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Katritsis DG. Pulsed Field Ablation for Atrioventricular Junctional Reentry: Simple is Complicated. Heart Rhythm 2024:S1547-5271(24)03389-7. [PMID: 39341433 DOI: 10.1016/j.hrthm.2024.09.058] [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: 09/20/2024] [Revised: 09/24/2024] [Accepted: 09/25/2024] [Indexed: 10/01/2024]
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Shen C, Bai R, Jia Z, Feng M, Yu Y, Du X, Fu G, Wu T, Jiang Y, Jin H, Yu L, Fang R, Zhuo W, Dai J, Gao F, Wang B, Chen S, Qiu X, Du T, Yu X, Luo C, Lu Y, Ouyang F, Chu H. Unexpected transient atrioventricular block and slow junctional rhythm using pulsed field ablation for slow pathway modification: excited or cautious for ablators. Heart Rhythm 2024:S1547-5271(24)03319-8. [PMID: 39304002 DOI: 10.1016/j.hrthm.2024.09.023] [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: 05/30/2024] [Revised: 08/16/2024] [Accepted: 09/09/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Data regarding the effects of pulsed field ablation (PFA) on atrioventricular nodal reentrant tachycardia (AVNRT) are limited. OBJECTIVE To evaluate the outcomes of PFA for AVNRT, and its impact on dual-pathway electrophysiology. METHODS A larger cohort of patients with typical AVNRT underwent slow pathway (SP) modification (SPM) using a focal PFA catheter in a biphasic/bipolar manner. The primary endpoints were the efficacy and safety of PFA during the procedure and 6-month follow-up. RESULTS The acute success of SPM was achieved in all 40 patients. The total ablation time was 7.9±3.8 seconds for 6.4±2.2 ablation sites (ASs). Slow junctional rhythm (SJR) was induced in 32 (80%) patients lasting 28.9±10.3 seconds in 3.0±1.1 ASs per patient. SP was located 11.1±1.2 mm from the largest His activation (LHA). At 9 ASs, SJR could be reinduced after an increase of contact force (CF) from 1.3±0.5g to 6.4±1.3g (P<0.0001). Transient atrioventricular block (AVB) was recorded in 7(17.5%) patients (1 second-degree and 6 third-degree AVB) lasting 435.3±227.4 seconds, with a shorter AS-LHA distance than patients without AVB (7.7±0.6 mm vs. 11.3±1 mm, P<0.0001). PFA-related delayed atrial-His (n=6) and His-atrial (n=1) conduction preceded transient AVB with a constant His-ventricular interval. Normal PR interval was restored within 24 hours. All patients maintained sinus rhythm without any significant adverse events during 6-month follow-up. CONCLUSION Despite the high efficiency of PFA for SPM, the notable incidence of transient AVB warranted caution when applying it near the His bundle. SJR frequently occurred during SPM and was dependent on moderate CF.
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Affiliation(s)
- Caijie Shen
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Rong Bai
- The University of Arizona College of Medicine-Phoenix, Banner University Medical Center Phoenix, Phoenix, US
| | - Zhenyu Jia
- Health Science Center, Ningbo University, Ningbo, China
| | - Mingjun Feng
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Yibo Yu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Xianfeng Du
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Guohua Fu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Tao Wu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Yongxing Jiang
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - He Jin
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Lipu Yu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Renyuan Fang
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Weidong Zhuo
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Jiating Dai
- Health Science Center, Ningbo University, Ningbo, China
| | - Fang Gao
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Binhao Wang
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Si Chen
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Xinhui Qiu
- The University of Arizona College of Medicine-Phoenix, Banner University Medical Center Phoenix, Phoenix, US
| | - Tingsha Du
- Health Science Center, Ningbo University, Ningbo, China
| | - Xinzhi Yu
- Health Science Center, Ningbo University, Ningbo, China
| | - Chenxu Luo
- Health Science Center, Ningbo University, Ningbo, China
| | - Yiqi Lu
- Health Science Center, Ningbo University, Ningbo, China
| | - Feifan Ouyang
- Department of Cardiology, University Center of Cardiovascular Science, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany.
| | - Huimin Chu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, China.
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Ezzeddine FM, Asirvatham SJ, Nguyen DT. Pulsed Field Ablation: A Comprehensive Update. J Clin Med 2024; 13:5191. [PMID: 39274404 PMCID: PMC11396515 DOI: 10.3390/jcm13175191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/28/2024] [Accepted: 08/28/2024] [Indexed: 09/16/2024] Open
Abstract
One of the recent advancements in the field of cardiac electrophysiology is pulsed field ablation (PFA). PFA is a novel energy modality that does not rely on thermal processes to achieve ablation which, in turn, results in limited collateral damage to surrounding structures. In this review, we discuss the mechanisms, safety, efficacy, and clinical applications of PFA for the management of atrial and ventricular arrhythmias. We also summarize the published pre-clinical and clinical studies regarding this new technology.
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Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
- Department of Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
- Department of Clinical Anatomy, Mayo Clinic, Rochester, MN 55905, USA
| | - Duy T Nguyen
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Della Rocca DG, Cespón-Fernández M, Keelani A, Raffa S, Pannone L, Almorad A, Ströker E, Borisov G, Bala G, Sieira J, Vetta G, Alothman O, Sorgente A, Audiat C, Overeinder I, Frommhold M, Del Monte A, La Meir M, Natale A, Chierchia GB, Geller JC, de Asmundis C, Sarkozy A. Focal Pulsed Field Ablation for Premature Ventricular Contractions: A Multicenter Experience. Circ Arrhythm Electrophysiol 2024; 17:e012826. [PMID: 39234745 DOI: 10.1161/circep.124.012826] [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: 02/05/2024] [Accepted: 07/15/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a novel technology for catheter-based atrial arrhythmia treatment. Evidence of its application for ventricular arrhythmia ablation is still limited. In this study, we describe the feasibility and efficacy of focal PFA for premature ventricular contraction (PVC) ablation. METHODS A prospective cohort of 20 patients referred for PVC ablation at 2 centers was enrolled, regardless of the presence of structural heart disease, PVC morphology, or previous ablation attempts. All procedures were performed using the CENTAURI System in combination with contact force sensing catheters and 3-dimensional electroanatomical mapping systems. Energy output and the number of applications were left to the operator's discretion. RESULTS Eleven (55%) procedures were conducted under general anesthesia, 6 (30%) under deep sedation, and 3 (15%) under light sedation. Muscular contraction was observed in one case (5%). Median procedural and fluoroscopy times were 95.5 and 6.55 minutes, respectively. The median number of PFA applications was 8 with a median contact force of 10g. A statistically significant (76%) reduction was observed in mean peak-to-peak bipolar electrogram voltage before and after ablation (0.707 versus 0.098 mV; P=0.008). Ventricular irritative firing was observed in 11 (55%) patients after PFA. The median follow-up was 120 days. Acute procedural success was achieved in 17 of 20 (85% [95% CI, 0.70-1]) patients. Two of the patients with procedural failure had late success with >80% clinical PVC burden suppression during follow-up, and 2 of 17 patients with acute success had late PVC recurrence, which accounts for a total of 17 of 20 (85% [95% CI, 0.70-1]) patients with chronic success. Transient ST-segment depression occurred in 1 patient, and the right bundle branch block was induced in 2 others (permanently only in one case). CONCLUSIONS PVC ablation using a focal PFA is feasible, effective, and safe, with promising acute and long-term results in several ventricular locations. Irritative firing is frequently observed. Coronary evaluation should be considered when targeting the outflow tract.
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Affiliation(s)
- Domenico Giovanni Della Rocca
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (D.G.D.R., A.N.)
| | - María Cespón-Fernández
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
- Galicia Sur Health Research Institute, Vigo, Spain (M.C.-F.)
| | - Ahmad Keelani
- Division of Cardiology, Arrhythmia Section, Zentralklinik, Bad Berka, Germany (A.K., S.R., G. Borisov, O.A., M.F., J.C.G.)
| | - Santi Raffa
- Division of Cardiology, Arrhythmia Section, Zentralklinik, Bad Berka, Germany (A.K., S.R., G. Borisov, O.A., M.F., J.C.G.)
| | - Luigi Pannone
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Alexandre Almorad
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Erwin Ströker
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Georgi Borisov
- Division of Cardiology, Arrhythmia Section, Zentralklinik, Bad Berka, Germany (A.K., S.R., G. Borisov, O.A., M.F., J.C.G.)
| | - Gezim Bala
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Juan Sieira
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Giampaolo Vetta
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Obaida Alothman
- Division of Cardiology, Arrhythmia Section, Zentralklinik, Bad Berka, Germany (A.K., S.R., G. Borisov, O.A., M.F., J.C.G.)
| | - Antonio Sorgente
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Charles Audiat
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Ingrid Overeinder
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Markus Frommhold
- Division of Cardiology, Arrhythmia Section, Zentralklinik, Bad Berka, Germany (A.K., S.R., G. Borisov, O.A., M.F., J.C.G.)
| | - Alvise Del Monte
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Mark La Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Belgium (M.L.M.)
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (D.G.D.R., A.N.)
- Division of Cardiology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy (A.N.)
| | - Gian-Battista Chierchia
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - J Christoph Geller
- Division of Cardiology, Arrhythmia Section, Zentralklinik, Bad Berka, Germany (A.K., S.R., G. Borisov, O.A., M.F., J.C.G.)
- Faculty of Medicine, Otto-von-Guericke University Magdeburg, Germany (J.C.G.)
| | - Carlo de Asmundis
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
| | - Andrea Sarkozy
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R., M.C.-F., L.P., A.A., E.S., G. Bala, J.S., G.V., A. Sorgente, C.A., I.O., A.D.M., G.-B.C., C.d.A., A. Sarkozy)
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Fan A, Liu G, Wu X. Nanosecond pulse electric field treatment initiates mitochondrial apoptosis pathway by inducing mitochondrial morphological changes in myocardial cells. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01828-5. [PMID: 39093488 DOI: 10.1007/s10840-024-01828-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/09/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND As an emerging myocardial ablation technique, the mechanism of nanosecond pulse electric field (nsPEF) ablation is currently less studied. Mitochondria are one of the important membrane structure organelles in cells, participating in numerous life activities within the cell. This study aimed to explore the morphological changes of mitochondria in living cells following nsPEF treatment. METHODS Myocardial cells were treated with a self-made solid-state LTD high-voltage nanosecond pulse generator with a pulse width of 100 ns for 80 times. The changes in mitochondrial membrane potential and cell apoptosis in rat myocardial cells after nsPEFs were investigated using JC-1 assay kit, apoptosis double staining assay kit, and mitochondrial fluorescence probe. RESULTS The results showed that after nsPEF treatment, the mitochondrial membrane potential decreased, apoptosis increased, and the average mitochondrial area decreased from 0.48 µm2 in live myocardial cells to 0.16 µm2. The average circumference ranges from 3.17 µm dropped to 1.60 µm. The shape factor decreased from 1.92 to 1.41. The aspect ratio has decreased from 2.16 to 1.59. nsPEF treatment induces changes in the morphology of myocardial cell mitochondria. CONCLUSIONS Based on the results of mitochondrial membrane potential and apoptosis, it can be inferred that under this equipment and parameter conditions, nsPEF treatment first causes changes in mitochondrial morphology, and then initiates the mitochondrial apoptosis pathway, which may provide experimental basis for investigating the potential mechanism of nsPEF ablation of myocardial cells.
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Affiliation(s)
- Aqing Fan
- University of Science and Technology of China, Hefei, 230000, China
| | - Gengliang Liu
- University of Science and Technology of China, Hefei, 230000, China
| | - Xiaodong Wu
- Suzhou Institute of Biomedical Engineering Technology, Chinese Academy of Sciences, No. 88 Keling Road, Huqiu District, Suzhou City, 215163, Jiangsu Province, China.
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Zhai Z, Ling Y, Wang Y, Shi L, Liu X. Preclinical evaluation of reversible pulsed electrical field: electrophysiological and histological assessment of myocardium. Front Cardiovasc Med 2024; 11:1426920. [PMID: 39149581 PMCID: PMC11325456 DOI: 10.3389/fcvm.2024.1426920] [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: 05/02/2024] [Accepted: 06/25/2024] [Indexed: 08/17/2024] Open
Abstract
Background Pulsed field ablation, as a non-thermal ablation modality, has received increasing attention. The aim of this study is to explore whether a reversible pulsed electric field (RPEF) can temporarily inhibit electrical conduction and provide a novel method for precise ablation of arrhythmia. Methods RPEF energy was delivered from an ablation catheter to the atrium of six dogs, followed by a series of electrogram and histology assessments. Results RPEF ablation of ordinary myocardium resulted in an average reduction of 68.3% (range, 53.7%-83.8%) in electrogram amplitude, while 5 min later, the amplitude in eight electrograms returned to 77.9% (range, 72.4%-87.3%) of baseline. Similarly, the amplitude of the sinoatrial node electrograms reduced by an average of 73.0% (range, 60.2%-84.4%) after RPEF ablation, but recovered to 84.9% (range, 80.3%-88.5%) of baseline by 5 min. No necrotic change was detected in histopathology. Transient third-degree atrioventricular block occurred following the ablation of the maximum His potential sites with RPEF, the duration of which was voltage dependent. The histopathological results showed necrosis of the myocardium at the ablation sites but no injury to His bundle cells. Conclusions RPEF can be applied to transiently block electrical conduction in myocardial tissues contributing to precise ablation.
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Affiliation(s)
- Zongwang Zhai
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Peking University Shougang Hospital, Beijing, China
| | - Yuchen Ling
- Department of Research and Development, Shanghai HT Co. Ltd., Shanghai, China
| | - Yanjiang Wang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liang Shi
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xingpeng Liu
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Zhai Z, Wang Y, Shi L, Liu X. Impact of Pulsed Electric Field Ablation on His Bundle Conduction: A Preclinical Canine Study. Med Sci Monit 2024; 30:e945007. [PMID: 39078809 PMCID: PMC11297367 DOI: 10.12659/msm.945007] [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: 05/01/2024] [Accepted: 07/12/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Pulsed field ablation (PFA), as a non-thermal ablation modality, has received increasing attention. The aim of this study was to evaluate the effect of PFA upon His bundle via its implementation with different voltages on the maximum His bundle potential in canines, providing scientific basis for clinical application. MATERIAL AND METHODS Pulsed electrical field energy was delivered from a ablation catheter to the maximum His potential of 7 dogs, followed by a series of electrogram and histology assessments. RESULTS The baseline AH and HV intervals were 55.3±3.7 ms (range, 53.0-59.0 ms), and 34.9±1.3 ms (range, 34.0-36.0 ms), respectively, which were elevated to 65.0±5.4 ms (range, 59.0-70.0 ms) and 35.7±2.7 ms (range, 34.0-37.0 ms) after PFA. Before ablation and immediately after the recovery of third-degree AVB, the AH interval was prolonged (P<0.05) while the HV interval remained unchanged (P>0.05). After ablation, all 7 canines experienced transient third-degree AVB, with a voltage-dependent duration. Masson staining results revealed no apparent damage in His bundle cells. CONCLUSIONS Within a certain voltage range of pulse electric field, ablation of the maximum His potential in canines can result in transient third-degree AVB, providing a new route for guiding safe ablation of para-Hisian arrhythmia.
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Affiliation(s)
- Zongwang Zhai
- Department of Cardiology, Peking University Shougang Hospital, Beijing, PR China
| | - Yanjiang Wang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, PR China
| | - Liang Shi
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, PR China
| | - Xingpeng Liu
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, PR China
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Adragão P, Matos D, Carmo P, Costa FM, Ramos S. Pulsed-field ablation vs radiofrequency ablation for ventricular tachycardia: First in-human case of histologic lesion analysis. Heart Rhythm 2023; 20:1395-1398. [PMID: 37488032 DOI: 10.1016/j.hrthm.2023.07.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Pedro Adragão
- Cardiology and Electrophysiology Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Daniel Matos
- Cardiology and Electrophysiology Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal.
| | - Pedro Carmo
- Cardiology and Electrophysiology Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Francisco Moscoso Costa
- Cardiology and Electrophysiology Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Sância Ramos
- Cardiology and Electrophysiology Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
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Marashly Q, Najjar SN, Hahn J, Rector GJ, Khawaja M, Chelu MG. Innovations in ventricular tachycardia ablation. J Interv Card Electrophysiol 2023; 66:1499-1518. [PMID: 35879516 DOI: 10.1007/s10840-022-01311-z] [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: 02/21/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
Catheter ablation of ventricular arrhythmias (VAs) has evolved significantly over the past decade and is currently a well-established therapeutic option. Technological advances and improved understanding of VA mechanisms have led to tremendous innovations in VA ablation. The purpose of this review article is to provide an overview of current innovations in VA ablation. Mapping techniques, such as ultra-high density mapping, isochronal late activation mapping, and ripple mapping, have provided improved arrhythmogenic substrate delineation and potential procedural success while limiting duration of ablation procedure and potential hemodynamic compromise. Besides, more advanced mapping and ablation techniques such as epicardial and intramyocardial ablation approaches have allowed operators to more precisely target arrhythmogenic substrate. Moreover, advances in alternate energy sources, such as electroporation, as well as stereotactic radiation therapy have been proposed to be effective and safe. New catheters, such as the lattice and the saline-enhanced radiofrequency catheters, have been designed to provide deeper and more durable tissue ablation lesions compared to conventional catheters. Contact force optimization and baseline impedance modulation are important tools to optimize VT radiofrequency ablation and improve procedural success. Furthermore, advances in cardiac imaging, specifically cardiac MRI, have great potential in identifying arrhythmogenic substrate and evaluating ablation success. Overall, VA ablation has undergone significant advances over the past years. Innovations in VA mapping techniques, alternate energy source, new catheters, and utilization of cardiac imaging have great potential to improve overall procedural safety, hemodynamic stability, and procedural success.
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Affiliation(s)
- Qussay Marashly
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Salim N Najjar
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Joshua Hahn
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Graham J Rector
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Muzamil Khawaja
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Mihail G Chelu
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA.
- Baylor St. Luke's Medical Center, Houston, USA.
- Texas Heart Institute, Houston, USA.
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10
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Kos B, Mattison L, Ramirez D, Cindrič H, Sigg DC, Iaizzo PA, Stewart MT, Miklavčič D. Determination of lethal electric field threshold for pulsed field ablation in ex vivo perfused porcine and human hearts. Front Cardiovasc Med 2023; 10:1160231. [PMID: 37424913 PMCID: PMC10326317 DOI: 10.3389/fcvm.2023.1160231] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction Pulsed field ablation is an emerging modality for catheter-based cardiac ablation. The main mechanism of action is irreversible electroporation (IRE), a threshold-based phenomenon in which cells die after exposure to intense pulsed electric fields. Lethal electric field threshold for IRE is a tissue property that determines treatment feasibility and enables the development of new devices and therapeutic applications, but it is greatly dependent on the number of pulses and their duration. Methods In the study, lesions were generated by applying IRE in porcine and human left ventricles using a pair of parallel needle electrodes at different voltages (500-1500 V) and two different pulse waveforms: a proprietary biphasic waveform (Medtronic) and monophasic 48 × 100 μs pulses. The lethal electric field threshold, anisotropy ratio, and conductivity increase by electroporation were determined by numerical modeling, comparing the model outputs with segmented lesion images. Results The median threshold was 535 V/cm in porcine ((N = 51 lesions in n = 6 hearts) and 416 V/cm in the human donor hearts ((N = 21 lesions in n = 3 hearts) for the biphasic waveform. The median threshold value was 368 V/cm in porcine hearts ((N = 35 lesions in n = 9 hearts) cm for 48 × 100 μs pulses. Discussion The values obtained are compared with an extensive literature review of published lethal electric field thresholds in other tissues and were found to be lower than most other tissues, except for skeletal muscle. These findings, albeit preliminary, from a limited number of hearts suggest that treatments in humans with parameters optimized in pigs should result in equal or greater lesions.
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Affiliation(s)
- Bor Kos
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Lars Mattison
- Cardiac Ablation Solutions, Medtronic, Inc., Minneapolis, MN, United States
| | - David Ramirez
- Department of Surgery, Visible Heart® Laboratories, University of Minnesota, Minneapolis, MN, United States
| | - Helena Cindrič
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Daniel C. Sigg
- Cardiac Ablation Solutions, Medtronic, Inc., Minneapolis, MN, United States
| | - Paul A. Iaizzo
- Department of Surgery, Visible Heart® Laboratories, University of Minnesota, Minneapolis, MN, United States
| | - Mark T. Stewart
- Cardiac Ablation Solutions, Medtronic, Inc., Minneapolis, MN, United States
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
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11
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Qiu J, Dai M, Bai Y, Chen G. Potential Application of Pulsed Field Ablation in Ventricular Arrhythmias. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040723. [PMID: 37109681 PMCID: PMC10143478 DOI: 10.3390/medicina59040723] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023]
Abstract
Pulsed field ablation (PFA) is a new ablative method for the therapy of arrhythmia. Recent preclinical and clinical studies have already demonstrated the feasibility and safety of PFA for the treatment of atrial fibrillation (AF). However, the application of PFA may not be limited to the above fields. There are some data on the application of PFA on ventricular arrhythmias (VAs), such as ventricular fibrillation (VF) and ventricular tachycardia (VT). Further, a case report about PFA has been published recently, in which PFA was successfully applied to the ablation of premature ventricular contractions (PVCs) from the right ventricular outflow tract. Thus, we aimed to review recent research findings of PFA in ventricular ablation and evaluate the possibility of its application in VAs.
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Affiliation(s)
- Jie Qiu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Meiyan Dai
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Yang Bai
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Guangzhi Chen
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave., Wuhan 430030, China
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12
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Ezzeddine FM, Ward RC, Asirvatham SJ, DeSimone CV. Mapping and ablation of ventricular fibrillation substrate. J Interv Card Electrophysiol 2023:10.1007/s10840-022-01454-z. [PMID: 36598715 DOI: 10.1007/s10840-022-01454-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: 10/20/2022] [Accepted: 12/09/2022] [Indexed: 01/05/2023]
Abstract
Ventricular fibrillation (VF) is a life-threatening arrhythmia and a common cause of sudden cardiac death (SCD). A basic understanding of its mechanistic underpinning is crucial for enhancing our knowledge to develop innovative mapping and ablation techniques for this lethal rhythm. Significant advances in our understanding of VF have been made especially in the basic science and pre-clinical experimental realms. However, these studies have not yet translated into a robust clinical approach to identify and successfully ablate both the structural and functional substrate of VF. In this review, we aim to (1) provide a conceptual framework of VF and an overview of the data supporting the spatiotemporal dynamics of VF, (2) review experimental approaches to mapping VF to elucidate drivers and substrate for maintenance with a focus on the His-Purkinje system, (3) discuss current approaches using catheter ablation to treat VF, and (4) highlight current unknowns and gaps in the field where future work is necessary to transform the clinical landscape.
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Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert Charles Ward
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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13
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Ezzeddine FM, Darlington AM, DeSimone CV, Asirvatham SJ. Catheter Ablation of Ventricular Fibrillation. Card Electrophysiol Clin 2022; 14:729-742. [PMID: 36396189 DOI: 10.1016/j.ccep.2022.06.002] [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] [Indexed: 06/16/2023]
Abstract
Ventricular fibrillation (VF) is a common cause of sudden cardiac death (SCD) and is unfortunately without a cure. Current therapies focus on prevention of SCD, such as implantable cardioverter-defibrillator (ICD) implantation and anti-arrhythmic agents. Significant progress has been made in improving our understanding and ability to target the triggers of VF, via advanced mapping and ablation techniques, as well as with autonomic modulation. However, the critical substrate for VF maintenance remains incompletely defined. In this review, we discuss the evidence behind the basic mechanisms of VF and review the current role of catheter ablation in patients with VF.
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Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Ashley M Darlington
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA.
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14
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Moshkovits Y, Grynberg D, Heller E, Maizels L, Maor E. Differential effect of high-frequency electroporation on myocardium vs. non-myocardial tissues. Europace 2022; 25:748-755. [PMID: 36305566 PMCID: PMC9935033 DOI: 10.1093/europace/euac191] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/30/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS Pulsed-field ablation (PFA) is an emerging non-thermal ablation method based on the biophysical phenomenon of electroporation. Data on PFA cardiac selectivity nature and tissue-specific thresholds are lacking. We aim to compare the in vivo differential effect of high-frequency irreversible electroporation (HF-IRE) protocols on various tissues. METHODS AND RESULTS Twenty-three Sprague-Dawle rodents were allocated into three different protocols of 300, 600, and 900 V, respectively, while delivering twenty 100 µs bursts of a 150 kHz biphasic square wave to five tissues; cardiac muscle, skeletal muscle, liver, carotid artery and sciatic nerve. Lesions were evaluated quantitatively by histologic analysis and by morphometric evaluation. There were eight, seven and eight animals in the 300, 600, and 900 V protocols, respectively. High-frequency electroporation protocols showed a graded effect on myocardial tissue with larger lesions in the 900 V protocol compared with the other two protocols as demonstrated by width (P = 0.02), length (P = 0.01) and fibrosis ratio (P = 0.001). This effect was not observed for other tissues with attenuated degree of damage. No damage to the carotid artery was observed in all protocols. Partial damage to the sciatic nerve was observed in only two samples (25%) in the 600 V group and in one sample (14.3%) in the 900 V group. CONCLUSION Electroporation effect is tissue-specific such that myocardium is more prone to electroporation damage compared with neural and vascular tissues. Our results suggest no neural or vascular damage with using a low-amplitude HF-IRE protocol. Further investigation is warranted to better identify other tissue-specific thresholds.
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Affiliation(s)
| | | | - Eyal Heller
- Leviev Heart Center, Sheba Medical Center, Derech Sheba 2, Ramat-Gan 52621, Israel,Sackler School of Medicine, Tel Aviv University, Tel-Aviv 39040, Israel
| | - Leonid Maizels
- Leviev Heart Center, Sheba Medical Center, Derech Sheba 2, Ramat-Gan 52621, Israel,Sackler School of Medicine, Tel Aviv University, Tel-Aviv 39040, Israel
| | - Elad Maor
- Corresponding author. Tel: +972546444022; fax: +97246385777. E-mail address:
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15
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Gómez-Barea M, García-Sánchez T, Ivorra A. A computational comparison of radiofrequency and pulsed field ablation in terms of lesion morphology in the cardiac chamber. Sci Rep 2022; 12:16144. [PMID: 36167959 PMCID: PMC9515184 DOI: 10.1038/s41598-022-20212-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 09/09/2022] [Indexed: 11/15/2022] Open
Abstract
Pulsed Field Ablation (PFA) has been developed over the last years as a novel electrical ablation technique for treating cardiac arrhythmias. It is based on irreversible electroporation which is a non-thermal phenomenon innocuous to the extracellular matrix and, because of that, PFA is considered to be safer than the reference technique, Radiofrequency Ablation (RFA). However, possible differences in lesion morphology between both techniques have been poorly studied. Simulations including electric, thermal and fluid physics were performed in a simplified model of the cardiac chamber which, in essence, consisted of a slab of myocardium with blood in motion on the top. Monopolar and bipolar catheter configurations were studied. Different blood velocities and catheter orientations were assayed. RFA was simulated assuming a conventional temperature-controlled approach. The PFA treatment was assumed to consist in a sequence of 20 biphasic bursts (100 µs duration). Simulations indicate that, for equivalent lesion depths, PFA lesions are wider, larger and more symmetrical than RFA lesions for both catheter configurations. RFA lesions display a great dependence on blood velocity while PFA lesions dependence is negligible on it. For the monopolar configuration, catheter angle with respect to the cardiac surface impacted both ablation techniques but in opposite sense. The orientation of the catheter with respect to blood flow direction only affected RFA lesions. In this study, substantial morphological differences between RFA and PFA lesions were predicted numerically. Negligible dependence of PFA on blood flow velocity and direction is a potential important advantage of this technique over RFA.
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Affiliation(s)
- Mario Gómez-Barea
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, 08018, Barcelona, Spain.
| | - Tomás García-Sánchez
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, 08018, Barcelona, Spain
| | - Antoni Ivorra
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, 08018, Barcelona, Spain
- Serra Húnter Fellow Programme, Universitat Pompeu Fabra, 08018, Barcelona, Spain
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16
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Marie Butty E, Forsyth B, Labato MA. Irreversible Electroporation Balloon Therapy for Palliative Treatment of Obstructive Urethral Transitional Cell Carcinoma in Dogs. J Am Anim Hosp Assoc 2022; 58:231-239. [PMID: 36049240 DOI: 10.5326/jaaha-ms-7160] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 11/11/2022]
Abstract
Progression of transitional cell carcinoma (TCC) in dogs often leads to urinary obstruction. This observational pilot study aimed to evaluate the safety and efficacy of irreversible electroporation (IRE) balloon therapy for the palliative treatment of TCC with partial urethral obstruction. Three client-owned dogs diagnosed with TCC causing partial urethral obstruction were enrolled. After ultrasonographic and cystoscopic examination, IRE pulse protocols were delivered through a balloon catheter device inflated within the urethral lumen. After the procedure, the patients were kept overnight for monitoring and a recheck was planned 28 days later. No complication was observed during the procedure and postprocedural monitoring. After 28 days, one dog had a complete normalization of the urine stream, one dog had stable stranguria, and one dog was presented with a urethral obstruction secondary to progression of the TCC. On recheck ultrasound, one dog had a 38% diminution of the urethral mass diameter whereas the other two dogs had a mass stable in size. IRE balloon therapy seems to be a feasible and apparently safe minimally invasive novel therapy for the palliative treatment of TCC causing urethral obstruction. Further studies are needed to better characterize the safety, efficacy, and outcome of this therapy.
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Affiliation(s)
- Emmanuelle Marie Butty
- From the Department of Clinical Sciences, Small Animal Internal Medicine, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts (E.M.B., M.A.L.)
| | - Bruce Forsyth
- Research and Development Interventional Oncology, Boston Scientific Corporation, Marlborough, Massachusetts (B.F.)
| | - Mary Anna Labato
- From the Department of Clinical Sciences, Small Animal Internal Medicine, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts (E.M.B., M.A.L.)
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Qiu J, Lan L, Wang Y. Pulsed Electrical Field in Arrhythmia Treatment: Current Status and Future Directions. Pacing Clin Electrophysiol 2022; 45:1255-1262. [PMID: 36029174 DOI: 10.1111/pace.14586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
Pulsed electrical field (PEF) ablation is a promising novel ablation modality for the treatment of arrhythmia, especially for atrial fibrillation(AF). It relies on electroporation inducing cellular permeabilization by the formation of pores in cell membranes, potentially resulting in cell death. Due to its' non-thermal nature and remarkable tissue selectivity, PEF ablation has be expected largely to replace conventional energy sources, such as radiofrequency (RF) and cryothermy. Up to now, the results in almost all clinical studies of PFA for AF ablation are optimistic, both in terms of effectiveness and safety. The possibility of clinical application of this technology to ventricular tachycardia(VT) has also been supported by several animal models. In this review, we aim to give an overview of the mechanism and technical progress of PFA in cardiac arrhythmia treatment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jie Qiu
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lan Lan
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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18
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Ezzeddine FM, Ward RC, Jiang Z, Tri JA, Agboola K, Hu T, Lodhi F, Tan NY, Ladas TP, Christopoulos G, Sugrue AM, Tolkacheva EG, Munoz FDC, McLeod CJ, Asirvatham SJ, DeSimone CV. Novel insights into the substrate involved in maintenance of ventricular fibrillation: results from continuous multipolar mapping in a canine model. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01333-7. [PMID: 35948726 DOI: 10.1007/s10840-022-01333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/01/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND While the triggers for ventricular fibrillation (VF) are well-known, the substrate required for its maintenance remains elusive. We have previously demonstrated dynamic spatiotemporal changes across VF from electrical induction of VF to asystole. Those data suggested that VF drivers seemed to reside in the distal RV and LV. However, signals from these areas were not recorded continuously. The aim of this study was to map these regions of significance with stationary basket electrodes from induction to asystole to provide further insights into the critical substrate for VF rhythm sustenance in canines. METHODS In six healthy canines, three multipolar basket catheters were positioned in the distal right ventricle (RV), RV outflow tract, and distal left ventricle (LV), and remained in place throughout the study. VF was induced via direct current application from an electrophysiologic catheter. Surface and intracardiac electrograms were recorded simultaneously and continuously from baseline, throughout VF, and until asystole, in order to get a complete electrophysiologic analysis of VF. Focused data analysis was also performed via two defined stages of VF: early VF (immediately after induction of VF to 10 min) and late VF (after 10 min up to VF termination and asystole). RESULTS VF was continuously mapped for a mean duration of 54 ± 9 min (range 42-70 min). Immediately after initiation of VF in the early phase, the distal LV region appeared to drive the maintenance of VF. Towards the terminal stage of VF, the distal RV region appeared to be responsible for VF persistence. In all canines, we noted local termination of VF in the LV, while VF on surface ECG continued; conversely, subsequent spontaneous termination of VF in the RV was associated with termination of VF on surface ECG into a ventricular escape rhythm. Continuous mapping of VF showed trends towards an increase in peak-to-peak ventricular electrogram cycle length (p = 0.06) and a decrease in the ventricular electrogram amplitude (p = 0.06) after 40 min. Once we could no longer discern surface QRS activity, we demonstrated local ventricular myocardial capture in both the RV and LV but could not reinitiate sustained VF despite aggressive ventricular burst pacing. CONCLUSIONS This study describes the evolution of VF from electrical initiation to spontaneous VF termination without hemodynamic support in healthy canines. These data are hypothesis-generating and suggest that critical substrate for VF maintenance may reside in both the distal RV and LV depending on stage of VF. Further studies are needed to replicate these findings with hemodynamic support and to translate such findings into clinical practice. Ventricular fibrillation maintenance may be dependent on critical structures in the distal RV. ECG: electrocardiogram; LV: left ventricle; RV: right ventricle; RVOT: right ventricular outflow tract; VF: ventricular fibrillation.
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Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert C Ward
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Zhi Jiang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jason A Tri
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kolade Agboola
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tiffany Hu
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Fahad Lodhi
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Thomas P Ladas
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Georgios Christopoulos
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Alan M Sugrue
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elena G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Freddy Del-Carpio Munoz
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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19
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Haissaguerre M, Cheniti G, Hocini M, Sacher F, Ramirez FD, Cochet H, Bear L, Tixier R, Duchateau J, Walton R, Surget E, Kamakura T, Marchand H, Derval N, Bordachar P, Ploux S, Takagi T, Pambrun T, Jais P, Labrousse L, Strik M, Ashikaga H, Calkins H, Vigmond E, Nademanee K, Bernus O, Dubois R. Purkinje network and myocardial substrate at the onset of human ventricular fibrillation: implications for catheter ablation. Eur Heart J 2022; 43:1234-1247. [PMID: 35134898 PMCID: PMC8934691 DOI: 10.1093/eurheartj/ehab893] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/25/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Mapping data of human ventricular fibrillation (VF) are limited. We performed detailed mapping of the activities underlying the onset of VF and targeted ablation in patients with structural cardiac abnormalities. METHODS AND RESULTS We evaluated 54 patients (50 ± 16 years) with VF in the setting of ischaemic (n = 15), hypertrophic (n = 8) or dilated cardiomyopathy (n = 12), or Brugada syndrome (n = 19). Ventricular fibrillation was mapped using body-surface mapping to identify driver (reentrant and focal) areas and invasive Purkinje mapping. Purkinje drivers were defined as Purkinje activities faster than the local ventricular rate. Structural substrate was delineated by electrogram criteria and by imaging. Catheter ablation was performed in 41 patients with recurrent VF. Sixty-one episodes of spontaneous (n = 10) or induced (n = 51) VF were mapped. Ventricular fibrillation was organized for the initial 5.0 ± 3.4 s, exhibiting large wavefronts with similar cycle lengths (CLs) across both ventricles (197 ± 23 vs. 196 ± 22 ms, P = 0.9). Most drivers (81%) originated from areas associated with the structural substrate. The Purkinje system was implicated as a trigger or driver in 43% of patients with cardiomyopathy. The transition to disorganized VF was associated with the acceleration of initial reentrant activities (CL shortening from 187 ± 17 to 175 ± 20 ms, P < 0.001), then spatial dissemination of drivers. Purkinje and substrate ablation resulted in the reduction of VF recurrences from a pre-procedural median of seven episodes [interquartile range (IQR) 4-16] to 0 episode (IQR 0-2) (P < 0.001) at 56 ± 30 months. CONCLUSIONS The onset of human VF is sustained by activities originating from Purkinje and structural substrate, before spreading throughout the ventricles to establish disorganized VF. Targeted ablation results in effective reduction of VF burden. KEY QUESTION The initial phase of human ventricular fibrillation (VF) is critical as it involves the primary activities leading to sustained VF and arrhythmic sudden death. The origin of such activities is unknown. KEY FINDING Body-surface mapping shows that most drivers (≈80%) during the initial VF phase originate from electrophysiologically defined structural substrates. Repetitive Purkinje activities can be elicited by programmed stimulation and are implicated as drivers in 37% of cardiomyopathy patients. TAKE-HOME MESSAGE The onset of human VF is mostly associated with activities from the Purkinje network and structural substrate, before spreading throughout the ventricles to establish sustained VF. Targeted ablation reduces or eliminates VF recurrence.
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Affiliation(s)
- Michel Haissaguerre
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Ghassen Cheniti
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Meleze Hocini
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Frederic Sacher
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - F. Daniel Ramirez
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Hubert Cochet
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Laura Bear
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Romain Tixier
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Josselin Duchateau
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Rick Walton
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Elodie Surget
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Tsukasa Kamakura
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Hugo Marchand
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Nicolas Derval
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Pierre Bordachar
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Sylvain Ploux
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Takamitsu Takagi
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Thomas Pambrun
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Pierre Jais
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Louis Labrousse
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Mark Strik
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Hiroshi Ashikaga
- Arrhythmia Service, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Hugh Calkins
- Arrhythmia Service, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Ed Vigmond
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, IMB, U1045 Pessac, France
| | | | - Olivier Bernus
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Remi Dubois
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
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20
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The Purkinje network plays a major role in low-energy ventricular defibrillation. Comput Biol Med 2021; 141:105133. [PMID: 34954609 DOI: 10.1016/j.compbiomed.2021.105133] [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: 10/15/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND During ventricular fibrillation (VF), targeting the excitable gap (EG) of reentry throughout the myocardium with low-energy surface stimulation shows promise for painless defibrillation. However, the Purkinje network may provide alternative pathways for reentry to evade termination. This study investigates the role of the Purkinje network in painless defibrillation. METHODS In a computational human biventricular model featuring a Purkinje network, VF was initiated with 4 Hz epicardial pacing. Defibrillation was attempted by stimulating myocardial surface EG with a low-energy 2 ms duration pulse at 2x stimulus capture, which was administered at coupling intervals incremented by 0.25 s between 0.25 and 5 s after VF initiation. Defibrillation was accomplished if reentry ceased ≤ 1 s after the defibrillation pulse. The protocol was repeated with the Purkinje network and myocardial surface EG stimulated simultaneously, and again after uncoupling the Purkinje network from the myocardium. RESULTS VF with the Purkinje network coupled and uncoupled had comparable dominant frequency in the left (3.81 ± 0.44 versus 3.77 ± 0.53 Hz) and right (3.80 ± 0.37 versus 3.76 ± 0.48 Hz) ventricles. When uncoupling the Purkinje network, myocardial surface EG stimulation terminated VF for all defibrillation pulses. When coupled, myocardial EG surface stimulation terminated VF for only 55% of the defibrillation pulses, but improved to 100% when stimulated simultaneously with Purkinje network EG. Defibrillation failures were attributed to EG evading stimulation in the Purkinje network. CONCLUSIONS Defibrillation that exclusively targets myocardium can fail due to accessory pathways in the Purkinje network that allow for reentrant activity to evade termination and maintain VF. Painless defibrillation strategies should be adapted to include the Purkinje network.
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21
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Analysis of vulnerability to reentry in acute myocardial ischemia using a realistic human heart model. Comput Biol Med 2021; 141:105038. [PMID: 34836624 DOI: 10.1016/j.compbiomed.2021.105038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/25/2021] [Accepted: 11/12/2021] [Indexed: 11/21/2022]
Abstract
Electrophysiological alterations of the myocardium caused by acute ischemia constitute a pro-arrhythmic substrate for the generation of potentially lethal arrhythmias. Experimental evidence has shown that the main components of acute ischemia that induce these electrophysiological alterations are hyperkalemia, hypoxia (or anoxia in complete artery occlusion), and acidosis. However, the influence of each ischemic component on the likelihood of reentry is not completely established. Moreover, the role of the His-Purkinje system (HPS) in the initiation and maintenance of arrhythmias is not completely understood. In the present work, we investigate how the three components of ischemia affect the vulnerable window (VW) for reentry using computational simulations. In addition, we analyze the role of the HPS on arrhythmogenesis. A 3D biventricular/torso human model that includes a realistic geometry of the central and border ischemic zones with one of the most electrophysiologically detailed model of ischemia to date, as well as a realistic cardiac conduction system, were used to assess the VW for reentry. Four scenarios of ischemic severity corresponding to different minutes after coronary artery occlusion were simulated. Our results suggest that ischemic severity plays an important role in the generation of reentries. Indeed, this is the first 3D simulation study to show that ventricular arrhythmias could be generated under moderate ischemic conditions, but not in mild and severe ischemia. Moreover, our results show that anoxia is the ischemic component with the most significant effect on the width of the VW. Thus, a change in the level of anoxia from moderate to severe leads to a greater increment in the VW (40 ms), in comparison with the increment of 20 ms and 35 ms produced by the individual change in the level of hyperkalemia and acidosis, respectively. Finally, the HPS was a necessary element for the generation of approximately 17% of reentries obtained. The retrograde conduction from the myocardium to HPS in the ischemic region, conduction blocks in discrete sections of the HPS, and the degree of ischemia affecting Purkinje cells, are suggested as mechanisms that favor the generation of ventricular arrhythmias.
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22
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Tan NY, Christopoulos G, Ladas TP, Jiang Z, Sugrue AM, Tri JA, Tolkacheva EG, Del-Carpio Munoz F, McLeod CJ, Asirvatham SJ, DeSimone CV. Regional and Temporal Variation of Ventricular and Conduction Tissue Activity During Ventricular Fibrillation in Canines. Circ Arrhythm Electrophysiol 2021; 14:e010281. [PMID: 34665643 DOI: 10.1161/circep.121.010281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Georgios Christopoulos
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Thomas P Ladas
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Zhi Jiang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Alan M Sugrue
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Jason A Tri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Elena G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis (E.G.T.)
| | - Freddy Del-Carpio Munoz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | | | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
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23
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Verma A, Asivatham SJ, Deneke T, Castellvi Q, Neal RE. Primer on Pulsed Electrical Field Ablation: Understanding the Benefits and Limitations. Circ Arrhythm Electrophysiol 2021; 14:e010086. [PMID: 34538095 DOI: 10.1161/circep.121.010086] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pulsed electrical field (PEF) energy is a promising technique for catheter ablation of cardiac arrhythmias. In this article, the key aspects that need to be considered for safe and effective PEF delivery are reviewed, and their impact on clinical feasibility is discussed. The most important benefit of PEF appears to be the ability to kill cells through mechanisms that do not alter stromal proteins, sparing sensitive structures to improve safety, without sacrificing cardiomyocyte ablation efficacy. Many parameters affect PEF treatment outcomes, including pulse intensity, waveform shape, and number of pulses, as well as electrode configuration and geometry. These physical and electrical characteristics must be titrated carefully to balance target tissue effects with collateral implications (muscle contraction, temperature rise, risk of electrical arcing events). It is important to note that any combination of parameters affecting PEF needs to be tested for clinical efficacy and safety. Applying PEF clinically requires knowledge of the fundamentals of this technology to exploit its opportunities and generate viable, durable health improvements for patients.
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Affiliation(s)
- Atul Verma
- Division of Cardiology, Southlake Regional Health Center, University of Toronto, Newmarket, Canada (A.V.)
| | - Samuel J Asivatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (S.J.A.)
| | - Thomas Deneke
- Division of Cardiology, Rhon-Klinikum Campus Bad Neustadt, Bad Neustadt, Germany (T.D.)
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24
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Rattanawong P, Ladia V, Minaskeian N, Sorajja D, Shen WK, Srivathsan KS. Empirical Ablation to Prevent Sequential Purkinje System Recruitment: A Novel Therapy for Idiopathic Ventricular Fibrillation. JACC Case Rep 2021; 3:517-522. [PMID: 34317571 PMCID: PMC8311030 DOI: 10.1016/j.jaccas.2021.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/21/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022]
Abstract
We report 3 cases (mean age 48.3 ± 11.6 years) of idiopathic ventricular fibrillation (IVF), in which a triggering premature ventricular complex leading to IVF could not be identified. All patients underwent posterior fascicle transection with empirical linear ablation of the mid-Purkinje potentials identified along the left ventricular interventricular inferior septum, and no ventricular fibrillation recurrence was documented in any of the patients. (Level of Difficulty: Advanced.)
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Affiliation(s)
| | - Vatsal Ladia
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Nareg Minaskeian
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Dan Sorajja
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Win-Kuang Shen
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona, USA
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25
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Di Biase L, Diaz JC, Zhang XD, Romero J. Pulsed field catheter ablation in atrial fibrillation. Trends Cardiovasc Med 2021; 32:378-387. [PMID: 34329732 DOI: 10.1016/j.tcm.2021.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/06/2021] [Accepted: 07/23/2021] [Indexed: 12/21/2022]
Abstract
Catheter ablation (CA) has become the mainstay therapy for the maintenance of sinus rhythm in patients with atrial fibrillation (AF), with pulmonary vein isolation (PVI) the most frequently used treatment strategy. Although several energy sources have been tested (including radiofrequency, cryothermal and laser), these are not devoid of safety issues and in many instances effectiveness is dependent on operator experience. Pulsed field ablation (PFA) is a novel energy source by which high-voltage electric pulses are used to create pores in the cellular membrane (i.e., electroporation), leading to cellular death. The amount of energy required to produce irreversible electroporation is highly tissue dependent. In consequence, a tailored protocol in which specific targeting of the atrial myocardium is achieved while sparing adjacent tissues is theoretically feasible, increasing the safety of the procedure. While large scale clinical trials are lacking, current clinical evidence has demonstrated significant efficacy in achieving durable PVI without ablation related adverse events.
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Affiliation(s)
- Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx 10467, NY, United States.
| | - Juan Carlos Diaz
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx 10467, NY, United States
| | - Xiao-Dong Zhang
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx 10467, NY, United States
| | - Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx 10467, NY, United States
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26
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Lindemann F, Nedios S, Seewöster T, Hindricks G. [Pulmonary vein isolation in atrial fibrillation using pulsed field ablation]. Herz 2021; 46:318-322. [PMID: 34142178 DOI: 10.1007/s00059-021-05047-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Atrial fibrillation is the most common supraventricular arrhythmia with increasing incidence and prevalence. Until now, thermal energy sources such as radiofrequency or cryoablation have been used for pulmonary vein isolation of atrial fibrillation but these have led to indiscriminate tissue destruction in the target area. Pulsed field ablation (PFA) is an energy modality that does not utilize thermal effects. An ultrarapid electric field produces irreversible changes in cell membrane pores (irreversible electroporation) culminating in cell death. The myocardium is very sensitive to PFA compared to the esophagus, the pulmonary veins or the phrenic nerve. Consequently, it is possible to perform effective ablation of the pulmonary veins in a very short time and to make the treatment time more effective without causing relevant collateral damage. The treatment offers a potential paradigm shift from catheter ablation of cardiac arrhythmia.
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Affiliation(s)
- F Lindemann
- Abteilung für Elektrophysiologie, Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland.
| | - S Nedios
- Abteilung für Elektrophysiologie, Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
| | - T Seewöster
- Abteilung für Elektrophysiologie, Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
| | - G Hindricks
- Abteilung für Elektrophysiologie, Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
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27
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McBride S, Avazzadeh S, Wheatley AM, O’Brien B, Coffey K, Elahi A, O’Halloran M, Quinlan LR. Ablation Modalities for Therapeutic Intervention in Arrhythmia-Related Cardiovascular Disease: Focus on Electroporation. J Clin Med 2021; 10:jcm10122657. [PMID: 34208708 PMCID: PMC8235263 DOI: 10.3390/jcm10122657] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023] Open
Abstract
Targeted cellular ablation is being increasingly used in the treatment of arrhythmias and structural heart disease. Catheter-based ablation for atrial fibrillation (AF) is considered a safe and effective approach for patients who are medication refractory. Electroporation (EPo) employs electrical energy to disrupt cell membranes which has a minimally thermal effect. The nanopores that arise from EPo can be temporary or permanent. Reversible electroporation is transitory in nature and cell viability is maintained, whereas irreversible electroporation causes permanent pore formation, leading to loss of cellular homeostasis and cell death. Several studies report that EPo displays a degree of specificity in terms of the lethal threshold required to induce cell death in different tissues. However, significantly more research is required to scope the profile of EPo thresholds for specific cell types within complex tissues. Irreversible electroporation (IRE) as an ablative approach appears to overcome the significant negative effects associated with thermal based techniques, particularly collateral damage to surrounding structures. With further fine-tuning of parameters and longer and larger clinical trials, EPo may lead the way of adapting a safer and efficient ablation modality for the treatment of persistent AF.
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Affiliation(s)
- Shauna McBride
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Sahar Avazzadeh
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Antony M. Wheatley
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Barry O’Brien
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 R6W6 Galway, Ireland; (B.O.); (K.C.)
| | - Ken Coffey
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 R6W6 Galway, Ireland; (B.O.); (K.C.)
| | - Adnan Elahi
- Translational Medical Device Lab (TMDL), Lamb Translational Research Facility, University College Hospital Galway, H91 V4AY Galway, Ireland; (A.E.); (M.O.)
- Electrical & Electronic Engineering, School of Engineering, National University of Ireland Galway, H91 HX31 Galway, Ireland
| | - Martin O’Halloran
- Translational Medical Device Lab (TMDL), Lamb Translational Research Facility, University College Hospital Galway, H91 V4AY Galway, Ireland; (A.E.); (M.O.)
| | - Leo R. Quinlan
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
- CÚRAM, SFI Research Centre for Medical Devices, National University of Ireland Galway, H92 W2TY Galway, Ireland
- Correspondence:
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28
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Noheria A, Anderson J. Advances in Mapping and Ablation of Ventricular Fibrillation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00899-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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La Rosa G, Quintanilla JG, Salgado R, González-Ferrer JJ, Cañadas-Godoy V, Pérez-Villacastín J, Jalife J, Pérez-Castellano N, Filgueiras-Rama D. Anatomical targets and expected outcomes of catheter-based ablation of atrial fibrillation in 2020. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:341-359. [PMID: 33283883 DOI: 10.1111/pace.14140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/18/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022]
Abstract
Anatomical-based approaches, targeting either pulmonary vein isolation (PVI) or additional extra PV regions, represent the most commonly used ablation treatments in symptomatic patients with atrial fibrillation (AF) recurrences despite antiarrhythmic drug therapy. PVI remains the main anatomical target during catheter-based AF ablation, with the aid of new technological advances as contact force monitoring to increase safety and effective radiofrequency (RF) lesions. Nowadays, cryoballoon ablation has also achieved the same level of scientific evidence in patients with paroxysmal AF undergoing PVI. In parallel, electrical isolation of extra PV targets has progressively increased, which is associated with a steady increase in complex cases undergoing ablation. Several atrial regions as the left atrial posterior wall, the vein of Marshall, the left atrial appendage, or the coronary sinus have been described in different series as locations potentially involved in AF initiation and maintenance. Targeting these regions may be challenging using conventional point-by-point RF delivery, which has opened new opportunities for coadjuvant alternatives as balloon ablation or selective ethanol injection. Although more extensive ablation may increase intraprocedural AF termination and freedom from arrhythmias during the follow-up, some of the targets to achieve such outcomes are not exempt of potential severe complications. Here, we review and discuss current anatomical approaches and the main ablation technologies to target atrial regions associated with AF initiation and maintenance.
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Affiliation(s)
- Giulio La Rosa
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain
| | - Jorge G Quintanilla
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ricardo Salgado
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain
| | - Juan José González-Ferrer
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Victoria Cañadas-Godoy
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Julián Pérez-Villacastín
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - José Jalife
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Nicasio Pérez-Castellano
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - David Filgueiras-Rama
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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30
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Bradley CJ, Haines DE. Pulsed field ablation for pulmonary vein isolation in the treatment of atrial fibrillation. J Cardiovasc Electrophysiol 2020; 31:2136-2147. [DOI: 10.1111/jce.14414] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/02/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Christopher J. Bradley
- Department of Cardiovascular Medicine, Beaumont HospitalOakland University William Beaumont School of Medicine Royal Oak Michigan
| | - David E. Haines
- Department of Cardiovascular Medicine, Beaumont HospitalOakland University William Beaumont School of Medicine Royal Oak Michigan
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31
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Sugrue A, Vaidya VR, Livia C, Padmanabhan D, Abudan A, Isath A, Witt T, DeSimone CV, Stalboerger P, Kapa S, Asirvatham SJ, McLeod CJ. Feasibility of selective cardiac ventricular electroporation. PLoS One 2020; 15:e0229214. [PMID: 32084220 PMCID: PMC7034868 DOI: 10.1371/journal.pone.0229214] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/31/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction The application of brief high voltage electrical pulses to tissue can lead to an irreversible or reversible electroporation effect in a cell-specific manner. In the management of ventricular arrhythmias, the ability to target different tissue types, specifically cardiac conduction tissue (His-Purkinje System) vs. cardiac myocardium would be advantageous. We hypothesize that pulsed electric fields (PEFs) can be applied safely to the beating heart through a catheter-based approach, and we tested whether the superficial Purkinje cells can be targeted with PEFs without injury to underlying myocardial tissue. Methods In an acute (n = 5) and chronic canine model (n = 6), detailed electroanatomical mapping of the left ventricle identified electrical signals from myocardial and overlying Purkinje tissue. Electroporation was effected via percutaneous catheter-based Intracardiac bipolar current delivery in the anesthetized animal. Repeat Intracardiac electrical mapping of the heart was performed at acute and chronic time points; followed by histological analysis to assess effects. Results PEF demonstrated an acute dose-dependent functional effect on Purkinje, with titration of pulse duration and/or voltage associated with successful acute Purkinje damage. Electrical conduction in the insulated bundle of His (n = 2) and anterior fascicle bundle (n = 2), was not affected. At 30 days repeat cardiac mapping demonstrated resilient, normal electrical conduction throughout the targeted area with no significant change in myocardial amplitude (pre 5.9 ± 1.8 mV, 30 days 5.4 ± 1.2 mV, p = 0.92). Histopathological analysis confirmed acute Purkinje fiber targeting, with chronic studies showing normal Purkinje fibers, with minimal subendocardial myocardial fibrosis. Conclusion PEF provides a novel, safe method for non-thermal acute modulation of the Purkinje fibers without significant injury to the underlying myocardium. Future optimization of this energy delivery is required to optimize conditions so that selective electroporation can be utilized in humans the treatment of cardiac disease.
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Affiliation(s)
- Alan Sugrue
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Vaibhav R. Vaidya
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher Livia
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental Therapeutics, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Deepak Padmanabhan
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Anas Abudan
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Ameesh Isath
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Tyra Witt
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental Therapeutics, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher V. DeSimone
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Paul Stalboerger
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental Therapeutics, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Suraj Kapa
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Samuel J. Asirvatham
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher J. McLeod
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
- * E-mail:
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32
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Aycock KN, Davalos RV. Irreversible Electroporation: Background, Theory, and Review of Recent Developments in Clinical Oncology. Bioelectricity 2019; 1:214-234. [PMID: 34471825 PMCID: PMC8370296 DOI: 10.1089/bioe.2019.0029] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Irreversible electroporation (IRE) has established a clinical niche as an alternative to thermal ablation for the eradication of unresectable tumors, particularly those near critical vascular structures. IRE has been used in over 50 independent clinical trials and has shown clinical success when used as a standalone treatment and as a single component within combinatorial treatment paradigms. Recently, many studies evaluating IRE in larger patient cohorts and alongside other novel therapies have been reported. Here, we present the basic principles of reversible electroporation and IRE followed by a review of preclinical and clinical data with a focus on tumors in three organ systems in which IRE has shown great promise: the prostate, pancreas, and liver. Finally, we discuss alternative and future developments, which will likely further advance the use of IRE in the clinic.
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Affiliation(s)
- Kenneth N Aycock
- Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Virginia
| | - Rafael V Davalos
- Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Virginia
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33
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Imnadze G, Zerm T. Prevention of ventricular fibrillation through de-networking of the Purkinje system: Proof-of-Concept Paper on the Substrate Modification of the Purkinje Network. Pacing Clin Electrophysiol 2019; 42:1285-1290. [PMID: 31424573 PMCID: PMC6852399 DOI: 10.1111/pace.13782] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/02/2019] [Accepted: 07/18/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Sudden cardiac death from ventricular fibrillation (VF) remains a major health problem worldwide. Currently, there are limited treatment options available to patients who suffer from episodes of VF. Because Purkinje fibers have been implicated as a source of initiation of VF, we are presenting the first paper of a series highlighting the promising results of substrate modulation through "De-Networking" of the Purkinje system preventing VF in patients without an alternative ablation strategy. METHODS AND RESULTS We studied 10 consecutive patients (two female) all but one implanted with an ICD with documented VF or fast polymorphic Ventricular tachycardia (VT) (five patients without history of structural heart disease, two with ischemic cardiomyopathy, one with hypertrophic obstructive cardiomyopathy, one with dilated cardiomyopathy, and one with aortic valve disease). After 3D electroanatomical mapping, the left bundle branch (LBB) and left ventricular Purkinje potentials were annotated creating a virtual triangle with the apex formed by the distal LBB and the base by the most distal Purkinje potentials. Linear radiofrequency catheter ablation at the base of the triangle was performed, followed by ablation within the virtual triangle sparing the LBB and both fascicles ("de-networking"). All patients were treated without complications. During 1-year follow-up, only 2/10(20%) patients experienced recurrence in form of a single episode of polymorphic VT/VF. CONCLUSION Catheter ablation of VF through "de-networking" of the Purkinje system in patients without overt arrhythmia substrate or trigger appears safe and effective and will require further study in a larger patient cohort.
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Affiliation(s)
- Guram Imnadze
- Heart and Diabetes Center North Rhine‐WestphaliaClinic of Arrhythmia MagnagementBad OeynhausenNordrhein‐Westfalen, DE
- Ruhr‐Universitat Bochum Medizinische FakultatArrhythmia ManagementBochumNordrhein‐Westfalen, DE
- Department of Arrhythmia ManagementKlinikum OsnabrueckOsnabrueckGermany
| | - Thomas Zerm
- Electrophysiology DepartmentAlbertinen Hospital, Academic Teaching Hospital of the University of Hamburg ‐ EppendorfHamburgGermany
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DeSimone CV, Asirvatham SJ. Purkinje tissue modification and ventricular fibrillation. Pacing Clin Electrophysiol 2019; 42:1291-1293. [PMID: 31407803 DOI: 10.1111/pace.13781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/11/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.,Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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35
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Es R, Groen MHA, Stehouwer M, Doevendans PA, Wittkampf FHM, Neven K. In vitro analysis of the origin and characteristics of gaseous microemboli during catheter electroporation ablation. J Cardiovasc Electrophysiol 2019; 30:2071-2079. [DOI: 10.1111/jce.14091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/04/2019] [Accepted: 07/21/2019] [Indexed: 12/15/2022]
Affiliation(s)
- René Es
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Marijn H. A. Groen
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Marco Stehouwer
- Department of Extracorporeal CirculationSt Antonius HospitalNieuwegein The Netherlands
| | - Pieter A. Doevendans
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
- Netherlands Heart InstituteUtrecht The Netherlands
| | - Fred H. M. Wittkampf
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Kars Neven
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
- Department of ElectrophysiologyAlfried Krupp KrankenhausEssen Germany
- Faculty of HealthWitten/Herdecke UniversityWitten Germany
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36
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Redefining the electroanatomy of the cardiac conduction system. Heart Rhythm 2019; 17:131-132. [PMID: 31449882 DOI: 10.1016/j.hrthm.2019.08.021] [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: 08/14/2019] [Indexed: 11/22/2022]
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37
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Sugrue A, Vaidya V, Yasin O, Isath A, Abudan A, Padmanabhan D, Kapa S, Asirvatham SJ. Development of a novel ablation hood to prevent systemic embolization of microbubbles and particulate emboli. J Interv Card Electrophysiol 2019; 58:281-288. [PMID: 31372780 DOI: 10.1007/s10840-019-00595-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation ablation results in microbubbles and particulate emboli formation. We aimed to develop and test the early feasibility of a novel ablation hood to contain microbubbles and particulate emboli with the ultimate goal of preventing systemic embolization. METHODS In seven canines, we developed, iterated, and tested a novel retractable hood that can cover the catheter-tissue ablation site. The number and volume (nL) of microbubbles formed during ablation with and without the hood was measured using an extracorporeal circulation loop. Wilcoxon's signed-rank test was used to compare the number of bubbles detected with and without the hood. RESULTS The hood reduced systemic embolization of microbubbles in 21/28 (75%) of ablations. Both atrial and ventricular ablations showed a statistically significant reduction in bubble number (476 ± 811 without hood vs 173 ± 226 with hood, p = 0.02; 2669 ± 1623 without hood vs 1417 ± 970 with hood, p = 0.04, respectively) and bubble volume (3.3 ± 7.6 nL without hood vs 0.2 ± 0.56 nL with hood, p = 0.006; 6.1 ± 5.2 nL without hood vs 1.9 ± 1.4 nL with hood, p = 0.05, respectively). CONCLUSIONS Use of a novel hood to cover the ablation catheter at the site of catheter-tissue contact has the potential to provide a means to reduce systematic embolization of microbubbles. Further work is required to examine particulate emboli, but these data show the early feasibility of this design concept.
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Affiliation(s)
- Alan Sugrue
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vaibhav Vaidya
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Omar Yasin
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ameesh Isath
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anas Abudan
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deepak Padmanabhan
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suraj Kapa
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA.
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38
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Sugrue A, Vaidya V, Witt C, DeSimone CV, Yasin O, Maor E, Killu AM, Kapa S, McLeod CJ, Miklavčič D, Asirvatham SJ. Irreversible electroporation for catheter-based cardiac ablation: a systematic review of the preclinical experience. J Interv Card Electrophysiol 2019; 55:251-265. [PMID: 31270656 DOI: 10.1007/s10840-019-00574-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/26/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Irreversible electroporation (IRE) utilizing high voltage pulses is an emerging strategy for catheter-based cardiac ablation with considerable growth in the preclinical arena. METHODS A systematic search for articles was performed from three sources (PubMed, EMBASE, and Google Scholar). The primary outcome was the efficacy of tissue ablation with characteristics of lesion formation evaluated by histologic analysis. The secondary outcome was focused on safety and damage to collateral structures. RESULTS Sixteen studies met inclusion criteria. IRE was most commonly applied to the ventricular myocardium (n = 7/16, 44%) by a LifePak 9 Defibrillator (n = 9/16, 56%), NanoKnife Generator (n = 2/16, 13%), or other custom generators (n = 5/16, 31%). There was significant heterogeneity regarding electroporation protocols. On histological analysis, IRE was successful in creating ablation lesions with variable transmurality depending on the electric pulse parameters and catheter used. CONCLUSION Preclinical studies suggest that cardiac tissue ablation using IRE shows promise in delivering efficacious, safe lesions.
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Affiliation(s)
- Alan Sugrue
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Vaibhav Vaidya
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Chance Witt
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Omar Yasin
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elad Maor
- Leviev Heart Center, Sheba Medical Center, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ammar M Killu
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Suraj Kapa
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher J McLeod
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, University of Ljubljana, Trzaska 25, 1000, Ljubljana, Slovenia
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Pulsed electric fields for cardiac ablation and beyond: A state-of-the-art review. Heart Rhythm 2019; 16:1112-1120. [DOI: 10.1016/j.hrthm.2019.01.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Indexed: 12/15/2022]
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40
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Katritsis DG. What Cannot be Missed: Must-read Papers, 2018. Arrhythm Electrophysiol Rev 2019; 8:81-82. [DOI: 10.15420/aer.2019.8.2.fo1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Tzou WS, Hussein AA, Madhavan M, Viswanathan MN, Steinberg BA, Ceresnak SR, Davis DR, Park DS, Wang PJ, Kapa S. Year in Review in Cardiac Electrophysiology. Circ Arrhythm Electrophysiol 2019; 12:e007142. [PMID: 30744401 DOI: 10.1161/circep.118.007142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Wendy S Tzou
- Department of Medicine, University of Colorado, Aurora (W.S.T.)
| | - Ayman A Hussein
- Department of Cardiovascular Medicine, Cleveland Clinic, OH (A.A.H.)
| | - Malini Madhavan
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (M.M., S.K.)
| | - Mohan N Viswanathan
- Department of Medicine, Stanford University Medical Center, Palo Alto, CA (M.N.V., P.J.W.)
| | | | - Scott R Ceresnak
- Department of Medicine, Stanford Children's Health, Palo Alto, CA (S.R.C.)
| | - Darryl R Davis
- Division of Cardiology, University of Ottawa Heart Institute, Ontario, Canada (D.R.D.)
| | - David S Park
- Department of Medicine, New York University Langone Health, NY (D.S.P.)
| | - Paul J Wang
- Department of Medicine, Stanford University Medical Center, Palo Alto, CA (M.N.V., P.J.W.)
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (M.M., S.K.)
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42
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Sugrue A, Asirvatham SJ. Highlights from Heart Rhythm 2018: Innovative Techniques. J Innov Card Rhythm Manag 2018; 9:3330-3335. [PMID: 32494506 PMCID: PMC7252867 DOI: 10.19102/icrm.2018.090905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alan Sugrue
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester MN, USA
| | - Samuel J. Asirvatham
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester MN, USA
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester MN, USA
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