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Wang Z, Liang M, Sun J, Zhang J, Han Y. A New Hope for the Treatment of Atrial Fibrillation: Application of Pulsed-Field Ablation Technology. J Cardiovasc Dev Dis 2024; 11:175. [PMID: 38921675 PMCID: PMC11204042 DOI: 10.3390/jcdd11060175] [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: 04/04/2024] [Revised: 05/17/2024] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
In recent years, the prevalence of and mortality associated with cardiovascular diseases have been rising in most countries and regions. AF is the most common arrhythmic condition, and there are several treatment options for AF. Pulmonary vein isolation is an effective treatment for AF and is the cornerstone of current ablation techniques, which have one major limitation: even when diagnosed and treated at a facility that specializes in ablation, patients have a greater chance of recurrence. Therefore, there is a need to develop better ablation techniques for the treatment of AF. This article first compares the current cryoablation (CBA) and radiofrequency ablation (RFA) techniques for the treatment of AF and discusses the utility and advantages of the development of pulsed-field ablation (PFA) technology. The current research on PFA is summarized from three perspectives, namely, simulation experiments, animal experiments, and clinical studies. The results of different stages of experiments are summarized, especially during animal studies, where pulmonary vein isolation was carried out effectively without causing injury to the phrenic nerve, esophagus, and pulmonary veins, with higher safety and shorter incision times. This paper focuses on a review of various a priori and clinical studies of this new technique for the treatment of AF.
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Affiliation(s)
- Zhen Wang
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang 110819, China;
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China; (M.L.); (J.S.); (J.Z.)
| | - Ming Liang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China; (M.L.); (J.S.); (J.Z.)
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Shenyang 110016, China
| | - Jingyang Sun
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China; (M.L.); (J.S.); (J.Z.)
| | - Jie Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China; (M.L.); (J.S.); (J.Z.)
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China; (M.L.); (J.S.); (J.Z.)
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Shenyang 110016, China
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Estevez-Laborí F, O'Brien B, González-Suárez A. Difference between endocardial and epicardial application of pulsed fields for targeting Epicardial Ganglia: An in-silico modelling study. Comput Biol Med 2024; 174:108490. [PMID: 38642490 DOI: 10.1016/j.compbiomed.2024.108490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Pulsed Field Ablation (PFA) has recently been proposed as a non-thermal energy to treat atrial fibrillation by selective ablation of ganglionated plexi (GP) embedded in epicardial fat. While some of PFA-technologies use an endocardial approach, others use epicardial access with promising pre-clinical results. However, as each technology uses a different and sometimes proprietary pulse application protocol, the comparation between endocardial vs. epicardial approach is almost impossible in experimental terms. For this reason, our study, based on a computational model, allows a direct comparison of electric field distribution and thermal-side effects of both approaches under equal conditions in terms of electrode design, pulse protocol and anatomical characteristics of the tissues involved. METHODS 2D computational models with axial symmetry were built for endocardial and epicardial approaches. Atrial (1.5-2.5 mm) and fat (1-5 mm) thicknesses were varied to simulate a representative sample of what happens during PFA ablation for different applied voltage values (1000, 1500 and 2000 V) and number of pulses (30 and 50). RESULTS The epicardial approach was superior for capturing greater volumes of fat when the applied voltage was increased: 231 mm3/kV with the epicardial approach vs. 182 mm3/kV with the endocardial approach. In relation to collateral damage to the myocardium, the epicardial approach considerably spares the myocardium, unlike what happens with the endocardial approach. Although the epicardial approach caused much more thermal damage in the fat, there is not a significant difference between the approaches in terms of size of thermal damage in the myocardium. CONCLUSIONS Our results suggest that epicardial PFA ablation of GPs is more effective than an endocardial approach. The proximity and directionality of the electric field deposited using an epicardial approach are key to ensuring that higher electric field strengths and increased temperatures are obtained within the epicardial fat, thus contributing to selective ablation of the GPs with minimal myocardial damage.
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Affiliation(s)
| | | | - Ana González-Suárez
- Translational Medical Device Lab, School of Medicine, University of Galway, Ireland; IBIO, Escuela Superior de Ingeniería, Ciencia y Tecnología, Universidad Internacional de Valencia, Valencia, Spain.
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Jiang S, Qian F, Ji S, Li L, Liu Q, Zhou S, Xiao Y. Pulsed Field Ablation for Atrial Fibrillation: Mechanisms, Advantages, and Limitations. Rev Cardiovasc Med 2024; 25:138. [PMID: 39076550 PMCID: PMC11264014 DOI: 10.31083/j.rcm2504138] [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: 10/11/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 07/31/2024] Open
Abstract
Pulsed field ablation with irreversible electroporation for the treatment of atrial fibrillation involves tissue-specific and non-thermal energy-induced cell necrosis, which helps avoid complications, such as pulmonary vein stenosis, atrial collateral tissue damage, and extensive atrial structural damage, often encountered with traditional thermal ablation. In existing clinical trials, pulsed field ablation has shown excellent effects on pulmonary vein isolation in patients with paroxysmal and persistent atrial fibrillation. Pulsed field ablation is easy, simple, and quick and can reduce iatrogenic injury. Therefore, the application of pulsed field ablation technology in the treatment of atrial fibrillation has a promising future. Notably, the adjustment of parameters in pulsed field ablation with different ablation catheter systems can strongly affect the area and depth of the necrotic myocardium, which greatly affects the likelihood of atrial fibrillation recurrence and incidence of adverse complications after ablation. In this paper, we review the mechanisms, advantages, and limitations of pulsed field ablation based on the results of a series of previous studies and provide ideas and directions for future research.
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Affiliation(s)
- Shali Jiang
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, 410011 Changsha, Hunan, China
- Xiangya School of Medicine, Central South University, 410013 Changsha, Hunan, China
| | - Frank Qian
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Shuting Ji
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, 410011 Changsha, Hunan, China
- Xiangya School of Medicine, Central South University, 410013 Changsha, Hunan, China
| | - Luohong Li
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, 410011 Changsha, Hunan, China
- Xiangya School of Medicine, Central South University, 410013 Changsha, Hunan, China
| | - Qiming Liu
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, 410011 Changsha, Hunan, China
| | - Shenghua Zhou
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, 410011 Changsha, Hunan, China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, 410011 Changsha, Hunan, China
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Pérez JJ, González-Suárez A. How intramyocardial fat can alter the electric field distribution during Pulsed Field Ablation (PFA): Qualitative findings from computer modeling. PLoS One 2023; 18:e0287614. [PMID: 37917621 PMCID: PMC10621855 DOI: 10.1371/journal.pone.0287614] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/08/2023] [Indexed: 11/04/2023] Open
Abstract
Even though the preliminary experimental data suggests that cardiac Pulsed Field Ablation (PFA) could be superior to radiofrequency ablation (RFA) in terms of being able to ablate the viable myocardium separated from the catheter by collagen and fat, as yet there is no formal physical-based analysis that describes the process by which fat can affect the electric field distribution. Our objective was thus to determine the electrical impact of intramyocardial fat during PFA by means of computer modeling. Computer models were built considering a PFA 3.5-mm blunt-tip catheter in contact with a 7-mm ventricular wall (with and without a scar) and a 2-mm epicardial fat layer. High voltage was set to obtain delivered currents of 19, 22 and 25 A. An electric field value of 1000 V/cm was considered as the lethal threshold. We found that the presence of fibrotic tissue in the scar seems to have a similar impact on the electric field distribution and lesion size to that of healthy myocardium only. However, intramyocardial fat considerably alters the electrical field distribution and the resulting lesion shape. The electric field tends to peak in zones with fat, even away from the ablation electrode, so that 'cold points' (i.e. low electric fields) appear around the fat at the current entry and exit points, while 'hot points' (high electric fields) occur in the lateral areas of the fat zones. The results show that intramyocardial fat can alter the electric field distribution and lesion size during PFA due to its much lower electrical conductivity than that of myocardium and fibrotic tissue.
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Affiliation(s)
- Juan J. Pérez
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Ana González-Suárez
- Translational Medical Device Lab, School of Engineering, University of Galway, Galway, Ireland
- Universidad Internacional de Valencia—VIU, Valencia, Spain
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O'Brien B, Reilly J, Coffey K, González-Suárez A, Quinlan L, van Zyl M. Cardioneuroablation Using Epicardial Pulsed Field Ablation for the Treatment of Atrial Fibrillation. J Cardiovasc Dev Dis 2023; 10:238. [PMID: 37367403 DOI: 10.3390/jcdd10060238] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting millions of people worldwide. The cardiac autonomic nervous system (ANS) is widely recognized as playing a key role in both the initiation and propagation of AF. This paper reviews the background and development of a unique cardioneuroablation technique for the modulation of the cardiac ANS as a potential treatment for AF. The treatment uses pulsed electric field energy to selectively electroporate ANS structures on the epicardial surface of the heart. Insights from in vitro studies and electric field models are presented as well as data from both pre-clinical and early clinical studies.
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Affiliation(s)
- Barry O'Brien
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - John Reilly
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - Ken Coffey
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - Ana González-Suárez
- School of Engineering, University of Galway, H91 TK33 Galway, Ireland
- Translational Medical Device Lab, University of Galway, H91 YR71 Galway, Ireland
| | - Leo Quinlan
- Physiology and Cellular Physiology Research Laboratory, CURAM SFI Centre for Research in Medical Device, University of Galway, H91 TK33 Galway, Ireland
| | - Martin van Zyl
- Cardiac Electrophysiology, Royal Jubilee Hospital, Victoria, BC V8R 1J8, Canada
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González-Suárez A, Pérez JJ, O’Brien B, Elahi A. In Silico Modelling to Assess the Electrical and Thermal Disturbance Provoked by a Metal Intracoronary Stent during Epicardial Pulsed Electric Field Ablation. J Cardiovasc Dev Dis 2022; 9:jcdd9120458. [PMID: 36547455 PMCID: PMC9784210 DOI: 10.3390/jcdd9120458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Pulsed Electric Field (PEF) ablation has been recently proposed to ablate cardiac ganglionic plexi (GP) aimed to treat atrial fibrillation. The effect of metal intracoronary stents in the vicinity of the ablation electrode has not been yet assessed. Methods: A 2D numerical model was developed accounting for the different tissues involved in PEF ablation with an irrigated ablation device. A coronary artery (with and without a metal intracoronary stent) was considered near the ablation source (0.25 and 1 mm separation). The 1000 V/cm threshold was used to estimate the ‘PEF-zone’. Results: The presence of the coronary artery (with or without stent) distorts the E-field distribution, creating hot spots (higher E-field values) in the front and rear of the artery, and cold spots (lower E-field values) on the sides of the artery. The value of the E-field inside the coronary artery is very low (~200 V/cm), and almost zero with a metal stent. Despite this distortion, the PEF-zone contour is almost identical with and without artery/stent, remaining almost completely confined within the fat layer in any case. The mentioned hot spots of E-field translate into a moderate temperature increase (<48 °C) in the area between the artery and electrode. These thermal side effects are similar for pulse intervals of 10 and 100 μs. Conclusions: The presence of a metal intracoronary stent near the ablation device during PEF ablation simply ‘amplifies’ the E-field distortion already caused by the presence of the vessel. This distortion may involve moderate heating (<48 °C) in the tissue between the artery and ablation electrode without associated thermal damage.
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Affiliation(s)
- Ana González-Suárez
- School of Engineering, University of Galway, H91 TK33 Galway, Ireland
- Translational Medical Device Lab, University of Galway, H91 YR71 Galway, Ireland
- Correspondence:
| | - Juan J. Pérez
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, 46022 Valencia, Spain
| | - Barry O’Brien
- AtriAN Medical Limited, Unit 204, University of Galway Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - Adnan Elahi
- School of Engineering, University of Galway, H91 TK33 Galway, Ireland
- Translational Medical Device Lab, University of Galway, H91 YR71 Galway, Ireland
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