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Shehadeh M, Wan EY, Biviano A, Mollazadeh R, Garan H, Yarmohammadi H. Esophageal injury, perforation, and fistula formation following atrial fibrillation ablation. J Interv Card Electrophysiol 2024; 67:409-424. [PMID: 38038816 DOI: 10.1007/s10840-023-01708-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Esophageal perforation and fistula formation are rare but serious complications following atrial fibrillation ablation. In this review article, we outline the incidence, pathophysiology, predictors, and preventative strategies of this dreaded complication. METHODS We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles reporting complications following atrial fibrillation ablation, including esophageal injury and fistula formation, were included for systematic review. RESULTS A total of 130 manuscripts were identified for the final review process. The overall incidence of esophageal injury following atrial fibrillation ablation was significantly higher with thermal ablation modalities (radiofrequency 5-40%, cryoballoon 3-25%, high-intensity focused ultrasound < 10%) as opposed to non-thermal ablation modalities (no cases reported to date). The incidence of esophageal perforation and fistula formation with the use of thermal ablation modalities is estimated to occur in less than 0.25% of all atrial fibrillation ablation procedures. The use of luminal esophageal temperature monitoring probe and mechanical esophageal deviation showed protective effect toward reducing the incidence of this complication. The prognosis is very poor for patients who develop atrioesophageal fistula, and the condition is rapidly fatal without surgical intervention. CONCLUSIONS Esophageal perforation and fistula formation following atrial fibrillation ablation are rare complications with poor prognosis. Various strategies have been proposed to protect the esophagus and reduce the incidence of this fearful complication. Pulsed field ablation is a promising new ablation technology that may be the future answer toward reducing the incidence of esophageal complications.
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Affiliation(s)
- Malik Shehadeh
- Division of Cardiology, Mount Sinai Heart Institute, Columbia University, Miami, FL, USA
| | - Elaine Y Wan
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Irving Medical Center, New York, NY, USA
| | - Angelo Biviano
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Irving Medical Center, New York, NY, USA
| | - Reza Mollazadeh
- Department of Cardiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Hasan Garan
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Irving Medical Center, New York, NY, USA
| | - Hirad Yarmohammadi
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Irving Medical Center, New York, NY, USA.
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Gracia E, Miranda-Arboleda AF, Hoyos C, Matos CD, Osorio J, Romero JE, Zei PC. Understanding Lesion Creation Biophysics and Improved Lesion Assessment during Radiofrequency Catheter Ablation. The Perfect Combination to Achieve Durable Lesions in Atrial Fibrillation Ablation. Rev Cardiovasc Med 2024; 25:44. [PMID: 39077337 PMCID: PMC11263146 DOI: 10.31083/j.rcm2502044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 07/31/2024] Open
Abstract
Atrial fibrillation (AF) is a prevalent arrhythmia, while pulmonary vein isolation (PVI) has become a cornerstone in its treatment. The creation of durable lesions is crucial for successful and long-lasting PVI, as inconsistent lesions lead to reconnections and recurrence after ablation. Various approaches have been developed to assess lesion quality and transmurality in vivo, acting as surrogates for improved lesion creation and long-term outcomes utilizing radiofrequency (RF) energy. This review manuscript examines the biophysics of lesion creation and different lesion assessment techniques that can be used daily in the electrophysiology laboratory when utilizing RF energy. These methods provide valuable insights into lesion effectiveness, facilitating optimized ablation procedures and reducing atrial arrhythmia recurrences. However, each approach has its limitations, and a combination of techniques is recommended for comprehensive lesion assessment during AF catheter ablation. Future advancements in imaging techniques, such as magnetic Resonance Imaging (MRI), optical coherence tomography, and photoacoustic imaging, hold promise in further enhancing lesion evaluation and guiding treatment strategies.
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Affiliation(s)
- Ely Gracia
- Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Andres F. Miranda-Arboleda
- Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Carolina Hoyos
- Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Carlos D. Matos
- Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jose Osorio
- HCA Electrophysiology, Mercy Hospital, Miami, FL 33133, USA
| | - Jorge E. Romero
- Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Paul C. Zei
- Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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3
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Waranugraha Y, Tsai CT, Lin LY. Index-Guided High-Power Radiofrequency Catheter Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis Study. Curr Cardiol Rep 2023; 25:1397-1414. [PMID: 37874469 DOI: 10.1007/s11886-023-01968-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW Studies have suggested the superiority of high-power compared to standard-power radiofrequency ablation ablation (RFCA). This study aimed to assess the efficacy and safety of high-power compared to standard-power RFCA guided by ablation index (AI) or lesion index (LSI). RECENT FINDINGS A systematic review and meta-analysis study comparing IGHP and IGLP approaches for AF ablation was conducted. The relevant published studies comparing IGHP and IGSP methods for RFCA in AF patients until October 2022 were collected from Cochrane, ProQuest, PubMed, and ScienceDirect. A total of 2579 AF patients from 11 studies were included, 1682 received IGHP RFCA, and 897 received IGSP RFCA. To achieve successful pulmonary vein isolation (PVI), the IGHP RFCA group had a significantly shorter procedure time than the IGHP RFCA group (mean difference (MD) -19.91 min; 95% CI -25.23 to -14.59 min; p < 0.01), radiofrequency (RF) application time (MD -10.92 min; 95% CI -14.70 to -7.13 min; p < 0.01), and fewer number of lesions (MD -10.90; 95% CI -18.77 to -3.02; p < 0.01) than the IGSP RFCA. First-pass PVI was significantly greater in the IGHP RFCA group than in the IGSP RFCA group (risk ratio (RR) 1.17; 95% CI 1.07 to 1.28; p < 0.01). The IGHP RFCA is an effective and efficient strategy for AF ablation. The superiority of IGHP RFCA includes the shorter procedure time, shorter RF application time, fewer number of lesions for complete PVI, and more excellent first-pass PVI.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Brawijaya, Universitas Brawijaya Hospital, Malang, Indonesia
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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Tampakis K, Pastromas S, Sykiotis A, Kampanarou S, Kourgiannidis G, Pyrpiri C, Bousoula M, Rozakis D, Andrikopoulos G. Real-time cardiovascular magnetic resonance-guided radiofrequency ablation: A comprehensive review. World J Cardiol 2023; 15:415-426. [PMID: 37900261 PMCID: PMC10600785 DOI: 10.4330/wjc.v15.i9.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023] Open
Abstract
Cardiac magnetic resonance (CMR) imaging could enable major advantages when guiding in real-time cardiac electrophysiology procedures offering high-resolution anatomy, arrhythmia substrate, and ablation lesion visualization in the absence of ionizing radiation. Over the last decade, technologies and platforms for performing electrophysiology procedures in a CMR environment have been developed. However, performing procedures outside the conventional fluoroscopic laboratory posed technical, practical and safety concerns. The development of magnetic resonance imaging compatible ablation systems, the recording of high-quality electrograms despite significant electromagnetic interference and reliable methods for catheter visualization and lesion assessment are the main limiting factors. The first human reports, in order to establish a procedural workflow, have rationally focused on the relatively simple typical atrial flutter ablation and have shown that CMR-guided cavotricuspid isthmus ablation represents a valid alternative to conventional ablation. Potential expansion to other more complex arrhythmias, especially ventricular tachycardia and atrial fibrillation, would be of essential impact, taking into consideration the widespread use of substrate-based strategies. Importantly, all limitations need to be solved before application of CMR-guided ablation in a broad clinical setting.
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Affiliation(s)
- Konstantinos Tampakis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece.
| | - Sokratis Pastromas
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Alexandros Sykiotis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | | | - Georgios Kourgiannidis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Chrysa Pyrpiri
- Department of Radiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Maria Bousoula
- Department of Anesthesiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Dimitrios Rozakis
- Department of Anesthesiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - George Andrikopoulos
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
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5
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Morales G, Hunter TD, Rajendra A, Boo LM, Osorio J. Real-world trends in atrial fibrillation ablation indicate increasing durability of pulmonary vein isolation at repeat ablation. Pacing Clin Electrophysiol 2023; 46:535-542. [PMID: 36689951 DOI: 10.1111/pace.14666] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/14/2022] [Accepted: 01/13/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Durable electrical isolation of pulmonary veins (PVs) is associated with better outcomes after atrial fibrillation (AF) ablation, but previous studies of AF recurrence have reported high rates of reconnection despite successful acute isolation. This study aims to quantify historical trends in the durability of PV isolation (PVI) as radiofrequency (RF) ablation catheters, additional ablation technologies, and associated workflows have evolved. METHODS The study population included adult patients receiving a first repeat ablation for AF between September 2013 and July 2019 at the study site. All index ablations were performed at the same site with an RF catheter and included PVI. Three generations of irrigated RF catheters based on the same technology platform were used by the site during the timeframe of this study. RESULTS A total of 224 patients were included in the analysis. At repeat ablation, the mean number of patients with at least one reconnected PV dropped significantly with subsequent catheter generation, from 78.3% to 56.7% to 27.0% (p < .0001). Moreover, the mean number of reconnected PVs were significantly reduced from 1.48 to 0.92 to 0.47 (p < .0001), representing a 68.3% reduction across the 3 generations of devices. CONCLUSION Significant improvement in durable PVI was seen with successive generations of RF catheter over a 6-year period. In addition to catheter technology, ancillary advances in ablation technologies, workflows, and operator experience likely contributed to these improvements.
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Affiliation(s)
- Gustavo Morales
- Arrhythmia Institute at Grandview, Grandview Medical Center, Birmingham, Alabama, USA
| | - Tina D Hunter
- Real World Evidence and Late Phase, CTI Clinical Trial and Consulting Services, Covington, Kentucky, USA
| | - Anil Rajendra
- Arrhythmia Institute at Grandview, Grandview Medical Center, Birmingham, Alabama, USA
| | | | - Jose Osorio
- Arrhythmia Institute at Grandview, Grandview Medical Center, Birmingham, Alabama, USA
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Effectiveness and Safety of High-Power Radiofrequency Ablation Guided by Ablation Index for the Treatment of Atrial Fibrillation. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5609764. [PMID: 35991126 PMCID: PMC9391153 DOI: 10.1155/2022/5609764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/09/2022] [Accepted: 07/21/2022] [Indexed: 11/25/2022]
Abstract
Background To investigate the efficacy and safety of ablation index- (AI-) guided high-power radiofrequency ablation in the treatment of atrial fibrillation (AF). Methods Outcomes of radiofrequency (RF) applications were compared in a swine ventricular endocardial model (n = 10 each for 50 W, 40 W, and 30 W; AI = 500). And a total of 100 consecutive patients with paroxysmal AF undergoing pulmonary vein isolation (PVI) were included. The patients were divided into two groups (n = 50 for each) as follows: control group, treated with conventional power (30 W) ablation mode; and study group, treated with high power (40 W) radiofrequency ablation mode. All groups were treated with the same AI value guided the ablation (target AI = 400/500 on posterior/anterior wall, respectively). Acute pulmonary vein (PV) reconnection was assessed post adenosine administration 20 minutes after ablation. Subsequently, pathological observation of porcine heart lesions and necrotic tissue was performed. Additionally, statistical analyses were carried out on patients' baseline clinical characteristics, surgical data, and total RF energy. Results In swine ventricular endocardial RF applications, compared with 40 W and 30 W, the use of 50 W was associated with shallower tissue lesion depth (p < 0.001) and greater lesion maximum diameter (p < 0.001). Compared with 40 W and 30 W, tissue necrosis caused by 50 W was the deepest and largest (p < 0.001). In pulmonary vein isolation (PVI), there was no significant difference in baseline data between the study group and control group (p > 0.05). In patients with paroxysmal atrial fibrillation, the procedure time in the high-power group was significantly shortened (p < 0.001). The ablation time was significantly shorter (p < 0.001). Compared with control group, RF energy per point and acute pulmonary vein (PV) reconnection were lower (p < 0.001), and first-pass PVI was higher (p < 0.01) in study group. There were no significant differences in complications and sinus rhythm maintenance at 12 months between the two groups (p > 0.05). Conclusions Compared with conventional (30 W) PVI, AI-guided high-power (40 W) was safe and associated with shorter procedure time and reduced acute PV reconnection.
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Cardiac Radiofrequency Ablation Simulation Using a 3D-Printed Bi-Atrial Thermochromic Model. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12136553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Radiofrequency ablation (RFA) is a treatment used in the management of various arrhythmias including atrial fibrillation. Enhanced training for electrophysiologists through the use of physical simulators has a significant role in improving patient outcomes. The requirements for a high-fidelity simulator for cardiac RFA are challenging and not fully met by any research or commercial simulator at present. In this study, we have produced and evaluated a 3D-printed, bi-atrial model contained in a custom-made enclosure for RFA simulation using a new soft tissue-mimicking polymer, Layfomm-40, combined with thermochromic pigment and barium sulphate in an acrylic paint carrier. We evaluated the conductive properties of Layfomm-40, its sensitivity to RFA, and its visibility in X-ray imaging, and carried a full simulation of RFA in the cardiac catheterization laboratory by an electrophysiologist. We demonstrated that a patient-specific 3D-printed Layfomm-40 bi-atrial model coated with a custom thermochromic/barium sulphate paint was compatible with the CARTO3 electroanatomic mapping system and could be effectively imaged using X-ray fluoroscopy. We demonstrated the effective delivery and visualization of radiofrequency ablation lesions in this model. The simulator meets nearly all the requirements for high-fidelity physical simulation of RFA. The use of such simulators is likely to have impact on the training of electrophysiologists and the evaluation of novel RFA devices.
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8
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Continuous cardiac thermometry via simultaneous catheter tracking and undersampled radial golden angle acquisition for radiofrequency ablation monitoring. Sci Rep 2022; 12:4006. [PMID: 35256627 PMCID: PMC8901729 DOI: 10.1038/s41598-022-06927-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/24/2022] [Indexed: 01/18/2023] Open
Abstract
The complexity of the MRI protocol is one of the factors limiting the clinical adoption of MR temperature mapping for real-time monitoring of cardiac ablation procedures and a push-button solution would ease its use. Continuous gradient echo golden angle radial acquisition combined with intra-scan motion correction and undersampled temperature determination could be a robust and more user-friendly alternative than the ultrafast GRE-EPI sequence which suffers from sensitivity to magnetic field susceptibility artifacts and requires ECG-gating. The goal of this proof-of-concept work is to establish the temperature uncertainty as well as the spatial and temporal resolutions achievable in an Agar-gel phantom and in vivo using this method. GRE radial golden angle acquisitions were used to monitor RF ablations in a phantom and in vivo in two sheep hearts with different slice orientations. In each case, 2D rigid motion correction based on catheter micro-coil signal, tracking its motion, was performed and its impact on the temperature imaging was assessed. The temperature uncertainty was determined for three spatial resolutions (1 × 1 × 3 mm3, 2 × 2 × 3 mm3, and 3 × 3 × 3 mm3) and three temporal resolutions (0.48, 0.72, and 0.97 s) with undersampling acceleration factors ranging from 2 to 17. The combination of radial golden angle GRE acquisition, simultaneous catheter tracking, intra-scan 2D motion correction, and undersampled thermometry enabled temperature monitoring in the myocardium in vivo during RF ablations with high temporal (< 1 s) and high spatial resolution. The temperature uncertainty ranged from 0.2 ± 0.1 to 1.8 ± 0.2 °C for the various temporal and spatial resolutions and, on average, remained superior to the uncertainty of an EPI acquisition while still allowing clinical monitoring of the RF ablation process. The proposed method is a robust and promising alternative to EPI acquisition to monitor in vivo RF cardiac ablations. Further studies remain required to improve the temperature uncertainty and establish its clinical applicability.
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Hiner E, Shah DP. Choice of Steerable Sheath Impacts Contact Force Stability During Pulmonary Vein Isolation. J Innov Card Rhythm Manag 2022; 12:4790-4795. [PMID: 34970468 PMCID: PMC8712057 DOI: 10.19102/icrm.2021.121205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 11/20/2022] Open
Abstract
A stable contact force (CF) is correlated with more effective radiofrequency (RF) ablation (RFA) lesions and long-term procedural outcomes. Efforts to improve catheter stability include jet ventilation, pacing, steerable sheaths, and CF-sensing ablation catheters. This study compares CF stability and effective RF lesions between two commercially available steerable sheaths. Thirty patients underwent first-time RFA at a single center using the Agilis™ NxT (Abbott, Chicago, IL, USA) or SureFlex™ (Baylis Medical, Montreal, Canada) steerable sheath. High-power short-duration RFA was utilized, targeting a 10-Ω drop. Sheath performance was assessed for the entire procedure and around each pulmonary vein (PV) in terms of mean CF, CF variability, RF time per lesion, and inefficient contact lesions (defined as lesions with a CF of less than 5 g for at least 10% of the RF delivery time). The operator-targeted mean CF was achieved using both sheaths; however, the overall CF variability was 12.8% lower when using the SureFlex™ sheath (p = 0.08). The CF variability was generally 16% greater in the right PVs than the left PVs (p = 0.001) but trended lower with the SureFlex™ sheath. There were 8% more inefficient contact lesions created when using the Agilis™ sheath as compared to the SureFlex™ sheath (p = 0.035), especially in the right inferior PV (p = 0.009). The RF time per lesion was, on average, 12% (1.4 seconds) shorter when using the SureFlex™ sheath than the Agilis™ sheath (p < 0.05). The choice of steerable sheath may affect both catheter stability and lesion quality, especially in the right PVs.
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Affiliation(s)
- Evan Hiner
- Ascension Health Providence Hospital and Medical Center, Southfield, MI, USA
| | - Dipak P Shah
- Ascension Health Providence Hospital and Medical Center, Southfield, MI, USA
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10
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Waranugraha Y, Rizal A, Firdaus AJ, Sihotang FA, Akbar AR, Lestari DD, Firdaus M, Nurudinulloh AI. The superiority of high-power short-duration radiofrequency catheter ablation strategy for atrial fibrillation treatment: A systematic review and meta-analysis study. J Arrhythm 2021; 37:975-989. [PMID: 34386124 PMCID: PMC8339091 DOI: 10.1002/joa3.12590] [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: 03/30/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Radiofrequency catheter ablation (RFCA) using the high-power short duration (HPSD) results in better ablation lesion formation in the swine model. This systematic review and meta-analysis purposed to investigate the safety and efficacy profile between HPSD and low-power long-duration (LPLD) ablation strategies to treat atrial fibrillation (AF) patients. METHODS We completed the literature review after identifying the relevant articles comparing HPSD and LPLD ablation methods for AF recorded in ClinicalTrials.com, CENTRAL, PubMed, and ScienceDirect until February 2021. The overall effects were calculated using pooled risk ratio (RR) and mean difference (MD) for categorical and continuous data, respectively. We also estimated the 95% confidence interval (CI). RESULTS The HPSD strategy took shorter procedure time (MD = -33.75 min; 95% CI = -44.54 to -22.97; P < .01), fluoroscopy time (MD = -5.73 min; 95% CI = -8.77 to -2.70; P < .001), and ablation time (MD = -17.71; 95% CI = -21.02 to -14.41) than LPLD strategy. The HPSD RFCA was correlated with lower risk of esophageal thermal injury (RR = 0.75; 95% CI = 0.59 to 0.94; P = .02). The HPSD method resulted in higher first-pass pulmonary vein isolation (PVI) (RR = 1.36; 95% CI = 1.13 to 1.64; P < .01), lower PV reconnection (RR = 0.47; 95% CI = 0.34 to 0.64; P < .01), and lower recurrent AF (RR = 0.72; 95% CI = 0.54 to 0.96; P = .02) than LPLD strategy. CONCLUSION HPSD RFCA was superior to the conventional LPLD RFCA in terms of safety and efficacy in treating AF patients.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular MedicineFaculty of MedicineUniversitas Brawijaya, Dr. Saiful Anwar General HospitalMalangIndonesia
- Brawijaya Cardiovascular Research CenterUniversitas BrawijayaMalangIndonesia
| | - Ardian Rizal
- Department of Cardiology and Vascular MedicineFaculty of MedicineUniversitas Brawijaya, Dr. Saiful Anwar General HospitalMalangIndonesia
- Brawijaya Cardiovascular Research CenterUniversitas BrawijayaMalangIndonesia
| | - Achmad J. Firdaus
- Department of Cardiology and Vascular MedicineFaculty of MedicineUniversitas Brawijaya, Dr. Saiful Anwar General HospitalMalangIndonesia
- Brawijaya Cardiovascular Research CenterUniversitas BrawijayaMalangIndonesia
| | - Fransiska A. Sihotang
- Department of Cardiology and Vascular MedicineFaculty of MedicineUniversitas Brawijaya, Dr. Saiful Anwar General HospitalMalangIndonesia
- Brawijaya Cardiovascular Research CenterUniversitas BrawijayaMalangIndonesia
| | - Akita R. Akbar
- Department of Cardiology and Vascular MedicineFaculty of MedicineUniversitas Brawijaya, Dr. Saiful Anwar General HospitalMalangIndonesia
- Brawijaya Cardiovascular Research CenterUniversitas BrawijayaMalangIndonesia
| | - Defyna D. Lestari
- Department of Cardiology and Vascular MedicineFaculty of MedicineUniversitas Brawijaya, Dr. Saiful Anwar General HospitalMalangIndonesia
- Brawijaya Cardiovascular Research CenterUniversitas BrawijayaMalangIndonesia
| | - Muhammad Firdaus
- Department of Cardiology and Vascular MedicineFaculty of MedicineUniversitas Brawijaya, Dr. Saiful Anwar General HospitalMalangIndonesia
- Brawijaya Cardiovascular Research CenterUniversitas BrawijayaMalangIndonesia
| | - Akhmad I. Nurudinulloh
- Department of Cardiology and Vascular MedicineFaculty of MedicineUniversitas Brawijaya, Dr. Saiful Anwar General HospitalMalangIndonesia
- Brawijaya Cardiovascular Research CenterUniversitas BrawijayaMalangIndonesia
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11
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Kotadia ID, Williams SE, O'Neill M. High-power, Short-duration Radiofrequency Ablation for the Treatment of AF. Arrhythm Electrophysiol Rev 2020; 8:265-272. [PMID: 32685157 PMCID: PMC7358956 DOI: 10.15420/aer.2019.09] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
High-power, short-duration (HPSD) ablation for the treatment of AF is emerging as an alternative to ablation using conventional ablation generator settings characterised by lower power and longer duration. Although the reported potential advantages of HPSD ablation include less tissue oedema and collateral tissue damage, a reduction in procedural time and superior ablation lesion formation, clinical studies of HPSD ablation validating these observations are limited. One of the main challenges for HPSD ablation has been the inability to adequately assess temperature and lesion formation in real time. Novel catheter designs may improve the accuracy of intra-ablation temperature recording and correspondingly may improve the safety profile of HPSD ablation. Clinical studies of HPSD ablation are on-going and interpretation of the data from these and other studies will be required to ascertain the clinical value of HPSD ablation.
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Affiliation(s)
| | | | - Mark O'Neill
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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12
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Falkenberg M, Ford AJ, Li AC, Lawrence R, Ciacci A, Peters NS, Christensen K. Unified mechanism of local drivers in a percolation model of atrial fibrillation. Phys Rev E 2019; 100:062406. [PMID: 31962501 PMCID: PMC7314598 DOI: 10.1103/physreve.100.062406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Indexed: 11/07/2022]
Abstract
The mechanisms of atrial fibrillation (AF) are poorly understood, resulting in disappointing success rates of ablative treatment. Different mechanisms defined largely by different atrial activation patterns have been proposed and, arguably, this dispute has slowed the progress of AF research. Recent clinical evidence suggests a unifying mechanism of local drivers based on sustained reentrant circuits in the complex atrial architecture. Here, we present a percolation inspired computational model showing spontaneous emergence of AF that strongly supports, and gives a theoretical explanation for, the clinically observed diversity of activation. We show that the difference in surface activation patterns is a direct consequence of the thickness of the discrete network of heart muscle cells through which electrical signals percolate to reach the imaged surface. The model naturally follows the clinical spectrum of AF spanning sinus rhythm, paroxysmal AF, and persistent AF as the decoupling of myocardial cells results in the lattice approaching the percolation threshold. This allows the model to make the prediction that, for paroxysmal AF, reentrant circuits emerge near the endocardium, but in persistent AF they emerge deeper in the bulk of the atrial wall. If experimentally verified, this may go towards explaining the lowering ablation success rate as AF becomes more persistent.
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Affiliation(s)
- Max Falkenberg
- Blackett Laboratory, Imperial College London, London SW7 2AZ, United Kingdom
- Centre for Complexity Science, Imperial College London, London SW7 2AZ, United Kingdom
- Centre for Cardiac Engineering, Imperial College London, London W12 0NN, United Kingdom
| | - Andrew J. Ford
- Blackett Laboratory, Imperial College London, London SW7 2AZ, United Kingdom
| | - Anthony C. Li
- Blackett Laboratory, Imperial College London, London SW7 2AZ, United Kingdom
| | - Robert Lawrence
- Blackett Laboratory, Imperial College London, London SW7 2AZ, United Kingdom
| | - Alberto Ciacci
- Blackett Laboratory, Imperial College London, London SW7 2AZ, United Kingdom
- Centre for Complexity Science, Imperial College London, London SW7 2AZ, United Kingdom
- Centre for Cardiac Engineering, Imperial College London, London W12 0NN, United Kingdom
| | - Nicholas S. Peters
- Centre for Cardiac Engineering, Imperial College London, London W12 0NN, United Kingdom
- National Heart & Lung Institute, Imperial College London, London, W12 0NN, United Kingdom
| | - Kim Christensen
- Blackett Laboratory, Imperial College London, London SW7 2AZ, United Kingdom
- Centre for Complexity Science, Imperial College London, London SW7 2AZ, United Kingdom
- Centre for Cardiac Engineering, Imperial College London, London W12 0NN, United Kingdom
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Atrial fibrillation ablation using very short duration 50 W ablations and contact force sensing catheters. J Interv Card Electrophysiol 2018; 52:1-8. [PMID: 29460232 PMCID: PMC5924666 DOI: 10.1007/s10840-018-0322-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/26/2018] [Indexed: 11/29/2022]
Abstract
Purpose The optimal radiofrequency (RF) power and lesion duration using contact force (CF) sensing catheters for atrial fibrillation (AF) ablation are unknown. We evaluate 50 W RF power for very short durations using CF sensing catheters during AF ablation. Methods We evaluated 51 patients with paroxysmal (n = 20) or persistent (n = 31) AF undergoing initial RF ablation. Results A total of 3961 50 W RF lesions were given (average 77.6 ± 19.1/patient) for an average duration of only 11.2 ± 3.7 s. As CF increased from < 10 to > 40 g, the RF application duration decreased from 13.7 ± 4.4 to 8.6 ± 2.5 s (p < 0.0005). Impedance drops occurred in all ablations, and for patients in sinus rhythm, there was loss of pacing capture during RF delivery suggesting lesion creation. Only 3% of the ablation lesions were at < 5 g and 1% at > 40 g of force. As CF increased, the force time integral (FTI) increased from 47 ± 24 to 376 ± 102 gs (p < 0.0005) and the lesion index (LSI) increased from 4.10 ± 0.51 to 7.63 ± 0.50 (p < 0.0005). Both procedure time (101 ± 19.7 min) and total RF energy time (895 ± 258 s) were very short. For paroxysmal AF, the single procedure freedom from AF was 86% at 1 and 2 years. For persistent AF, it was 83% at 1 year and 72% at 2 years. There were no complications. Conclusions Short duration 50 W ablations using CF sensing catheters are safe and result in excellent long-term freedom from AF for both paroxysmal and persistent AF with short procedure times and small amounts of total RF energy delivery.
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