bluuebunny/crossref_metadata_2025 huggingface dataset:
Six-month follow-up after pulmonary vein isolation using pulsed field ablation for paroxysmal atrial fibrillation
Authors: Reinsch N , Fueting A , Hartl S , Neven K
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). Only a few small clinical studies have been published on the mid- and long-term outcome. Herein, we present the six-month clinical outcomes of PFA in PAF.

Methods

In PAF patients, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. In a subset of patients, pre- and post-ablation high-density bipolar voltage 3D maps (Carto 3D) were performed. Procedural parameters, acute success, in-hospital safety and arrhythmia recurrence were assessed over 6-month follow-up. Efficacy was evaluated by freedom from a ≥ 30-sec. recurrence of AF/atrial flutter (AFL)/atrial tachycardia (AT). Follow-up included 7-day Holter ECGs and/or telephonic interviews at days 90 and 180 after ablation.

Results

his study included a total of 108 patients (mean age: 65±10 years; 44% female). Mean CHA2DS2-VASc-score was 2,3±1,7. Median duration since first AF diagnosis was 21 [IQR: 3 to 58] months. Pre- and post-ablation high-density maps were performed in 36/108 (33%) of patients. Skin-to skin procedure time was 78±35 min. Fluoroscopy time and dosis area product were 19±7 min and 5,56±4,64 Gy.cm2, respectively. Left atrial dwell time of the PFA catheter was 27±11 min. Acute pulmonary vein isolation rate was 100% of PVs using PFA only. Primary adverse events occurred in 3.7% of patients (1 groin hematoma, 2 pericardial tamponades, 1 stroke with lethal outcome). Five patients were lost to FU. During a mean FU of 205±84 days, 81 of 103 patients (79%) remained free of any symptomatic or documented AF/AFL/AT episode after a single procedure. In 22 (21%) patients at least one episode of AF/AFL/AT was documented. In 6/22 (27%) patients, a re-do procedure was performed. In 2/6 (33%) patients, a reconduction of the PVs (1 LIPV, 1 posterior carina on both sides) was seen. In the remaining 4/6 (67%) patients, during re-do procedure typical or atypical flutter was treated, in presence of durable PV isolation.

Conclusions

PVI using PFA results in a reasonable 6-month atrial arrhythmia recurrence rate and safety profile. The success rate may be reduced due to the long duration since first AF diagnosis. PV reconduction rate during re-do procedure was 33% in a limited number of patients.
Impact of catheter ablation for persistent atrial fibrillation with heart failure, compared to preserved and reduced ejection fraction
Authors: Inamura Y , Inaba O , Michishita T , Kono T , Isonaga Y , Ohya H , Takagi T , Sato A , Matsumura Y , Nitta J , Sasano T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation for persistent atrial fibrillation (AF) in patients with heart failure is known to improve heart failure. However, there were few reports comparing the outcomes of catheter ablation for patients with heart failure with reduced ejection fraction (HFpEF) and heart failure with preserved ejection fraction (HFpEF).

Method

Patients with E/e’ > 15 and EF > 50% on preoperative echocardiography were defined HFpEF, and those with EF < 40% were defined as HFrEF. We compared ablation outcomes and postoperative BNP changes between patients with HFpEF (HFpEF-group) and HFrEF (HFrEF-group).

Result

There were 166 cases of HFpEF-group and 177 of HFrEF-group among the cases with catheter ablation for persistent AF in our hospital from 2013 to 2021. The median preoperative BNP was 190.7 pg/ml in HFrEF-group and 144.3 in HFpEF-group, significantly higher in HFrEF-group (P=0.001). After a mean follow-up of 37.2 months, maintenance of sinus rhythm without any antiarrhythmic drugs was significantly better in the HFrEF-group (64.4% and 53.6%, p=0.048). After one year of ablation, median BNP was significantly higher in HFpEF-group (HFpEF: 37.5 pg/ml, HFrEF: 22.0 pg/ml; p=0.017), contrary to before ablation.

Conclusion

Catheter ablation for persistent AF with HFrEF showed better ablation outcomes and improved BNP levels compared to those with HFpEF.
Comparision of pulsed field ablation vs. high power short duration-ablation for pulmonary vein isolation
Authors: Woermann J , Schipper J , Lueker J , Van Den Bruck J , Filipovic K , Erlhoefer S , Pavel F , Scheuerlen C , Dittrich S , Steven D , Sultan A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The newly introduced non-thermal pulsed field ablation (PFA) is a promising technology to achieve fast pulmonary vein isolation (PVI) with high acute success rates and comparable safety features. However, previous studies have shown that high power short duration ablation (HPSD) is also highly effective and fast to achieve PVI with potentially less AF recurrence. Data comparing PFA to HPSD-PVI is lacking.

Objective

This study compared procedural parameter and outcome using the novel PFA-PVI to HPSD-PVI in patients with paroxysmal or persistent atrial fibrillation (PAF/persAF).

Methods

Between 09/2021 and 10/2022 all consecutive patients undergoing de-novo PVI (PFA or HPSD) were included in this analysis. For PFA-PVI a shapeable (flower/basket shape) 5 spline 20 electrode catheter was used. For HPSD-PVI a power setting of 70W/7s (70W/5s at posterior wall) was considered as HPSD. Furthermore, a 3D mapping system was used. Follow-up consisted of out-clinic pts visit, teleconsultation, 48h Holter ECG and CIED interrogation if applicable.

Results

A total of 114 patients (57 PFA [17(30%) PAF; 40(70%) persAF 40(70%)] were included in this analysis. PVI was successful in all patients. The PFA group revealed a significantly shorter procedure duration (65±17 min vs. 95±23 min, p<0.01) but longer fluoroscopy time (PFA 15±5min and HPSD 12±3min; p<0.001). However, the overall fluoroscopy dosage was comparable between groups (PFA: 3484±2072mGy*cm2; HPSD: 3168±2346mGy*cm2; p=0.448). Two tamponades occurred in the PFA while in HPSD two pts suffered groin bleedings.

At follow-up after three months (33±12 days) 46 PFA (80.7%) and 44 HPSD pts (77.2%) were free from atrial arrhythmia after a single procedure (p=0.819). One clinically non.significant PV stenosis occurred in the HPSD group.

Conclusion

PFA and HPSD-PVI seem to be highly effective and safe to achieve PVI in the setting of PAF and persAF with comparable arrhythmia free survival. However, procedure duration for PFA PVI is significantly shorter and therefore may be of potential benefit.
Achieving a very low fluoroscopy exposure in cryoballon ablation of the pulmonary veins: learning curve of 3D-wide-band dielectric mapping guided ablation
Authors: Bastian D , Buia V , Walascheck J , Xhakupi H , Hoefler D , Rittger H , Vitali-Serdoz L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) using cryoballoon (CB) ablation is associated with an increased radiation exposure compared with radiofrequency ablation. The novel high resolution wide-band dielectric imaging system improved our strategy of radiation exposure reduction without affecting acute efficacy and safety and giving additional insights on the atrial voltage mapping of the selected patients.

Purpose

To evaluated the reduction of fluoroscopy use over time during consecutive CB PVI performed with the use of a new 3D mapping system.

Methods

The study population comprised 89 consecutive patients who underwent in our Centre between Juni 2021 and Juli 2022 to third-generation CB-based PVI with the wide band dielectric system and X-Ray System with enhanced collimation, frame reduction and stored fluoroscopy. All included patients gave written informed consent for TEE and PVI and agreed to the anonymous evaluation of their data for research and quality control. We analyzed the reduction in fluoroscopy use among time.

Results

The mean radiation exposure data among all patients demonstrate a significant reduction compared with the literature data od CB-PVI: mean fluoroscopy time 3,95 ± 4,12 minutes and mean DAP 15,45 ± 27,18 cGy*cm2. Analysing the learning curve, we identified every 30 patients a significant reduction in X-Ray use achieving a reduction of ca. 80% in the last group of patients compared with the former one. The results are summarized in the Table and Graph. No major complications occurred

Conclusion

The analysis of the fluoroscopy utilization and exposure during CB-PVI performed with a novel 3D mapping system using wide-band dielectric imaging demonstrated a significant learning curve. A stepwise progressive reduction can be identified leading to a reduction of ca. 80% of radiation use among the last 30 procedures compared to the first 30 ones reflecting individual and team proficiency in using the new imaging system. A very low-radiation exposure during CB-PVI can be achieved with this approach.
Evaluation of force time integral, force time current integral and lesion size index in a new force sensing catheter
Authors: Bahlke F , Syvaeri J , Englert F , Erhard N , Popa M , Krafft H , Risse E , Telishevska M , Lengauer S , Lennerz C , Reents T , Hessling G , Deisenhofer I , Bourier F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Radiofrequency current remains one of the most important ablation techniques in the EP lab. Creating durable lesions is key to successful ablation. Evaluating lesion quality and progression of lesion growth is difficult as many parameters influence lesion formation. Therefore, several approaches were developed, as monitoring RF duration, power and contact force seems insufficient in clinical practice. Force-time-integral (FTI) and force-time-current-integral (FTCI), as well as the ablation index (AI) and lesion size index (LSI) showed decent results in past studies. Recently, a new force sensing catheter (NFSC) was released. By now, data about lesion formation and correlation with the FTI, FTCI and LSI is lacking with this NFSC. This study aimed to further investigate lesion formation with the NFSC in an ex vivo model.

Methods

30 RF-lesions were created using an ex vivo porcine cardiac model with the NFSC catheter. The experimental setup consisted of a saline-filled container, a dispersive electrode, a heated thermostat and a circulation pump to imitate in vivo conditions. Global impedance was kept at 120 Ohm as well as the temperature at 37°C. In a first set of lesions, CF was varied (1g, 5g, 10g, 20g). Three lesions were created in each CF-level with 30W. In a second set of lesion, CF was kept at 10 – 15 g, but ablation power was set to 20W, 30W, 40W, 50W, 60W and 70W. In every power level, three lesions were created.

All parameters (power, temperature, global impedance, contact force, lesion size) were measured constantly during application of RF-current, enabling real-time correlation of RF parameters and lesion size. In case of an audible steam pop, RF application was stopped.

Results

1640 measurement in 30 lesions were included into the analysis. Mean lesion diameter was 7.82 ± 1.52 mm, mean lesion depth 4.80 ± 1.08 mm. Baseline global impedance (GI) was 138.10 ± 10.93 Ω, mean GI-drop 28.10 ± 8.00 Ω. In average, CF of 12.10 ± 5.87 g was used.

Correlations of lesion size, FTI and FTCI are shown in table 1. Interestingly, LSI correlated best with lesion size (r = 0.851 and r = 0.852 for lesion depth and diameter; p<0.001). Figure 1 illustrates a scatter plot of LSI and lesion depth (Figure 1a) and lesion diameter (Figure 1b).

Figure 2 shows dynamic changes in lesion depth compared to changes in LSI and FTCI. During RF-application, development of lesion formation and LSI is comparable from approximately second 7 onwards. FTCI is rising in a linear manner, whereas lesion formation increases monoexponentially.

Conclusion

In the NFSC, lesion size correlates strongest with the LSI in power levels up to 70 Watts. FTI and FTCI also showed decent correlations. Regarding dynamic changes in lesion size, LSI is best comparable to actual lesion growth.
Noninvasive continuous arterial pressure monitoring shortens atrial fibrillation ablation procedural duration
Authors: Parollo M , Di Cori A , Fiorentini F , De Lucia R , Barletta V , Viani S , Paperini L , Canu A , Mazzocchetti L , Sbragi S , Segreti L , Grifoni G , Soldati E , Zucchelli G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter atrial fibrillation (AF) ablation is in most centres commonly carried out with continuous invasive radial arterial blood pressure (BP) monitoring. Novel devices enable continuous non-invasive BP monitoring, with acceptable agreement and optimal safety profile when compared to standard of care invasive BP monitoring, leading to improved patient comfort in the electrophysiology lab.

Purpose

Aim of the study was to assess in terms of procedural efficiency continuous non-invasive BP monitoring during transcatheter atrial fibrillation ablation.

Methods

We prospectively enrolled 42 consecutive patients (age 61±9 years, 80% male) undergoing transcatheter AF ablation (60% paroxysmal, 40% persistent) at our centre undergoing AF ablation with continuous BP measurement using a non-invasive finger volume clamp device. We then compared them with an historical cohort of 42 consecutive patients undergoing AF ablation (62% paroxysmal, 38% persistent) with standard of care invasive BP monitoring with a radial cannula. We compared the two groups in terms of total procedural duration (in and out from the EP lab).

Results

Mean total procedural duration was 165,29±54,95 minutes in the non-invasive group and 196,55±46,67 minutes in the invasive group (P=0,006).

Conclusion

In patients undergoing AF ablation, non-invasive finger volume-clamp continuous BP monitoring allowed for a significant reduction of total procedural duration when compared to standard of care invasive BP monitoring. Larger studies are needed to confirm these results.
Identification of the fossa ovalis by voltage mapping using a high-density mapping catheter
Authors: Tran V , Bergamin C H , Pruvot E
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transseptal puncture (TP) is routinely performed under fluoroscopy and/or echocardiography guidance. Additional methods to localize the fossa ovalis (FO) may decrease radiation exposure, as well as periprocedural risk. In the recent years, high-density mapping (HDM) catheters have been used for mapping and ablation of left atrial (LA) arrhythmias.

Purpose

The aim of this study is to determine whether a HDM catheter can reliably identify the specific FO electrogram (EGM) patterns.

Methods

During atrial fibrillation (AF) ablation, a voltage map of the right-sided atrial septum was created using a HDM catheter (Pentaray, Biosense Webster, USA, spacing 2-6-2 mm). The location of the FO was identified by transesophageal echocardiogram and fluoroscopy guidance prior to TP. At the end of the procedure, a 3D phantom was created during catheter retrieval from the left to the right atrium through the TP. Post ablation analysis was done to evaluate whether the HDM catheter was able to record EGM characteristics of the FO.

Results

Fifteen patients were included (male 63%, mean age 61.2±11.7 y. o.); 80% of the cases were in sinus rhythm, 53% had a normal LA size, and the mean CHADS2-VA2SC score was 1.5 ± 1.6. One patent fossa ovalis and one septal pouch of the left atrium were seen. In all patients, an area of low voltage could be identified in the vicinity of the transseptal puncture. In 74%, the location of transseptal puncture was inside of the area of low voltage. The mean voltage value of this area was 0.6 ± 0.3 mV, whereas the mean voltage value of the myocardium surrounding the "low voltage area" was 4.3 ± 2.1 mV (P<0.01). The surface of the low voltage could be best demarcated using a scale from 0.05 -1.5 mV with an area measured at 3.8 ± 2.6 cm2 [Figure 1]. At other voltage scales, the FO surface demonstrated smaller areas of low voltage (scale/surface [mV/cm2] : 0.05-0.5/ 0.8 ± 1.3; 0.05-1.0/2.2 ± 1.8; 0.5-1.0/2.3±1.6). In 63%, fractionated potentials were recorded in the area of the FO [Figure 1].

Conclusions

Based on its EGM characteristics, the fossa ovalis can be accurately localized with a high-density mapping catheter. This finding will certainly help to implement radiation free procedure particularly when echocardiographic modalities are not available.

Figure 1:

Mapping of the region of the fossa ovalis with a high density mapping catheter revealed an area of low voltage with fractionnated electrogram. Fossa ovalis was identified by transseptal puncture.

TP: phantom of the catheters, CS: coronary sinus, H: His, IVC: inferior vena cava, SVC: superior vena cava, * fractionnated electrogram
LA workflow recommendations for intracardiac echocardiography integration with artificial intelligence 3D algorithm
Authors: Di Biase L , Lin A , Grupposo V , Marazzato J , Tarantino N , Haiman G , Haimovich D , Matthew R , Alcazar J , Costa G , Urman R , Zou F , Zhang X
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

The creation of an artificial intelligence imaging algorithm, the CARTOSOUND FAM Module, shows promise in enhancing current intracardiac echocardiography (ICE) practices, particular in atrial fibrillation (AF) ablation. However, there is a gap of knowledge associated with how to best optimize current practices. This study aims to provide workflow recommendations based on a high-volume US center.

Methods

The CARTOSOUND FAM Module is an automated version of the legacy CARTOSOUND Module. It incorporates an automatic algorithm that enables automatic detection of cardiac anatomy using a series of 2D ultrasound views. The left atrial (LA) algorithm uses a series of 2D ultrasound frames acquired from the right atrium (RA)/fossa ovalis and the RVOT to: create a 3D volume reconstruction of the LA anatomies (LA Body, LAA, LSPV, LIPV, RSPV, and RIPV), provide 3D auto-segmentation for the relevant anatomical structures, generate 2D auto-contours that are overlaid on the corresponding 2D ultrasound frames, and demonstrate 2D auto-tagging for the relevant anatomical structures. Best practice recommendations have been collected and summarized.

Results

The required input for the CARTOSOUND FAM algorithm:

2D ULS distinct frames, with full spatial coverage of the LA body and its adjacent key anatomical structures (LAA and PVs), with at least 2 different views for each structure, and preferably clearly visualizing the ostium of the PV’s and LAA.

The 2D clips should be acquired while the SOUNDSTAR® catheter is positioned in the RA and/or the RVOT.

The selected frames within the ULS clip should be gated at the end-expiration phase and to the LA max volume (). LA frames with a temporal resolution of ~20 msec just before the opening of the mitral valve at the time of maximal atrial volume (end atrial diastole).

The selected frames within the ULS clip should be with depth 90-140mm.

The LA anatomy shall not have uncommon anatomical variation (e.g. 5th PV).

There shall be no map shift between the ULS data (frames) and the magnetic data (FAM, VISITAGs, EA points, etc.) in the CARTOSOUND® clinical procedure.

Conclusion

This study successfully reports on best workflow practices in using the CARTOSOUND FAM Module in conjunction with ICE. Further studies evaluating the safety and efficiency are required to validate reproducibility these recommendations.
Evaluation of laser balloon pulmonary vein isolation lesions during the acute and chronic phases using a high-resolution mapping system
Authors: Yamasaki T , Hattori T , Pak M , Kakita K
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Visually guided laser balloon (VGLB) has proven ample efficacy in achieving durable pulmonary vein (PV) isolation (PVI). Though the isolation area post-cryoballoon ablation has been reported to regress at the chronic phase, the shrinkage of the isolation area using VGLB during the chronic phase has not been described.

Purpose

This study aims to evaluate the differences in isolation areas created by VGLB between the acute and chronic phases using a high-resolution mapping system.

Methods

We assessed 26 patients who underwent a second procedure due to atrial fibrillation recurrence. Of them, 8 patients were treated with the third-generation VGLB and 18 patients were treated with the first-generation VGLB at the first session. In all patients, the voltage maps were created with high-resolution mapping catheters just after PVI (acute phase) and during the second session (chronic phase). With each map, the isolation area (<0.1mV) around the PV antrum was calculated. We validated the persistent durability of PVI, and then the regression of isolation lesions was analyzed in patients without any PV reconnections.

Results

The isolation areas were re-evaluated at 8.3±6.6 months after the initial procedure. Twenty patients (76.9%) preserved persistent isolation lesions of all four PVs. Of them, the reduction of the isolation areas on the left- and right-sided PV antrum were 1.6±3.2 cm² (10.7±23.1% of the acute phase) and 4.8±3.6 cm² (27.8±18.9%), respectively. The analysis of the results revealed that the isolation area of the right-sided PV antrum yielded statistical shrinkage during the chronic phase (P=0.001), even though the electrical isolation was preserved.

Conclusion

After VGLB ablation, the isolation area of the right-sided PV antrum significantly regressed at the chronic phase, while the rate of durable PVI was high in line with the previous report.
A new criterium for optimal energy application in ultra-high-power short-duration ablation
Authors: Ukena C , Spittler R , Benz A , Slawik J , Ferro G , Pavlicek V , Rostock T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Ultra-high-power short-duration (UHPSD) ablation with the novel QDOT™ catheter allows to maintain a target temperature by automatically adjusting flow and power during a 4-second application of 90 Watt. However, the optimal contact-force for a sufficient lesion generation is yet to be determined.

Methods

This study comprised 41 patients with symptomatic atrial fibrillation undergoing pulmonary vein isolation (PVI) with the QDot catheter using the UHPSD mode with 90 W for 4 seconds. All UHPSD applications for circumferential PVI were analyzed. Suboptimal UHPSD applications were defined as either an impedance drop of ≤5% or a cumulative temperature-limited energy ≤330 W.

Results

A total of 1904 UHPSD applications (46.4 applications per patient) were performed with an average contact force (aCF) of 12.3±6.4 g with a mean maximum temperature (maxTemp) of 48.4±3.8 °C and a mean impedance drop (ImpDrop) of 10±3.2%. An ImpDrop ≤5% occurred in 67 (3.5%) UHPSD applications which was associated with lower aCF (10.6±7 vs. 12.4±6.4 g; p=0.024) and a lower maxTemp (45.8±3.8 vs. 48.5±3.8 °C; p<0.001) as compared to UHPSD applications with an ImpDrop >5%. A cumulative energy ≤330 W was observed in 39 (2%) UHPSD applications. Interestingly, low cumulative energy UHPSD applications (≤330 W) were characterized by a higher aCF (21±9.6 vs. 12.1±6.2 g; p<0.001). Furthermore, low cumulative energy was observed significantly more often in UHPSD applications with aCF <5.6 g or >21.1 g (10.2% vs 3.6%; p=0.004).

Conclusion

A low but also a high contact-force (<6 and >21g) are associated with suboptimal UHPSD applications. Thus, UHPSD applications require a ’15-gram window’ of contact-force to achieve an optimal cumulative energy.
Electrical connection between the left atrium and the pulmonary veins: a study to understand the contribution of myocardial fibers along the standard ablation circumference
Authors: Campos Garcia B , Alonso Martin C , Guerra Ramos J M , Moreno Weidmann Z L , Mendez Zurita F , Betancur Gutierrez A F , Vinolas Prat X , Rodriguez Font E
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein (PV) isolation with circumferential ablation around ipsilateral PVs is the standard strategy for atrial fibrillation ablation. The electrical connection between the left atrium (LA) and the pulmonary veins (PV) is determined by the heterogeneous arrangement of myocardial fibers along the PV-LA junction.

Purpose

We sought to assess which regions of the standard ablation circumference are the main contributors to the venoatrial electrical connection.

Methods

Forty-one patients underwent a specific atrial fibrillation ablation protocol in which the anterior and posterior segments of the standard circumference were ablated first. If PV isolation was not achieved, ablation was extended superiorly or inferiorly, based on the earliest atrial activation recorded during pacing from the PV. Complete PV isolation and the length of the areas non-requiring ablation (ANRA) at the time of electrical isolation were evaluated.

Results

Ablation of the anterior and posterior segments of the standard circumference led to isolation of 77% left-PV pairs and 51% right-PV pairs (p=0,015). A superior extension was required in 23% left-PV pairs and in 46% right-PV pairs, while an inferior extension was required only in 10% left-PV pairs and in 11% right-PV pairs. PV isolation was achieved before completing the standard ablation circumference in 97% left-PV pairs and in 94% right-PV pairs, with an ANRA of 35.8±9.0mm in left PVs (16.1±5.2 mm superior and 19.7±5.6 mm inferior, p<0,01), and 35.5±9.5 mm in right PVs (15.2±5.7 mm superior and 20.9±5.3mm inferior, p<0,01).

Conclusion

The myocardial fibers along the anterior and posterior regions of the standard ablation circumference are the main contributors to the electrical connection between the LA and the PVs. Ablation of these regions results in PV isolation in the majority of patients.
Pulsed-field ablation versus single catheter high-power short-duration radiofrequency ablation for atrial fibrillation: procedural characteristics, myocardial injury and midterm outcomes
Authors: Weidlich S , Serban T , Krisai P , Spiess F , Voellmin G , Osswald S , Knecht S , Sticherling C , Kuehne M , Badertscher P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed-field ablation (PFA) has emerged as a novel treatment strategy for patients with atrial fibrillation (AF). A direct comparison to high-power short-duration (HPSD) radiofrequency (RF) ablation using a single catheter is lacking.

Aim

To compare pulmonary vein isolation (PVI) using PFA versus single catheter HPSD-RF ablation regarding efficiency, safety, myocardial injury, and outcomes.

Methods

119 patients underwent PVI and were included (age 65.6 ± 10 years, ejection fraction 0.55 ± 0.11, left atrial size 41 ± 6.6 mm, paroxysmal AF 55%). 56 patients (47%) underwent PFA using a multi-electrode pentaspline PFA catheter with a biphasic waveform and 63 patients (53%) underwent single catheter HPSD-RF ablation without a multipolar mapping catheter.

Results

Using PFA the median procedure time was significantly shorter compared to the single catheter HPSD-RF group with 58 (IQR 51-70) min versus 83 (IQR 71-99) min (p<0.001), while fluoroscopic time was significantly longer with 12 (IQR 10-16) min versus 2.2 (IQR 1.3-3.6) min (p<0.001). First-pass isolation was achieved in 91% of the PFA group and 88% in the HPSD-RF group. 3.3 catheters vs. 1.0 catheters were used in the PFA group versus the HPSD-RF group, p<0.01. One procedural complications was observed in the PFA group and one complication in the HPSD-RF group (Tamponades). High sensitivity cardiac troponin levels were on average significantly higher in patients using the PFA system, 1520 (IQR 1010-1980) ng/l compared to 897 (IQR 725-1240) ng/l in the HPSD-RF group. During a median follow-up of 177 days (IQR 92-300), AF recurrence was observed in five patients (9%) from the PFA group and in 15 patients (24%) from the HPSD-RF group. (Figure 1)

Conclusion

PFA showed shorter procedure times but longer fluoroscopy times, higher levels of hs cTnT, and a possible improved AF-free survival.
Is pulmonary vein isolation using pulse field ablation safe and efficient ? data from a prospective registry
Authors: Chaumont C , Mcdonnell E , Savoure A , Eltchaninoff H , Anselme F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed field ablation (PFA) is a nonthermal ablative modality using a strong electrical field created around a dedicated catheter to produce pores in the cellular membrane. As the amount of energy required to produce electroporation is highly tissue dependent, the atrial myocardium can be specifically targeted while sparing adjacent tissues. This new ablation modality could increase the safety of pulmonary vein isolation (PVI) procedures compared to PVI using thermal energies. Real-life clinical data are still limited regarding safety and efficacy of PFA.

Purpose

To assess safety and mid-term efficacy of PVI performed using PFA.

Methods

We included all patients who underwent PVI for symptomatic atrial fibrillation (AF) using PFA in our hospital between June 2021 and June 2022. All procedures were performed under general anaesthesia. After patients received IV heparin and achieved ACT > 300 s, a 12 Fr multi-electrode pentaspline PFA catheter was advanced through a 13 Fr deflectable sheath into the left atrium. The catheter was positioned so that the splines achieved circumferential contact at the PV antra. Two applications (2.5 sec and 2 kV per application) were performed in "basket" configuration, then the catheter was slightly rotated (30-40°) before delivery of 2 additional applications. This sequence of ablation was repeated in "flower" configuration. This protocol was applied at each pulmonary vein. PVI was assessed with the PFA catheter. A 24-hour holter monitoring was performed at 4-month and one-year follow-up.

Results

The population consisted of 102 patients (73 paroxysmal AF, 29 persistent AF) with a mean age of 56 ± 13 yo. The mean procedure duration was 38 ± 9 min, and mean fluoroscopy duration was 8 ± 4 min (4 ± 4.2 Gy.cm2). The pulmonary vein signal completely disappeared after the first PFA application for each targeted vein and PVI was confirmed for all veins in all patients at the end of the procedure. Pericardial effusion requiring percutaneous drainage occurred in 1 patient during the early phase of our experience (patient n°8). There was no other complication. At 4-month follow-up, 91/102 patients (89%) were asymptomatic with no recurrence of AF. At one-year follow-up, 34/38 patients (89%) had no reccurence of documented atrial arrhythmia. 6 patients underwent a redo procedure : pulmonary vein reconnection was observed in 4/6.

Conclusion

PVI performed with PFA appeared safe and efficient with short procedure and acceptable fluoroscopy durations. Further data are required regarding long-term efficacy.
Artificial intelligence-enabled spatio-temporal dispersion mapping for persistent AF: Similarities and differences between pacing-induced or spontaneous AF
Authors: Bars C , Gitenay E , Monteau J , Lotteau S , Reist M , Serdi M , Appetiti A , Milpied P , Kalifa J , Seitz J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Volta Medical

Saint Joseph Hospital Marseille, France

Background

Spatiotemporal dispersion is an electrical footprint of atrial fibrillation (AF) drivers that has been successfully implemented to target extra-pulmonary veins (PVs) regions during persistent AF ablation.

Purpose

The aim of the study is to characterize spatiotemporal dispersion extent and location and to compare dispersion atrial localization and extent between pacing-induced AF and spontaneous AF.

Methods

Spatiotemporal dispersion maps were built with an artificial intelligence software (VX1, Volta Medical) and analyzed in 71 consecutives persistent (66%) and long-standing persistent (34%) AF patients admitted for a first ablation procedure. Fifty-two patients were in spontaneous AF (73%) at the outset of the procedure while AF was induced in 19 patients (27%) by burst pacing ± isoproterenol infusion. A semi-quantitative visual quantification of dispersion extent was conducted by implementing an atrial segmentation into 22 regions and a region-centered score from 0 (no dispersion) to 3 (high dispersion). Also, an automated quantification was performed as follows: (i) a gradient filter designed to extract atrial shapes from background was applied, (ii) dispersion areas were segmented using a color thresholding method, and (iii) a structuring element was used to connect segmented dispersion areas.

Results

The regional characterization of dispersion shows that dispersion distribution follows a similar pattern and is present in similar atrial regions, regardless of whether AF is spontaneous or induced (Figure 1). Global dispersion extent, however, is significantly higher in the left atrium of patients in spontaneous AF compared to patients with induced AF (15.43% ± 9.04 versus 9.86% ± 6.41, P=0.0025, Figure 2). Accordingly, the regional dispersion score tends to be lower when AF is induced. Dispersion hotspots are: LSPV anterior antrum -ridge (R1), RSPV anterior antrum (R5), anterior wall (R9), roof (R10), posterior wall (R11), and low left atrial septum (R15) in the left atrium. In the right atrium: low right atrial septum (R15) and posterior right atrium (R20) (Figure 1).

Conclusions

Artificial intelligence-enabled dispersion persistent AF mapping indicates that dispersion is reduced in induced vs. spontaneous-AF but that its distribution follows a similar pattern.
Predictors of atrial flutter recurrence after atrial fibrillation ablation: the crucial role of structural and morphological left atrial remodeling
Authors: Guichard J B , Ferro E , Mont J L
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted Grant - Abbott Medical

Introduction

Recurrence of supraventricular tachyarrhythmias after catheter ablation of atrial fibrillation (AF) is common, representing 30% of patients. Although AF recurrence occurs mostly, 10% of the patients face arrhythmia recurrence through atypical atrial flutter (AFL). The diagnostic and therapeutic management of atypical AFL is challenging. Predicting atypical AFL after AF catheter ablation is critical.

Purpose

To identify morphological and structural predictors of recurrence in the form of atypical AFL compared to AF based on Late Gadolinium Enhancement Cardiac Magnetic Resonance (LGE-CMR).

Methods

– From January 2013 to December 2021, 56 patients facing post AF-CA atypical AFL were included in the monocentric and retrospective cohort. 112 patients with AF recurrence were randomly included in the cohort from the general database. Pre-procedure LGE-CMR was post-processed for every patient to assess global and regional left and right atrial (LA, RA) fibrosis quantification using an image intensity ratio > 1.32 as fibrosis. Sphericity was calculated as the percentage of similarity with respect to a sphere, and the volume of LA and RA were calculated.

Results

– 168 patients who had faced supraventricular arrhythmia recurrence after AF-CA were included in the monocentric retrospective cohort. They were mainly male (72.1%), with a median CHADS-VASc score of 1.4 +/- 1.3, a number of previous CA of 2,2 +/- 0.4, and a biatrial dilation (LA volume index of 53.5 ml/m2, RA volume index of 59.6 ml/m2). An age superior to 65 (OR=6.61, CI95%:2.18-14.41, p<0.01), the number of previous CA procedures (OR=3.03, CI95%:1.17-7.81, p=0.02), a history of management of invasive additional lines (OR=2.48, CI95%:1.01-6.27, p=0.05), an elevated LA sphericity (OR=1.33, CI95%:1.11-1.59, p<0.01) and an increased LA fibrotic burden (OR=1.03, CI95%:1.00-1.07, p=0.04) independently predicted the occurrence of atypical AFL compared with AF recurrence after AF-CA (Figure 1). Specifically, an increased amount of fibrosis in the lateral LA zone area (OR=1.03, CI95%:1.01-1.04, p<0.01)] was an independent predictor of recurrence in the form of atypical AFL compared with AF recurrence (Figure 2).

Conclusion

The structural LA remodeling of AE, including LA fibrosis and LA sphericity, is a predictor of recurrence in the form of atypical atrial flutter compared with AF recurrence after AF-CA.
Single versus double transeptal puncture: characterization and outcomes in a single tertiary center
Authors: Lacerda Teixeira B , Silva Cunha P , Portugal G , Valente B , Coutinho Cruz M , Lousinha A , Veiga J , Delgado A S , Bras M , Paulo M , Guerra C , Cruz Ferreira R , Oliveira M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

An ablation catheter in conjunction with a circular mapping catheter (CMC) requiring a double transeptal puncture (TSP) for left atrial access is conventionally used for atrial fibrillation (AF) ablation in the majority of centers. In the recent years, different operators have combined a single transseptal puncture technique with 3D high-density mapping catheters for pulmonary veins isolation (PVI) in AF patients.

Objective

The aim of this analysis is to compare two different strategies, single versus double TSP, regarding duration of the procedure, radiation dose, complications and long-term outcomes.

Methods

Retrospective analysis of an AF large cohort of consecutive patients that underwent PVI with radiofrequency energy (RF) using a 3D mapping system, either with single or double TSP, from 2016 to 2020.

Results

We included 341 patients (female 35,8 %, paroxysmal AF 64,2 %) who underwent catheter ablation with RF. At the time of the ablation, age was 59,1 ± 11,8 years old, and the mean CHA2DS2-VASc score was 1,6 ± 1,3. All patients were taking oral anticoagulation. Single TSP was performed in 165 (48,4%%) patients and double TSP in 176 (51,6%) patients. In 56 (16,4%) cases (50 [30,3%] in the single TSP and 6 [3,4%] in the double TSP), the procedure was a repeat ablation after AF recurrence. Operator experience (defined as ≥5 years of AF ablation procedures) was equally distributed between the two groups. The average procedure time single (129 ± 33,2 minutes vs. 122 ± 34,9 minutes, for single and double TSP, respectively) did not reach statistical difference between the two groups (p = 0,55), but there was a significant difference regarding fluoroscopy time (13 ± 6,3 vs. 19 ± 9,1, for single and double TSP, respectively; p < 0,001). Acute complications were less frequent in the single TSP approach (5,6 % vs. 9,7 %, for single and double TSP, respectively), but did not reach statistical significance. At 2-year follow-up, sinus rhythm maintenance rate was similar in both groups (77% vs. 78%, p=0,85). At 2 and 4 year follow-up, the Kaplan-Meier survival curves revealed no difference in time to AF recurrence between the two groups (log- rank p = 0,974 and p = 0,965). However, further analysis of subgroups according to type of AF revealed a significant difference among the subgroup with persistent AF submitted to double TSP (log rank p = 0,007) during a total of follow-up of 4 years.

Conclusion

A simplified single-TSP technique using high-density multi-electrode 3D mapping is a safe and highly successful approach for AF ablation. This approach yields a substantial reduction in fluoroscopy time, with the potential to avoid acute complications when compared to a conventional double-TSP strategy.
Left common trunkus pulmonary veins have genetic background and poor rhythm outcome after atrial fibrillation catheter ablation
Authors: Choi S , Yang S Y , Oh J K , Kim D , Park J W , Yu H T , Uhm J S , Joung B , Lee M H , Hwang C , Pak H N
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

There is a genetic background in pulmonary vein (PV) development and atrial fibrillation (AF). However, the genetic trait of PV variations and their rhythm outcome after AF catheter ablation (AFCA) is unclear.

Objective

We explored the genetic and clinical characteristics and long-term rhythm outcomes of AF patients with PV variation or left common trunkus (LCT)-PV.

Methods

We included 2,897 AF patients (74.0% male, age 59.0 ± 10.7 years, 66.3% paroxysmal AF) with available genome-wide association study results, cardiac computed tomogram data, and protocol-based regular rhythm follow-up from the Yonsei AF ablation cohort database. We defined LCT-PV when the upper and lower PV separate at >10 mm distal to the left PV antrum margin. PV variations included both LCT-PV and accessory PVs. We analyzed the polygenic risk score (PRS) of 12 AF-associated genes (DSP, GJA1, HCN4, KCNQ1, NPPA, PITX2, RYR2, SCN5a, SHOX2, ATP2A2, TBX3, and TBX5) and long-term rhythm outcomes after AFCA.

Results

We found PV variation in 296 (10.2%) and LCT-PV in 102 (3.5%). PRS of 1,227 single nucleotid polymorphisms (SNPs) was significantly higher in PV variation patients (p=4.93e-08) and LCT-PV patients (p=1.95e-20). The patients with LCT-PV had higher CHA2DS2VASc scores (p=0.024) and lower atrial epicardial adipose tissue volume (p=0.034). During 39.7 ± 34.8 months follow-up period, LCT-PV patients had a significantly higher recurrence rate than their counter part in the paroxysmal AF sub-group (Log-rank p=0.036), but not in overall PV variations. LCT-PV with the highest 10% PRS was independently associated with AF recurrence after AFCA (HR 2.10, 95% CI 1.21-3.63, p=0.008).

Conclusions

Among the patients who underwent AFCA, PV variation, including LCT-PV, has a significant genetic background. The post-AFCA recurrence rate was significantly higher in patients with LCT-PV and high PRS, especially in paroxysmal AF.
Outpatient atrial fibrillation ablation: feasibility, safety and economic implications
Authors: Jimenez-Candil J , Hernandez J , Morinigo J L , Sanchez Garcia M , Cruz A , Oterino A , Sanchez P L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation of atrial fibrillation (CA-AF) is the most common ablation procedure in Spain.

Purpose

To analyze the feasibility of performing this procedure on an outpatient approach among patients undergoing scheduled to CA-AF.

Methods

We compared prospectively the results of all programmed CA-AF procedures in two consecutive periods: from April 1, 2018 to March 31, 2019 (conventional strategy CON-E]: discharge after at least one day of hospitalization, n=100) and from April 1, 2019 to December 31, 2021 (same-day discharge strategy [SDD-E] in which patients were referred for an outpatient procedure by intention to treat, n=320). We established a Primary Efficacy Objective (percentage of patients discharged on the same day in SDD-E), a Primary Safety Objective (cumulative incidence of urgent/unplanned care [UUC] in the 10 days following discharge) and a Secondary Objective (average cost per procedure including day hospital stay, hospitalization and UUC in the 10 days following discharge, using the most recent fees of the Spanish Public Health System).

Results

Primary Objective of Efficacy: in 358/380 procedures (94%) the patient was discharged within 12 hours after their arrival at the hospital (range of length of hospital stay: 7-10 hours). There was no difference in the early discharge rate between cryoablation vs. radiofrequency (94% vs. 95%; p=0.8). The reasons for patients being hospitalized after ablation in the same-day discharge strategy are displayed in Figure 1. Primary Objective of Safety: Twelve patients (12%) of the CON-E required urgency care within 10 days of discharge, compared to 53(14%) of the SDD-E (p=0.6), most of them due to recurrence of AF. Figure 2. Among SDD-E patients, one was hospitalizated due to severe groin haematoma on day 3 after discharge. The remaining 52 patients with UUC were discharged within 8 hours of arrival at the Medical Center. Secondary Objective: The SDD-E reduced hospital stays: 0 [Interquartilic Range: 0-0] vs. 1 [1-1] (p<0.001), resulting in lower cost per procedure: 552 euros (95% CI: 486-618) vs. 1738 euros (95% CI: 1172-1805) (p<0.001).

Conclusions

CA-AF can be performed with less than 12 hours of hospital stay in 94% of patients. Compared with the conventional strategy, SDD-E does not increase the rate UUC within 10 days of discharge and is associated with a significant reduction in cost per procedure.
Re-do ablation procedure characteristics after pulmonary vein isolation using pulsed field ablation for atrial fibrillation
Authors: Neven K , Fueting A , Hartl S , Reinsch N
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). A few small clinical studies and registries have reported an initial clinical success rate of approx. 80% after 1 year. Here, we present the results from re-do ablation after PVI using PFA for AF.

Methods

In symptomatic AF patients, re-do ablation in conscious sedation using a contact force sensing catheter and 45W RF energy was performed. In all patients, pre- and post-ablation high-density bipolar voltage 3D maps using a pentaspline diagnostic catheter were performed. Procedural parameters and acute success were assessed.

Results

Eighteen patients (age 67 years; 17% female; 56% PAF) from a total of 304 patients (age 67 years; 42% female; 47% PAF) (6%) treated with PFA as initial AF therapy underwent a re-do ablation 212 days after the index procedure. Mean CHA2DS2-VASc-score was 1,7 in the re-do group vs. 2,5 in the index procedure group. Mean duration since first AF diagnosis and BMI were not significantly different. In 12/18 (67%) patients, reconnection of at least 1 PV was found (LSPV 2x; LIPV 4x; RSPV 2x; RIPV 2x, left carina 4x; right carina 2x). All reconnected PVs were successfully reisolated. In 11/18 (61%) of patients, an atrial flutter (AFL) or tachycardia (AT) was identified (roof 5x; mitral isthmus 5x; anterior/septal 3x; cavotricuspid isthmus 5x). In 5/12 (42%) of patient with reconnection of at least 1 PV, AT/AFL occurred. In contrast, in all 6 patients (100%) with persistently isolated PVs AT/AFL occurred. All tachycardias were successfully ablated.

Conclusions

Re-do ablation rate after PFA for AF was relatively low (6%), involving mostly male patients. PV reconnection rate was 67%, site of PV reconnection was predominantly left-sided. In 61%, predominantly left-sided AT/AFL occurred. Notably, in all patients with persistently isolated PVs AT/AFL was observed.