Prospective study of zero-fluoroscopy laser balloon pulmonary vein isolation for the management of atrial fibrillation

BACKGROUND

In recent years, there has been increased focus on the development of safe and effective strategies to minimize and ultimately eliminate fluoroscopy use in the electrophysiology lab due to the inherent risks to patients and staff associated with this imaging source. However, studies examining these innovative fluoroless strategies for pulmonary vein isolation (PVI) using catheters without direct 3D mapping system integration are lacking. We sought to develop a method to perform zero-fluoroscopy laser balloon PVI for patients with atrial fibrillation (AF), and to test the safety and efficacy of this approach.

METHODS

We developed a standardized method for performing PVI using the X3 laser balloon (LB) system, 3-dimensional electroanatomic mapping (3D-EAM) and intracardiac echocardiography (ICE) in a cohort of patients with symptomatic AF. The primary endpoint of the study was the ability to perform PVI without the use of fluoroscopy. Secondary outcomes were rate of successful transseptal puncture on first attempt, first pass isolation of target PVs, mean procedural time, active laser time to achieve PVI, need for use of supplemental energy sources, and procedural complication rates.

RESULTS

Two hundred consecutive patients undergoing PVI were recruited in the study. In the zero-fluoroscopy group, LB PVI was successfully performed in 100% of participants (n = 100) without the need for fluoroscopy. Transseptal access was achieved in 100% of cases on the first attempt. Successful first pass PVI was achieved in 360 of the 387 pulmonary veins attempted (93%). Mean procedural time was 68.2 ± 16.2 min in the zero-fluoroscopy group versus 67.5 ± 17.0 min in the conventional fluoroscopy group. PVI was able to be achieved in 100% of cases in both groups without need for use of supplemental energy sources. In the zero-fluoroscopy group there were minimal complications, with 3% of all cases having groin complications and 1 patient with a pericardial effusion noted post-procedure which was managed conservatively.

CONCLUSIONS

We demonstrated that successful zero-fluoroscopy LB PVI could be performed at a single high-volume center by experienced operators in an effective manner, without significant complications.

Validation of lesion durability following pulmonary vein isolation using the new third-generation laser balloon catheter in patients with recurrent atrial fibrillation

BACKGROUND

The second- and third-generation endoscopic ablation systems (EAS2 and EAS3) have been launched in recent years. We aimed to assess the lesion durability as well as gap localization using the multigenerational novel technologies in patients with recurrent atrial fibrillation (AF).

METHODS

Consecutive patients who underwent second ablation for recurrent AF following the initial pulmonary vein isolation (PVI) with EAS2 or EAS3 were retrospectively investigated. The persistent durability of PVI, gap localization at the second procedure, and procedural/anatomical features of durable PVI were analyzed.

RESULTS

Among 225 patients treated with EAS3 (N = 125) and EAS2 (N = 100), 34 patients (EAS3: 13 patients, 50 PVs, EAS2: 21 patients, 82 PVs) underwent a second procedure because of recurrent AF mean 11.9 ± 9.3 months after the initial procedure. Persistent isolation of all four PVs was recorded in 6 (46.2%) patients in EAS3 group and 4 (19.1%) patients in EAS2 group (p = 0.130). Ninety-one out of 132 (68.9%) PVs were persistently isolated with a higher rate in EAS3 group (82.0% vs. EAS2 group: 61.0%, p = 0.0113). A total of 45 gaps were recorded in 41 PVs. Right superior PV (RSPV) was the predominantly common reconnected vein (15 gaps, 14 PVs) irrespective of generations (EAS3: 4 gaps in 3 PVs and EAS2: 12 gaps in 11 PVs). Logistic multivariate regression analysis revealed ablation without reduced energy dose (5.5-7 W) as an independent predictor of durable PVI [adjusted OR: 3.70, 95% CI (1.408-10.003)], p = 0.008].

CONCLUSION

The technical innovation resulted in a higher lesion durability in EAS3-guided PVI in patients with recurrent AF. The most common gap location was found at RSPV in successor EASs. Ablation without reduced energy was a predictor of durable PVI in successor EASs.

Impact of myocardial injury and inflammation due to ablation on the short-term and mid-term outcomes: Cryoballoon versus laser balloon ablation

BACKGROUND

Cryoballoon ablation (CBA) and laser balloon ablation (LBA) were developed as alternatives to conventional radiofrequency ablation for paroxysmal atrial fibrillation (PAF). Pathological findings after ablation such as myocardial injury and inflammation are thought to be different between CBA and LBA. However, the different impact of myocardial injury and inflammation after ablation on short- and mid-term outcomes remains unclear.

METHODS

Consecutive PAF patients who underwent CBA and LBA were enrolled from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry. The difference of the acute myocardial injury marker (hs-TnI), and changes of inflammation markers (C reactive protein; ΔCRP, and white blood cell; ΔWBC) after catheter ablation and the difference of the short-term (within 3 months after ablation) and mid-term (from 3 months to 6 months after ablation) outcomes were evaluated between the two groups.

RESULTS

The CBA and LBA groups consisted of 55 and 56 patients, respectively. After propensity score matching, CBA and LBA groups consisted of 37 patients, respectively. Hs-TnI value was significantly higher in CBA than LBA group, while ΔCRP and ΔWBC were significantly higher in LBA than CBA group. In the propensity score-matched pairs, the LBA group had a significantly greater risk of short-term arrhythmia recurrence than the CBA group, whereas no significant difference of mid-term arrhythmia recurrence were found between the two groups.

CONCLUSION

Myocardial injury and inflammation status differ between CBA and LBA groups. LBA group had stronger inflammation after ablation and had a significantly greater risk of short-term arrhythmia recurrence after PVI than CBA group.

Second-generation laser balloon ablation for the treatment of atrial fibrillation assessed by continuous rhythm monitoring: the LIGHT-AF study

AIMS

Balloon-based technologies have been developed to simplify catheter ablation of atrial fibrillation (AF), to improve the clinical outcome of the procedure and to achieve durable pulmonary vein isolation (PVI). The objective of this study is to evaluate the safety and efficacy of second-generation laser balloon (LB2) ablation in the treatment of AF using a continuous cardiac rhythm monitoring strategy. Atrial tachyarrhythmias (ATas) recurrences were assessed with implantable cardiac monitors (ICMs) or devices.

METHODS AND RESULTS

All patients underwent LB2 ablation procedure. The primary endpoint was the first recurrence of any, >5.5 and >24 h duration ATas after the blanking period (90 days). In-hospital visits were performed at 3, 6, and 12 months. Seventy-three patients (68% male, mean age 59.8 ± 11.3) were included in the study. The average procedure, fluoroscopy, and laser ablation times were 81.5 ± 30.1, 21.5 ± 12.4, and 33.8 ± 9.7, respectively. All PVs were isolated using the LB2 with no need of touch-up using focal catheters. No major complications occurred during or after the procedures. The one-year freedom from recurrences was 66.9% (95% CI: 57.0-76.7%), 81.0% (69.5-88.5%), and 86.8% (76.1-92.9%) considering any, 5.5-h and 24-h cut-off duration, respectively. At 3, 6, and 12 months, any ATas was recorded in 22%, 32%, and 25% of patients, with a ≥5% arrhythmic burden documented in 4%, 5%, and 3%, respectively. Few patients reported AF-related symptoms (7%, 8%, and 5%).

CONCLUSION

LB2 ablation is a safe and effective procedure, showing a high freedom from recurrences and low arrhythmic burden as documented by a continuous rhythm monitoring strategy.

Electrical isolation of the superior vena cava by laser balloon ablation in patients with atrial fibrillation

PURPOSE

The aim of the present study is to evaluate the feasibility and safety of SVC electrical isolation by LB ablation in patients with atrial fibrillation (AF) referred for pulmonary vein isolation (PVI).

METHODS

Electrical disconnection of the SVC was attempted by LB in 13 consecutive patients (59 ± 10.5 years, 11 male) with AF following PVI. PVI was successfully achieved by standard LB in all before attempting SVC isolation.

RESULTS

A laser beam was delivered with 6.3 ± 2.3 W and 8.4 ± 2.7 W (P = 0.001) during 5.38 ± 2.4 min and 9.75 ± 1.6 min (P = 0.024) to achieve SVC and PV, respectively. Isolation of the SVC by LB was accomplished in 8 patients (61%) without complications. Phrenic nerve palsy developed in 3 patients (23%), which resulted in early procedure termination before isolation. Technical problems or interposition of a pacemaker lead to prevented SVC isolation in the remaining 2 patients. After a mean follow-up of 19 ± 3 months, no patient recovered from phrenic nerve palsy.

CONCLUSIONS

SVC isolation by LB is feasible but associated with a high risk of phrenic nerve palsy. Limitation of laser delivery time and power appears insufficient to prevent this complication.