated mapping catheters can serve as a complementary tool to the current electroanatomical mapping system to improve treatment efficacy.
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Affiliation(s)
- Soo Young Park
- Department of Electrical Engineering, Columbia University, New York, USA
| | - Haiqiu Yang
- Department of Electrical Engineering, Columbia University, New York, USA
| | - Charles Marboe
- Department of Cell Biology and Pathology, Columbia University Irving Medical Center, New York, USA
| | - Ohad Ziv
- Department of Medicine, Cardiology Division, MetroHealth Hospital, Ohio, USA
| | - Kenneth Laurita
- Department of Medicine, Cardiology Division, MetroHealth Hospital, Ohio, USA
- Department of Biomedical Engineering, Case Western Reserve University, Ohio, USA
| | - Andrew Rollins
- Department of Biomedical Engineering, Case Western Reserve University, Ohio, USA
| | - Deepak Saluja
- Department of Medicine, Cardiology Division, Columbia University Irving Medical Center, New York, USA
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Sousa PA, Puga L, Adão L, Primo J, Khoueiry Z, Lebreiro A, Fonseca P, Lagrange P, Elvas L, Gonçalves L. Two years after pulmonary vein isolation guided by ablation index—a multicenter study. J Arrhythm 2022; 38:346-352. [PMID: 35785367 PMCID: PMC9237314 DOI: 10.1002/joa3.12696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Pedro A. Sousa
- Pacing & Electrophysiology Unit, Cardiology Department Coimbra's Hospital and University Center Coimbra Portugal
| | - Luís Puga
- Pacing & Electrophysiology Unit, Cardiology Department Coimbra's Hospital and University Center Coimbra Portugal
| | - Luís Adão
- Cardiology Department University Hospital Center of São João Porto Portugal
| | - João Primo
- Cardiology Department Vila Nova de Gaia & Espinho Hospital Center Portugal
| | - Ziad Khoueiry
- Cardiology Department Clinique Saint Pierre Perpignan France
| | - Ana Lebreiro
- Cardiology Department University Hospital Center of São João Porto Portugal
| | - Paulo Fonseca
- Cardiology Department Vila Nova de Gaia & Espinho Hospital Center Portugal
| | | | - Luís Elvas
- Pacing & Electrophysiology Unit, Cardiology Department Coimbra's Hospital and University Center Coimbra Portugal
| | - Lino Gonçalves
- Pacing & Electrophysiology Unit, Cardiology Department Coimbra's Hospital and University Center Coimbra Portugal
- ICBR, Faculty of Medicine University of Coimbra Coimbra Portugal
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Themistoclakis S, Calzolari V, De Mattia L, China P, Russo AD, Fassini G, Casella M, Caporaso I, Indiani S, Addis A, Basso C, Della Barbera M, Thiene G, Tondo C. In vivo Lesion Index (LSI) validation in percutaneous radiofrequency catheter ablation. J Cardiovasc Electrophysiol 2022; 33:874-882. [PMID: 35262242 DOI: 10.1111/jce.15442] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/06/2022] [Accepted: 01/30/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Lesion Index (LSI) has been developed to predict lesion efficacy during radiofrequency (RF) catheter ablation. However, its value in predicting lesions size has still to be established. The aim of our study was to assess the lesions size reproducibility for pre-specified values of LSI reached during RF delivery in an in vivo beating heart. METHODS Ablation lesions were created with different values of LSI in 7 domestic pigs by means of a contact force sensing catheter (TactiCathTM , Abbott). Lesions were identified during RF delivery by means of a 3D mapping system (EnSiteTM Precision, Abbott) and measured after heart explantation. Histology was carried out after gross examination on the first 3 lesions to confirm the accuracy of the macroscopic evaluation. RESULTS A total of 64 myocardial lesions were created. Thirty-nine lesions were excluded from the analysis for the following reasons: histological confirmation of macroscopic lesion measurement (n=3), transmurality (n=24), unfavorable anatomic position (n=10), not macroscopically identifiable (n=2). In a final set of 25 non-transmural lesions, injury width and depth were respectively 4.6±0.6 mm and 2.6±0.8 mm for LSI=4, 7.3±0.8 mm and 4.7±0.6 mm for LSI=5, and 8.6±1.2 mm and 7.2±1.1 mm for LSI=6. A strong linear correlation was observed between LSI and lesion width (r=0.87, p<0.00001) and depth (r=0.89, p<0.00001). Multiple linear regression analysis identified LSI as the only ablation parameter that significantly predicted lesion width (p<0.001) and depth (p<0.001). CONCLUSION In our in vivo study, LSI proved highly predictive of lesion size and depth. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | - Luca De Mattia
- Ospedale Ca'Foncello-ULSS2 Marca Trevigiana, Treviso, Italy
| | - Paolo China
- Ospedale dell'Angelo-ULSS3 Serenissima, Mestre-Venice, Italy
| | | | - Gaetano Fassini
- Heart Rhythm Center, Monzino Cardiac Center, IRCCS, Milan, Italy
| | - Michela Casella
- Heart Rhythm Center, Monzino Cardiac Center, IRCCS, Milan, Italy
| | - Igor Caporaso
- Abbott Medical Italia S.p.A., Sesto San Giovanni, Italy
| | | | - Alessandro Addis
- CRABCC, Biotechnology Research Center for Cardiothoracic Applications, Rivolta D'Adda, Italy
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Mila Della Barbera
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Gaetano Thiene
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Claudio Tondo
- Heart Rhythm Center, Monzino Cardiac Center, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Xu M, Yang Y, Zhang D, Jiang W. Meta-analysis of high power short duration in atrial fibrillation ablation - a superior efficient ablation strategy. Acta Cardiol 2022; 77:14-32. [PMID: 34218737 DOI: 10.1080/00015385.2021.1939512] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The high power short duration (HPSD) approach was hoped to further improve the efficacy and safety in radiofrequency ablation of atrial fibrillation (AF), compared with Low power long duration (LPLD). However, the conclusion was controversial based on the previous limited data. The aim of this meta-analysis was to evaluate whether the clinical benefits of HPSD are superior to that of LPLD. METHODS The PubMed, OVID, the Cochrane Library, and Elsevier's ScienceDirect databases were searched for clinical studies to compare HPSD and LPLD approach by simple search strings benefiting to a wider screened scope. RESULTS Fifteen trials with 3255 patients were included in this analysis. Pooled analyses suggested that HPSD was associated with a lower recurrence of atrial tachyarrhythmias (ATAs) at 1-year follow-up (OR: 0.49; 95% CI: 0.35 to 0.67, p < .0001), benefitted from AF recurrence reduced (OR: 0.46; 95% CI: 0.31 to 0.67, p < .0001), rather than atrial tachycardia/atrial flutter (AT/AFL), but similar at 6 months follow-up, with a decreased oesophageal thermal injury (ETI) (OR: 0.48; 95% CI: 0.30 to 0.77, p = .002). Meanwhile, the HPSD approach benefitted to increase first-pass pulmonary vein isolation (FPI) (OR: 0.47; 95% CI: 0.34 to 0.64, p < .00001) and decrease acute pulmonary vein re-isolation (PVR) (OR: 0.45; 95% CI: 0.35 to 0.58, p < .00001), both mainly embodied in left pulmonary veins (PVs). HPSD showed a decreased procedural time (SMD: -0.95; 95% CI: -1.06 to -0.85, p < .00001), ablation number for pulmonary vein isolation (PVI) (SMD: -0.41; 95% CI: -0.58 to -0.24, p < .00001) and fluoroscopy time (SMD: -0.22; 95% CI: -0.32 to -0.12, p < .0001), which benefits from PVI + additional ablation strategy (SMD: -0.33; 95% CI: -0.46 to -0.21, p < .0001). CONCLUSIONS The HPSD approach was associated with decreasing post-ablation AF recurrence in the 1-year follow-up, ETI, acute PVR (increasing FPI correspondingly), procedural time, ablation number for PVI and fluoroscopy time, benefitted to improve clinical outcomes and procedural process with improved safety.
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Affiliation(s)
- Min Xu
- Department of Cardiology, The Second Affiliated Hospital of North Sichuan Medical College (Mianyang 404 Hospital), Mianyang, SiChuan, China
| | - Yan Yang
- Department of Cardiology, The Second Affiliated Hospital of North Sichuan Medical College (Mianyang 404 Hospital), Mianyang, SiChuan, China
| | - Dayong Zhang
- Department of Cardiology, The Second Affiliated Hospital of North Sichuan Medical College (Mianyang 404 Hospital), Mianyang, SiChuan, China
| | - Weifeng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai, China
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Hiner E, Shah DP. Choice of Steerable Sheath Impacts Contact Force Stability During Pulmonary Vein Isolation. J Innov Card Rhythm Manag 2022; 12:4790-4795. [PMID: 34970468 PMCID: PMC8712057 DOI: 10.19102/icrm.2021.121205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 11/20/2022] Open
Abstract
A stable contact force (CF) is correlated with more effective radiofrequency (RF) ablation (RFA) lesions and long-term procedural outcomes. Efforts to improve catheter stability include jet ventilation, pacing, steerable sheaths, and CF-sensing ablation catheters. This study compares CF stability and effective RF lesions between two commercially available steerable sheaths. Thirty patients underwent first-time RFA at a single center using the Agilis™ NxT (Abbott, Chicago, IL, USA) or SureFlex™ (Baylis Medical, Montreal, Canada) steerable sheath. High-power short-duration RFA was utilized, targeting a 10-Ω drop. Sheath performance was assessed for the entire procedure and around each pulmonary vein (PV) in terms of mean CF, CF variability, RF time per lesion, and inefficient contact lesions (defined as lesions with a CF of less than 5 g for at least 10% of the RF delivery time). The operator-targeted mean CF was achieved using both sheaths; however, the overall CF variability was 12.8% lower when using the SureFlex™ sheath (p = 0.08). The CF variability was generally 16% greater in the right PVs than the left PVs (p = 0.001) but trended lower with the SureFlex™ sheath. There were 8% more inefficient contact lesions created when using the Agilis™ sheath as compared to the SureFlex™ sheath (p = 0.035), especially in the right inferior PV (p = 0.009). The RF time per lesion was, on average, 12% (1.4 seconds) shorter when using the SureFlex™ sheath than the Agilis™ sheath (p < 0.05). The choice of steerable sheath may affect both catheter stability and lesion quality, especially in the right PVs.
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Affiliation(s)
- Evan Hiner
- Ascension Health Providence Hospital and Medical Center, Southfield, MI, USA
| | - Dipak P Shah
- Ascension Health Providence Hospital and Medical Center, Southfield, MI, USA
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49
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Chu GS, Calvert P, Futyma P, Ding WY, Snowdon R, Gupta D. Local impedance for the optimization of radiofrequency lesion delivery: A review of bench and clinical data. J Cardiovasc Electrophysiol 2021; 33:389-400. [PMID: 34921465 DOI: 10.1111/jce.15335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/11/2021] [Accepted: 12/05/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Radiofrequency catheter ablation is a cornerstone of treatment for many cardiac arrhythmias. Progression in three-dimensional mapping and contact-force sensing technologies have improved our capability to achieve success, but challenges still remain. METHODS In this article, we discuss the importance of overall circuit impedance in radiofrequency lesion formation. This is followed by a review of the literature regarding recently developed "local impedance" technology and its current and future potential applications and limitations, in the context of established surrogate markers currently used to infer effective ablation. RESULTS We discuss the role of local impedance in assessing myocardial substrate, as well as its role in clinical studies of ablation. We also discuss safety considerations, limitations and ongoing research. CONCLUSION Local impedance is a novel tool which has the potential to tailor ablation in a manner distinct from other established metrics.
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Affiliation(s)
- Gavin S Chu
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Peter Calvert
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Research Unit, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Piotr Futyma
- Department of Cardiology, Medical College of the University of Rzeszów, St. Joseph's Heart Rhythm Center, Rzeszów, Poland, Rzeszów, Poland
| | - Wern Yew Ding
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Research Unit, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Richard Snowdon
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Research Unit, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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50
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Park SY, Singh-Moon R, Yang H, Saluja D, Hendon C. Quantification of irrigated lesion morphology using near-infrared spectroscopy. Sci Rep 2021; 11:20160. [PMID: 34635764 PMCID: PMC8505541 DOI: 10.1038/s41598-021-99725-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/29/2021] [Indexed: 12/20/2022] Open
Abstract
There are currently limited means by which lesion formation can be confirmed during radiofrequency ablation procedures. The purpose of this study was to evaluate the use of NIRS-integrated RFA catheters for monitoring irrigated lesion progression, ex vivo and in vivo. Open-irrigated NIRS-ablation catheters with optical fibers were fabricated to sample tissue diffuse reflectance. Spectra from 44 irrigated lesions and 44 non-lesion sites from ex vivo swine hearts (n = 15) were used to train and evaluate a predictive model for lesion dimensions based on key spectral features. Additional studies were performed in diluted blood to assess NIRS signatures of catheter-tissue contact status. Finally, the potential of NIRS-RFA catheters for guiding lesion delivery was evaluated in a set of in vivo pilot studies conducted in healthy pigs (n = 4). Model predictions for lesion depth (R = 0.968), width (R = 0.971), and depth percentage (R = 0.924) correlated well with measured lesion dimensions. In vivo deployment in preliminary trials showed robust translational consistency of contact discrimination (P < 0.0001) and lesion depth parameters (< 3% error). NIRS empowered catheters are well suited for monitoring myocardial response to RF ablation and may provide useful intraprocedural feedback for optimizing treatment efficacy alongside current practices.
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Affiliation(s)
- Soo Young Park
- Department of Electrical Engineering, Columbia University, 500 West 120th Street, New York, NY, 10027, USA
| | - Rajinder Singh-Moon
- Department of Electrical Engineering, Columbia University, 500 West 120th Street, New York, NY, 10027, USA
| | - Haiqiu Yang
- Department of Electrical Engineering, Columbia University, 500 West 120th Street, New York, NY, 10027, USA
| | - Deepak Saluja
- Department of Medicine (Cardiology), Columbia University College of Physicians and Surgeons, 630 W. 168th St, New York, NY, 10032, USA
| | - Christine Hendon
- Department of Electrical Engineering, Columbia University, 500 West 120th Street, New York, NY, 10027, USA.
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