bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of pulsed field ablation and cryoballoon ablation in atrial fibrillation
Authors: Schipper J , Dittrich S , Erlhoefer S , Scheurlen C , Woermann J , Van Den Bruck J , Filipovic K , Pavel F , Lueker J , Steven D , Sultan A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) using cryoballoon (CB) catheter ablation has emerged as a cornerstone for treatment of atrial fibrillation (AF). Recently pulsed field ablation (PFA) has been introduced for PVI. First data show high acute and favorable long-term outcome. So far, data comparing these "single shot" devices is sparse.

Objective

This analysis sought to provide procedural and outcome data comparing PFA to CB PVI. Furthermore, potentially postprocedural discomfort was evaluated.

Methods

A retrospective analysis of PVI procedures using PFA or CB was performed. Discomfort analysis was obtained by prescribed analgesic medication within first 48 h after PVI (fully digital patient file). During follow-up (FU) repeat outpatient visits and Holter ECG were performed.

Results

In all 108 patients with AF (54 PFA and 54 CB; PFA: 37 (69 %) men; CB: 38 (70 %) men) successful PVI was achieved. There were no significant differences regarding baseline characteristics. 17 (31 %) patients in the PFA group and 18 (33 %) patients in the CB group had paroxysmal AF. Procedure time trended to be shorter in the PFA group (PFA: 64.5±17.5 minutes; CB: 73.0±24.8 minutes; p=0.07). Sub-analysis of the PFA group revealed a significant shortening of procedure duration over time (first 27 PFA vs. second 27 PFA: 72.9±19.1 minutes vs. 56.1±10.7 minutes, p=0.001). Significantly less contrast medium was used for PFA PVI as compared to CB PVI (PFA: 12± 6 ml; CB: 51± 29 ml, p<0.0001). Fluoroscopy time was significantly longer for PFA PVI (PFA: 15.3±4.7 minutes, CB: 12.3±5.3 minutes; p=0.001). Analysis of postprocedural analgesic medication demand did not differ between PFA and CB PVI (PFA: 7 patients; CB: 10 patients; p=0.59). After a FU of 234±127 days 79% of patients remained in SR after PFA and 78% after CB PVI (p=0.88). In the PFA group 2 non-device related cardiac tamponades occurred.

Conclusion

A comparison of PFA to CB PVI revealed a comparable efficacy and safety profile with a steep learning curve and potentially shorter procedure duration. Amount of contrast medium is significantly higher for CB PVI. So far, arrhythmia-free survival seems to be still equal between both techniques. However, PFA is a safe and effective alternative to CB for PVI.
Identifying (electrophysiological) predictors of atrial fibrillation recurrences after catheter ablation: first results from the ISOLATION registry
Authors: Habibi Z , Verhaert D V M , Hermans B M J , Kawczynski M , Philippens S , Westra S W , Chaldoupi S M , Maesen B , Isaacs A , Zeemering S , Linz D , Vernooy K , Schotten U
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): a.o. The European Union (ITN Network Personalize AF: Personalized Therapies for Atrial Fibrillation: a translational network, grant number 860974; MAESTRIA: Machine Learning Artificial Intelligence Early Detection Stroke Atrial Fibrillation, grant number 965286).

Background/Introduction

Noninvasive quantification of electrophysiological properties of the atria is increasingly used for outcome prediction in atrial fibrillation (AF) patients. Data on the added value of ECG parameters to predict AF recurrences in patients undergoing AF ablation are scarce.

Purpose

To investigate the predictive performance of clinical and echocardiographic characteristics as well as features extracted from extended surface electrocardiogram (extECG) recordings for AF recurrences in patients after AF ablation.

Methods

ISOLATION is a prospective, observational, multicenter registry of patients scheduled for AF catheter ablation, including cryoballoon and radiofrequency ablation. 178 patients (66.4%) patients used anti arrhythmic drugs at baseline. Clinical characteristics and results of routine blood tests were collected. In addition, an extECG was recorded (12 additional leads, 5 minutes recording) before ablation to analyze P-wave characteristics. The main study endpoint was ablation success after 12 months, defined as freedom from any episode of documented atrial arrhythmia after the blanking period recorded on holter or ECG.

Results

Currently, 627 of 650 scheduled patients have been included. In total, 268 patients completed the 1-year follow-up. 190 patients (70.9%) had paroxysmal AF and 75 patients (28.0%) had persistent AF. Median age was 65±9 years, 38.1% were female. 46 patients (17.2%) had a recurrence of AF after 12 months [figure 1]. Univariate analysis showed that higher age (64 years vs. 69 years, p=0.023, Mann-Whitney U-test), lower P-wave mean area (4.402 mV vs. 3.567 mV, p=0.034) and lower P-wave mean amplitude (0.087 mV vs. 0.081 mV, p=0.033), were associated with a higher recurrence rate of AF [figure 2]. However, multivariate analysis showed no significant independent prognostic factors so far.

Conclusion

Our first results show that patients with AF recurrences after catheter ablation are older, show lower P-wave mean area and lower P-wave mean amplitude. We need to wait for the completion of follow-up in more patients, before we can determine the predictive value of P-wave parameters derived from extECGs for the prediction of AF recurrence and to identify predictive factors with more subtle effects on risk for AF recurrences.
The impact of posterior wall ablation in conjunction with pulmonary vein isolation in patients with persistent atrial fibrillation: a meta-analysis comparing cryoballoon vs. radiofrequency energy
Authors: Musat D , Milstein N S , Shaw R , Bhatt A , Habibi M , Preminger M , Sichrovsky T , Mittal S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) remains the cornerstone of atrial fibrillation (AF) ablation. In patients with persistent AF (PeAF), additional posterior wall ablation (PWA) has been proposed to improve outcomes. Individual small series have included patients ablated with a cryoballoon (CB) and radiofrequency (RF) energy and have yielded controversial results. We conducted a meta-analysis of available data to assess the incremental impact of PWA based on type of energy used for ablation.

Objective

To evaluate whether PVI + PWA is a more effective approach for treatment of PeAF than PVI alone based on ablation energy used.

Methods

The online databases (Pubmed, Medline, Embase) were searched using the terms "pulmonary vein isolation", "posterior wall isolation", or "posterior wall ablation". Out of 1917 studies, eight met our strict criteria (Table). Specifically, patients were undergoing de novo ablation for treatment of PeAF using either CB or RF. Patients had PVI alone vs PVI + PWA; studies that delivered additional ablations (except for cavotricuspid isthmus) were excluded. The primary outcome was recurrence of any atrial tachyarrhythmia (AT).

Results

The cohort consisted of 1607 patients (66 ± 17 years, 75% male); 830 (52%) patients were ablated CB and 777 (48%) patients were ablated with RF (Table). In the CB group, AT recurrence was significantly higher in patients who underwent PVI alone as compared to those who also had additional PWA (OR 2.55, 95% CI [1.89, 3.42], P < 0.0001, Figure). In contrast, in the RF group, outcome between the 2 groups (OR 1.40, 95% CI [0.81, 2.42], P = 0.22, Figure) was similar.

Conclusions

Addition of CB based PWA to PVI in patients with PeAF undergoing ablation was associated with improved long-term ablation success. However, RF based PVA did not appear to confer the same benefit. Additional randomized studies are needed to determine the impact of ablation energy in patients undergoing PWA during ablation of PeAF.
Veins without real-time pulmonary vein isolation during cryoballoon ablation strongly predict long-term atrial fibrillation recurrence
Authors: De Greef Y , Buysschaert I , Cecchini F , Sofianos D , Kupics K , Varnavas V , Stroker E , Schwagten B , De Cocker J , Tijskens M , Adriaenssens B , Wolf M , Abugattas J P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Absence of real-time PV isolation (PVI) by the Achieve catheter occurring in 15 to 40% of the veins during cryoballoon ablation (CBA) of atrial fibrillation (AF) raises doubt about adequate PVI.

Purpose

To determine whether veins without real-time PVI are predictive of long-term clinical outcome.

Methods and Results

803 of 1000 consecutive AF patients (mean age 64±10 years, 68% males) treated with CBA were followed for 3 years. Clinical success defined as freedom of documented AF at 3 years was achieved in 65.3% of the patients. The cohort was divided in 4 groups according to the number of PVs with real-time PVI: all veins (N=252(31,4%)), 3 (N=255(31,8%)), 2 (N=159(19,8%)) and 0-1 vein (N=137(17,1)). A vein without real-time PVI was associated with AF recurrence (HR=1.275; 95%CI 1.134-1.433; p<0.01), independent of established predictors as persistent AF type (HR=2.075; 95%CI 1.584-2.738; p<0.01), left atrial diameter (HR=1.050; 95%CI 1.028-1.072; p<0.01) and diagnosis-to-ablation time (HR=1.002; 95%CI 1.000-1.005; p=0.04). The highest clinical success was achieved in patients with real-time PVI in all veins (77.4%), gradually decreasing per increasing number of veins without real-time PVI: 66.3% for 1 vein, 58.5% for 2 and 48.9% for 3-4 veins (p<0.001). At repeat ablation (N=188), 83 out of 288 (28.8%) veins without real-time PVI were reconnected versus 99 out of the 430 (23.0%) veins with real-time PVI (p=0.08).

Conclusion

Veins without real-time PVI during CBA independently predict long-term AF recurrence with increasing AF recurrence per increase in veins without real-time PVI. A trend towards a higher reconnection rate in veins without real-time PVI suggest incomplete PVI or a less efficacious freeze resulting in less durable PVI.
Differences in acute outcomes and complications of pulmonary vein isolation using pulsed field ablation with or without 3D mapping system for paroxysmal atrial fibrillation
Authors: Fueting A , Reinsch N , 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). It is also used as off-label therapy for persistent AF. PFA can be performed "cryo-style" using fluoroscopy only, or additional pre- and post-ablation high-density 3D bipolar voltage maps can be performed to assess lesion formation and acute pulmonary vein isolation. We compared acute outcome after PFA using fluoroscopy only (X-ray) vs. PFA guided by 3D mapping (3D).

Methods

In patients with AF, 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 and in-hospital safety were assessed.

Results

A total of 4 operators treated 218 patients (mean age 66 years (range 35–86), female 43%, mean BMI 28 kg/m2 (range 20-42), mean CHA2DS2-VaSc score of 2,5 (range 0-7), first-time ablation 93%, paroxysmal AF/persistent AF/re-do 72/21/7%). Mean duration since first AF diagnosis was 42 months (range 1-336). Most procedures were performed under deep conscious sedation without intubation (99%). There were no selection criteria for the use of 3D mapping. Pre- and post-ablation high-density maps were performed in 28% of cases. Skin-to skin procedure time was 54±22 in the X-ray group vs. 123±35 min in the 3D group, respectively (p<0,0001). Fluoroscopy time was 17±7 in the X-ray group vs. 20±6 in the 3D group, respectively (p<0,01). Acute pulmonary vein isolation rate was 100% in both groups. There were no phrenic nerve palsies or esophageal complications. Major complications (3,7%) were pericardial tamponade (2,8%) and stroke (0,9%); one stroke resulted in death (0,5%). They occurred in 3,2% of patients in the X-ray group (3 pericardial tamponades, 2 strokes) vs. 4,8% in the 3D group (3 pericardial tamponades), respectively (p=ns). Minor complications (1,4%) were vascular (0,5%) and transient ischemic attack (TIA) (0,9%).

Conclusions

In a large, single center cohort of unselected patients, PVI using PFA with or without 3D mapping system resulted in a similar acute outcome and safety profile. Procedure and fluoroscopy times were significantly shorter in the fluoroscopy only group. There were no PFA-specific complications, but the frequency of catheter complications in this relatively old patient population demonstrates that there is still room for improvement.
Minimizing radiation in cryoballon-based ablation of the pulmonary veins through a novel high-resolution wide-band dielectric imaging system
Authors: Bastian D , Buia V , Walascheck J , My I , Rittger H , Vitali-Serdoz L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Purpose

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. We evaluated the procedural data of patients undergoing CB PVI with this new 3D electroanatomic mapping system

Methods

The study population comprised 89 consecutive patients who underwent third-generation CB-based PVI with the wide band dielectric system and X-Ray System with enhanced collimation, frame reduction and stored fluoroscopy. All the transeptal manouver were perfomed under transesofageal guidance. Our data were compared to the literature data regarding radiation exposure and fluoroscopy time during CB based PVI without the use of 3D electroanatomic mapping. Primary endpoints were the total dose area product (DAP) and the fluoroscopy time.

Results

Our mean DAP per procedure has been 15,45 ± 27,18 cGy*cm2, challenging the mean DAP in the recent literature from two high volume centers being about 389 to 1129 cGy*cm2 in CB based PVI. Our median fluoroscopy time was 3,95 ± 4,12 minutes, again challenging the mean fluoroscopy time reported in the literature of around 10 to 14,5 minutes in both CB PVI. Our mean mapping left atrium mapping time using Kodex was of about 7 minutes. No major complications occurred.

Conclusion

The combined use of an optimized fluoroscopy setting and a novel high resolution wide-band dielectric imaging system in CB based PVI can significantly reduce radiation exposure and fluoroscopy time and is associated to a high procedural safety.
Electrode tissue coupling (ETC) influences lesion formation stronger than contact force
Authors: Bahlke F , Wachter A , Krafft H , Popa M , Englert F , Erhard N , Telishevska M , Lengauer S , Risse E , Lennerz C , Reents T , Hessling G , Deisenhofer I , Bourier F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Several parameters are assumed to influence lesion size in RF ablation. Especially RF power, duration and contact force are considered for optimizing lesion quality and creating durable lesions. Recent data showed a significant influence of electrode-tissue-coupling (ETC) on lesion size and occurrence of steam pops. Therefore, this study aimed to investigate the impact of ETC and contact force on lesion progression in RF ablation.

Methods

RF-lesions were created using a contact force sensing catheter with the ability of measuring local impredance in an ex vivo porcine cardiac model. 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. RF power of 20W, 30W, 40W, and 50W was used. The ETC levels (full/minor) and CF-level (1-5g, 10-15g and 20-25g) were systematically varied between minor and full coupling. In minor ETC-level, only the distal end of the catheter is in contact with the tissue. In full ETC-level, the whole catheter tip is in contact with the tissue. All parameters (power, temperature, global and local impedance, contact force, ETC, 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

8654 measurements out of 72 lesions were included in analysis. Significant differences in lesion size were observed when ETC-level was differed. Lesion depth was significantly higher in full ETC-level (5.13 ± 0.99 mm vs. 9.45 ± 1.45 mm, p<0.001). No significant difference was seen in lesion diameter and depth by varying CF-level, when lesions were created in full ETC-level (Table 1). These findings are also illustrated in Figure 1.

When lesions were analyzed in minor ETC-level only, significant differences were observed, when CF-levels were varied (Table 2).

Conclusion

ETC is a main predictor of lesion size in RF-ablation. CF also influences lesion depth and diameter. However, significant differences were only observed in minor ETC-levels. Consequently, CF might be a main factor for durable lesions in RF-ablation, but the influence of varied CF decreases when ETC-level is rising.
Pulmonary vein isolation with a novel radiofrequency balloon catheter: real-world predictors of single shot isolation
Authors: My I , Bordignon S , Butt M , Rottner L , Lemoine M , Moser F , Wenzel J P , Obergassel J , Kirchhoff P , Reissmann B , Ouyang F , Chun K R J , Schmidt B , Rillig A , Metzner A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

A novel multi-electrode radiofrequency balloon (RFB) catheter has been released for pulmonary vein isolation (PVI).

Objectives

First multicenter real-world study to evaluate predictors of single shot PVI with the novel RFB catheter.

Methods

In this observational study consecutive patients with drug refractory paroxysmal or persistent atrial fibrillation (AF) undergoing first-time PVI were enrolled in two high-volume ablation centers. All procedures were conducted in conjunction with a 3D-mapping system. Clinical, procedural and ablation parameters were systematically analyzed.

Results

105 patients (58% males; 52% paroxysmal AF, 68 ± 11.3 mean age, left atrial volume index 38.6 ± 14.8 ml/m2) were included. 241/412 (58.5%) pulmonary veins were successfully isolated with a single shot (SS), with a time to isolation of 11.6 ± 8 s. Total number of radio frequency applications was 892 (mean 2.2/PV), resulting in successful isolation of 408/412 (99%) PVs at the end of the procedure. Mean electrodes’ impedance drop was significantly higher in the SS-PVI compared to the non-SS applications (21.5 ± 6.6 vs. 18.6 ± 6.5 Ohm). Concordantly, higher temperature rise was observed in the SS versus non-SS applications (10.9 ± 4.9°C vs. 9.6 ± 4.7°C).

Conclusion

In this multicenter real-world study, mean impedance drop and temperature rise emerged as valid predictors for SS-PVI with the novel RFB catheter. These parameters may help to guide efficient usage of the new RF balloon.
Comparison of zero fluoroscopy versus fluoroscopy guided ablation for atrial fibrillation: A single center experience
Authors: Jimenez Restrepo A , Sharma P , Vidaillet H , Hayes J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

With advances in mapping equipment and increased use of intracardiac echocardiography (ICE), atrial fibrillation (AF) ablations can be safely performed without fluoroscopy. Benefits include no radiation exposure to patient and staff and reduced long-term orthopedic complications related to use of lead aprons for staff. Published data comparing zero fluoroscopy ablation (ZFA) and conventional fluoroscopy guided ablation (CFA) for AF is limited to small case series and meta-analysis.

Aim

To evaluate the safety and procedural outcomes of a simplified ZFA approach, comparing it to standard of care (CFA).

Methods

Consecutive AF cases from 03/2021 to 09/2022 at our institution were included. 120 cases underwent ZFA (RF ablation, ICE and 3D mapping guided) and 155 cases underwent CFA (Cryo or RF ablation, fluoroscopy, ICE and 3D map guided). For the ZFA group, a simplified ICE based map of relevant anatomical structures was created, in order to guide trans-septal (TS) access and left -sided ablation (See figure) and no pre-procedural imaging was obtained. All CFA cases had pre-procedural cardiac CT or MRI to evaluate left atrial anatomy. Redo ablation cases represented 17% of the ZFA and 23% of the CFA patients. All cases were performed by operators with >12 years of experience, and all cases underwent general anesthesia. Only two ZFA cases required a brief period of fluoroscopy (under 2 min each) to achieve safe trans-septal access (including one case with a prior ASD closure device).

Results

Mean age was 67 for ZFA and 69 for CFA groups respectively (p=NS). 69% of ZFA and 71% of CFA cases were men. Persistent AF cases more frequently underwent posterior wall isolation in the ZFA group (98% vs 68%, P<0.01), but despite this, procedural times were similar for both groups (168±55 min ZFA vs 172±51 min CFA, P=NS). Procedural success (pulmonary vein isolation ± posterior wall isolation) was achieved in all ZFA and 99% of CFA cases. At a mean follow up 12 months, Freedom for AF was 81% for paroxysmal AF and 74% for persistent AF cases in the ZFA group, and 79% for paroxysmal AF cases and 71% for persistent AF cases in the CFA group (p=NS). Procedural complications included one TIA in the ZFA group and 2 pericardial effusions in the CFA group (p=NS). Use of antiarrhythmic drugs post ablation did not differ between the ZFA and the CFA groups (23% vs 27%, p=NS).

Conclusion

Our ZFA approach for AF was safe, effective and produced similar outcomes compared to a traditional CFA approach. ZFA has considerable health benefits for personnel and patients without compromising procedural outcomes. The cost of ICE catheters may be offset by eliminating the need for pre-procedural imaging (CT or MRI) commonly used prior to AF ablations. Our study adds to the growing literature supporting the safety of catheter ablation in a non-fluoroscopy environment.
Cerebral microembolic signal burden during pulsed field ablation: preliminary results from robotically-assisted transcranial doppler and magnetic resonance imaging
Authors: Della Rocca D , De Asmundis C , Stroker E , Sieira J , Sorgente A , Ceccarelli A , Bala G , Del Monte A , Pannone L , Overeinder I , Ramak R , Mouram S , Almorad A , Natale A , Chierchia G B
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Transcranial Doppler (TCD) has been used to monitor the burden of cerebral microembolic signals (MESs) during atrial fibrillation (AF) ablation. MES burden is considered a surrogate marker for stroke risk and has never been reported during AF ablation with pulsed field ablation (PFA).

Purpose

To assess the MES burden during AF ablation with point-by-point radiofrequency (RF) versus single-shot PFA.

Methods

Fifteen consecutive paroxysmal and persistent AF patients underwent catheter ablation via either single-shot (2000V) PFA [n=7, median age: 56yo (range:53-73), 85.7% males] or point-by point (45W) RF [n=8, median age: 58yo (range 56-74), 62.6% males] under uninterrupted oral anticoagulation and a periprocedural ACT≥300s.

Peri-procedural TCD was performed via a robotically-assisted ultrasound system, which includes an Artificial Intelligence-powered robotic headset designed to automate signal acquisition and reduce interoperator variability of TCD findings (Figure 1).

Ablation-related asymptomatic cerebral embolism (CE) was assessed via diffusion-weighted imaging (DWI) sequences at magnetic resonance imaging (MRI) performed 24-48h post-ablation.

Results

Among the 7 PFA patients, the median number of applications to achieve PV isolation was 35 (range:33-42). Five (71.4%) patients showed multiple MESs clustered in a shower-like pattern (Figure 2). The overall number of MES-showers was 51 [median: 9 (range:8-15)] and they were temporally correlated with a PFA application. Shower formation was more common after a PFA application to the right superior pulmonary vein [(PV); 19 cases (37.3%)], followed by the right inferior PV [16 cases (31.4%)], the left inferior PV [14 cases (27.5%)], and the left superior PV [2 cases (3.9%)].

A single shower-like pattern was documented among the 8 RF patients, following a stem-pop while ablating at the right inferior PV antrum.

There were no procedure-related complications and none of the 15 patients showed any post-ablation neurological symptoms.

The mean time from ablation to MRI was 29±4hours; DWI imaging revealed no acute cerebral microembolic lesions.

Conclusion

PFA generated a relevant number of MESs frequently clustered in short-lasting shower-like patterns. The composition of MESs, their exact mechanism of formation, and the impact on neurological outcomes are unknown and will be addressed in future studies.
Release of neuronal injury markers differs according to the technique of pulmonary vein isolation
Authors: Spieker M , Angendohr S , Bejinariu A , Gloeckner D , Brinkmeyer C , Schmidt J , Kelm M , Rana O
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Previous studies showed a release of neuronal injury markers during catheter ablation of atrial fibrillation using thermal energies such as radiofrequency or cryothermy. Pulsed field ablation (PFA), that is characterized by its tissue specificity, serves as an innovative technique for pulmonary vein isolation (PVI).

Purpose

To investigate the amount of neuronal injury marker release in patients undergoing first PVI using different ablation modalities.

Methods

We included 65 consecutive patients (age 69 ± 11 years, 52% females) that underwent PVI for the first time with either radiofrequency using standard ablation settings (RF; n = 11), radiofrequency with high-power short-duration (HPSD; n = 32) or PFA (PFA; n = 17) for atrial fibrillation. Protein S100B levels and Neuron-specific enolase (NSE) in coronary sinus blood were detected before and after PVI. The release of neuronal injury markers was assessed according to the ablation technique used.

Results

The change in high-sensitivity troponin (hsTnT) levels was similar in all groups (RF: Δ175.6±181.9 ng/l; HPSD: Δ153.1±233.5 ng/l; PFA: Δ181.1±257.6 ng/l; p=0.632). NSE was significantly released only in patients treated with PFA-PVI (25.2±13.4 to 45.2±24.9 ng/ml; p<0.001), but not in patients treated with RF-PVI or HPSD-PVI (both p>0.05). S100B was released in patients treated with RF-PVI (79.7±32.2 to 118.6±46.4 pg/ml; p=0.006) and PVI-PFA (80.6±38.1 to 138.1±82.7 pg/ml; p=0.002) after the procedure, while there was only a numerically increase in patients treated with PVI-HPSD (88.6±38.7 to 109.1±54.2 pg/ml; p=0.172). We detected no correlation between the release of neuronal biomarkers (Δ NSE and Δ S100B) and cardiac damage (Δ hsTnT) (all p>0.05). The ΔNSE/ΔhsTnT ratio (p<0.001), and the ΔS100B/ΔhsTnT ratio (p=0.002) was higher in patients undergoing PFA-PVI (ΔNSE/ΔhsTnT 0.19±0.20; ΔS100B/ΔhsTnT 0.75±1.35), than in patients undergoing RF-PVI (ΔNSE/ΔhsTnT 0.0±0.06; ΔS100B/ΔhsTnT 0.35±0.32) and HPSD-PVI (ΔNSE/ΔhsTnT 0.04±0.11; ΔS100B/ΔhsTnT 0.13±1.55).

Conclusion

The release of neuronal injury markers differs according to the technique used for PVI. Patients treated with PFA showed a higher release of neuronal injury markers compared to radiofrequency ablation, that was not explained by more myocardial damage. Future research needs to investigate the prognostic relevance in terms of atrial fibrillation recurrence of the neural injury induced by PFA compared to radiofrequency PVI.
Consideration of technique for prevention of phrenic nerve injury due to right pulmonary vein ablation of atrial fibrillation
Authors: Tanaka M , Hayashi S , Yasuda T , Kida R , Hashimoto S , Ooka J , Shimoda Y , Tanaka T , Kondo M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Back ground: Right phrenic nerve injury has been known well as a rare complication associated with ablation of right pulmonary vein (RPV) in patients with atrial fibrillation (AF) and pace mapping of the sites where the nerve can be stimulated from the endocardium has been the most commonly accepted real-time technique.

Purpose

To assess techniques of right phrenic nerve stimulation (PNS) and to consider effective ablation while avoiding phrenic nerve injury (PNI).

Methods

The consecutive 240 patients who underwent the initial radiofrequency catheter ablation (RFCA) of AF during May 2018 to July 2022 were studied retrospectively. All patients were performed point- by-point ablation and they had PNS from the ablation catheter for each point before ablation the anterior line of RPV. RFCA was performed with a 3.5 mm irrigated catheter using Carto3.

Results

Mean age 72.7-years, female 95 (39.6%), 123 patients (51.3%) with paroxysmal AF (PAF), mean body mass index (BMI) 23.4 kg/m2, mean left atrial diameter (LAD) 43.3mm. 5 patients (2.1%) confirmed capture on PNS given at 10v stimulation. Although the five patients had nothing in common in terms of age, gender, BMI, or LAD, the site of PNS capture was almost identical, from RPV carina to right superior pulmonary veins (RSPV) anterior area (Fig.1-5). The area captured by 10v stimulation is often large, diverting the ablation largely to the anterior wall to avoid PNI, which can contribute to recurrence if there is epicardial conduction from the right atrium. Therefore, in order to reduce the application area, pace map with 5v stimulation was performed and it detailed PN positioning. The yellow tags in Fig. 1-4 and light blue tags in Fig 5 showed pointes of PNS capture stimulated by 5v. There was no PNS capture exactly next to these tags and no PNI was occurred by RFCA there. RFCA including just next to the area of PNS capture was performed at the surgeon's discretion with an output of 30-45w, 10-25 seconds, and ablation index (AI) target of 400-450, and RPV isolation was achieved without PNI in all patients. Four months later, one patient showed in Fig.1 had recurrent AF, but no reconnection between 4PV and LA was recognized at the 2nd session.

Conclusion

2.1% of all patients showed PNS capture in this study. The area of PNS capture was almost same, and a pace map by 5v was effective for detailed identification of the area. Furthermore, PNI did not appear when the application was added just next to the area identified in 5v.
Incremental value of low-voltage area ablation in persistent atrial fibrillation: a systematic review and meta-analysis
Authors: Toumpourleka M , Patoulias D , Antoniadis A P , Triantafyllou K , Giannopoulos G , Meletidou M , Karamanidou M , Fragakis N , Vassilikos V
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

The optimal ablation approach for patients with persistent atrial fibrillation (AF) is a topic of high controversy. The efficacy of adjunctive ablation strategy beyond conventional pulmonary vein isolation remains uncertain.

Purpose

We sought to investigate the effectiveness of individualized low-voltage area (LVA) substrate modification in patients with persistent AF receiving conventional catheter ablation.

Methods

We systematically searched PubMed, Cochrane Library, and grey literature sources including clinicaltrials.gov, from inception to 1st November 2022, to identify relevant randomized controlled trials (RCTs). Patients with persistent AF undergoing conventional catheter ablation vs. ablation with additional LVA substrate modification were compared. Freedom from arrhythmia was set as the primary efficacy outcome and total procedure time as the secondary efficacy outcome. A prespecified subgroup analysis was performed for patients with presence of LVAs. We did not impose any filter regarding the study setting, sample size, study duration, or publication language. All analyses were performed using R version 4.1.0 and a two-sided p-value<0.05 was considered statistically significant.

Results

We pooled data from 5 RCTs with a total of 989 participants (31% female) with persistent AF. Ablation with additional LVA substrate modification resulted in a significantly increased likelihood for freedom from arrhythmia by 60%, compared to conventional AF ablation (odds ratio 1.60; 95% confidence interval 1.13-2.28; I2=39%; p=0.009). No difference in the total procedure time was identified between the two approaches (mean difference -28.94 min; 95% confidence interval -69.39 to 11.51 min; I2 = 98%, p=0.16). In patients with LVAs (n=240), additional LVA substrate modification yielded a higher probability for freedom from arrhythmia than conventional AF ablation (odds ratio 1.73; 95% confidence interval 1.03-2.90; I2=0%; p=0.04).

Conclusion

This meta-analysis demonstrates that an individualized ablation approach with low-voltage area substrate modification is associated with improved outcomes in patients with persistent AF.
Safety and durability of PFA for pulmonary vein isolation: comparison to a reference RF data base
Authors: De Becker B , O'neill L , De Smet M , Tavernier R , Le Polain De Waroux J B , Knecht S , Duytschaever M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulse field ablation (PFA) is a promising ablation technique for pulmonary vein isolation (PVI) with appealing advantages over RF including speed, tissue selectivity and the promise of enhanced durability. We determined procedural efficiency, safety and durability of PFA for PVI and compared its performance to a dataset of optimized radiofrequency (RF) ablation.

Methods

180 consecutive patients with paroxysmal or persistent AF undergoing PFA-guided PVI (conventional basket and flower applications for each vein) were included and compared to 180 patients who underwent optimized high-power RF-guided PVI in experienced hands in the POWER-PLUS study. Endpoints were procedural efficiency, safety, and the incidence of 4 isolated veins as evaluated by comprehensive activation mapping at repeat procedure for recurrence.

Results

Median age was 66 years with 72% paroxysmal AF (clinical characteristics comparable to the RF group). PVI was obtained in all patients with a procedure time of 47min (vs 71min in RF, p < 0.0001) and fluoroscopy time of 14min (vs 11min in RF, p < 0.0001). One serious adverse event (TIA) occurred in a patient with thrombocytosis (1/180, 0.6% vs 0% in RF). No patient experienced pericarditis (vs 1 in RF). During a median follow-up in the PFA group of 4.8 [3.0; 6.4] months, 8 patients underwent repeat for recurrence which revealed a status of 4 isolated veins in a quarter of the patients (2/8, 25%). In the POWER-PLUS study, repeat ablation for recurrence revealed durable isolation of all veins in half of the patients (7/13, 54%, p between groups 0.2). By the time of the EHRA symposium, results will be presented for 6 months in both groups.

Conclusion

PFA fulfills the promise of offering a short and safe PVI procedure, even when compared to optimized RF in experienced hands. Our data, showing PV reconnection as the dominant cause for recurrence, however temper the expectation of 100% durability. It remains to be seen, how operator expertise affects efficiency, safety, and durability of PFA.
Impact of vein of Marshall ethanol infusion on left atrial function: an MRI study
Authors: Arano Llach J , Junca G , Teis A , Sarrias A , Bazan V , Saez De Buruaga E , Villuendas R , Bayes-Genis A , Delgado V , Bisbal F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Previous data suggested that left atrial (LA) function may be impaired by extensive atrial fibrillation (AF) ablation. Ethanol infusion of Vein of Marshall (EI-VOM) as an adjunctive therapy to pulmonary vein isolation is an emerging therapeutic strategy that has shown to improve efficacy in persistent AF ablation procedures and mitral isthmus line. The impact of EI-VOM scar formation on LA function has not been addressed.

Purpose

To analyse the effect of EI-VOM on LA function, evaluated by magnetic resonance imaging (MRI) strain parameters.

Methods

Twelve patients referred for de novo persistent AF or any repeat procedure were included. MRI was performed previous (baseline) and 3-month after AF ablation. MRI images were analyzed off-line with specialized post-processing software. LA volumes, LA strain parameters, including LA global longitudinal strain (GLS), LA reservoir (LASr), conduit (LAScd) and contractile (LASct) strain; LA ejection fraction (LAEF), LA passive emptying function (LAPEF) and LA active emptying function (LAAEF) were measured from SSFPs two-chamber cine sequences.

Results

Two patients were excluded due to absence of VOM and failed ethanolization. Ten patients (83%) underwent both MRI studies (64 [55-71]years; 80% men; de novo ablation of persistent AF (50%)). Six patients received additional mitral isthmus line and three posterior wall isolation. Mean baseline indexed LA volume was 62.7ml/m2 [47-73]. Baseline LA strain and EF parameters were: LA GLS 17.16±15.3, LASr 17.80±14.9%, LAScd -5.96±3.7%, LASct -10.35±9.5%; LAPEF 5.89±9.8, LAAEF 23.87±17.0 and LAEF 27.6±18.3%. At 3-months follow-up, no AF recurrences were detected. No differences were found regarding LA volume (57.6ml/m2 [42-64], p=0.671), strain parameters (LA GLS Δ0.62, p=0.903; LASr Δ0.02, p=0.991; LAScd Δ-0.84, p=0.563; LASct Δ0.54, p= 0.874) and LAEF parameters (LAPEF Δ4.82, p=0.592; LAAEF Δ3.03, p=0.903; and LAEF Δ7.0, p=0.213).

Conclusions

EI-VOM appears as a safe adjunctive strategy in AF ablation in terms of LA function. The present study did not show impairment in the main MRI strain parameters.
Sex differences in the efficacy of atrial fibrillation ablation according to the age: insights from a large-scale multicenter registry
Authors: Tanaka N , Inoue K , Kobori A , Kaitani K , Morimoto T , Kurotobi T , Morishima I , Yamaji H , Matsui Y , Kusano K , Okada M , Tanaka K , Kimura T , Shizuta S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

We previously showed that females were associated with a higher risk of arrhythmia recurrence after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). Whether age influences sex differences in terms of recurrence after CA of AF still remains unknown.

Objective

We sought to investigate the sex differences in the efficacy of RFCA of AF according to an advanced age.

Methods

We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry), enrolling 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; females, 27.3%; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results

The entire cohort was divided into either an age≥75 (n=790; females, 40.3%) and age < 75 years (n=4220; females, 24.9%). In the age≥75 group, the 3-year cumulative incidence of AF recurrences was identical between the sexes both after a single procedure (female vs. male, 38.1% vs. 40.7%, Log-rank P=0.39) and multiple procedures (22.3% vs. 21.6%, Log-rank P=0.96). On the other hand, in the age <75 group, females more frequently experienced AF recurrence than males both after a single procedure (female vs. male, 44.9% vs. 38.8%, Log-rank P=0.0003) and multiple procedures (24.7% vs. 19.3%, Log-rank P <0.0001).

Conclusion

While the incidence of an arrhythmia recurrence after radiofrequency catheter ablation of AF was similar between the sexes in patients with an age≥75, females had a higher incidence of recurrence than males in patients with an age <75.
Local impedance tissue characterization to implement pulmonary veins isolation success in AF patients
Authors: Anselmino M , Lepillier A , De Sanctis V , Mazza A , Zakine C , Champ-Rigot L , Santagostino M , Garnier F , Bonacchi G , Di Donna P , Pandozi C , Battaglia A , Malacrida M , Cosaro G , Solimene F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Novel radiofrequency (RF) ablation technology permits local impedance (LI) assessment, enabling increased knowledge of the underlying tissue’s properties. In addition, LI can provide details on catheter tip contact and extent/effectiveness of radiofrequency (RF) delivery. To date, the extent to which left atrial (LA) tissue characterization by LI can guide RF ablation has not yet been explored.

Purpose

We aimed to assess LI capabilities of predicting RF ablation success in consecutive AF cases with different underlying cardiac tissue characteristics.

Methods

Two-hundred twelve consecutive patients undergoing de novo AF ablation at 16 European centers were included in the CHARISMA registry. A novel ablation catheter (Stablepoint) with dedicated algorithm (DirectSense) was used to measure LI at the distal electrode. Each ablation point was characterized in terms of RF delivery time, baseline LI and LI drop during ablation according to different atrial substrates: normal-voltage (NV, >0.5mV), intermediate-voltage (IV, 0.1-0.5mV) and low-voltage tissue (LV, <0.1mV). First pass isolation (FPI) was defined as successful PVI at or before completion of the first encircling lesion set regardless of visual gaps. Ablation endpoint was pulmonary vein isolation (PVI) as assessed by entrance and exit block. Data are reported as mean±SD.

Results

Atrial substrate was analyzed at 11405 (82%) sites with complete high-quality data. Ablation spots were more frequently deployed in NV areas (n=6714, 58.9%) than in areas of IV (n=4065, 35.6%) or LV (n=625, 5.5%). Both baseline LI (163.8±19Ω) and LI drop (23.0±9Ω) were higher in NV areas than in IV areas (baseline LI: 159.4±18Ω, p<0.0001; LI drop: 20.5±9Ω, p<0.0001) and LV areas (baseline LI: 157.8±18Ω, p<0.0001; LI drop: 19.5±9Ω, p<0.0001). RF delivery time was shorter in the NV (9±5s) than both in IV and LV areas (10±4s, p<0.0001 for IV; 10±4s, p<0.0001 for LV, respectively). The LI drop that best predicted successful ablation spots was >20Ω for NV areas (Sensitivity=62.5%, Specificity=91.5%, PPV=99.6%, Area under the receiver-operating characteristic curve (AUC)=0.7896, p<0.0001) and >18Ω for IV and LV areas (Sensitivity=57.7%, Specificity=94.6%, PPV=99.8%, AUC=0.8008, p<0.0001). No complication occurred. The acute procedural success was 100%, with all PVs successfully isolated in all study patients.

Conclusion

LI drop during ablation significantly differs according to atrial substrates. These findings suggest that a tailored AF ablation strategy taking into account the underling LA substrate may be useful.
How different very late recurrence of atrial fibrillation 5 years after catheter ablation?
Authors: Choi S , Yu H T , Kim D , Park J W , Kim T H , Uhm J S , Joung B , Lee M H , Hwang C , Pak H N
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health and Welfare the Basic Science Research Program run by the National Research Foundation of Korea (NRF).

Background

Atrial fibrillation (AF) is a chronic progressive disease that recurs continuously even after successful AF catheter ablation (AFCA).

Objective

We explored the mechanism of this long-term recurrence by comparing the patient characteristics and redo-ablation findings.

Methods

Among 4,248 patients who underwent a de novo AFCA and protocol-based rhythm follow-up at single centers, we enrolled 1,417 patients (71.7% male, age 60.0 [52.0–67.0] years, 57.9% paroxysmal AF) who experienced clinical recurrences (CRs) of the disease, and divided them according to the period of recurrence: within one year (n=645), 1–2 years (n=339), 2–5 years (n=308), and after 5-years (CR>5yr, n=125). We also compared the redo-mapping and ablation outcomes in 198 patients.

Results

In patients with a CR>5yr, the proportion of paroxysmal AF was higher (p=0.031); however, the left atrial (LA) volume (computed tomography, p=0.003), LA voltage (p=0.003), frequency of early recurrence (p<0.001), and use of post-procedure anti-arrhythmic drugs (p<0.001) were lower. A CR>5yr was independently associated with the low LA volume (odds ratio [OR] 0.99 [0.99–1.00], p=0.019), low LA voltage (OR 0.62 [0.41–0.95], p=0.030), and lower early recurrence (OR 0.39 [0.23–0.64], p<0.001). Extra-pulmonary vein (PV) triggers (P for trend 0.003) during repeat procedures were significantly greater in patients with a CR>5yr, despite no difference in the de novo protocol. The rhythm outcome of repeat ablation procedures did not differ with the timing of the CR (log-rank p=0.330).

Conclusions

Patients with a later CR showed a smaller LA volume, lower LA voltage, and higher extra-PV triggers during the repeat procedure, suggesting progression of AF.
One-year outcomes in patients undergoing very high-power short-duration temperature-controlled ablation for atrial fibrillation
Authors: Strisciuglio T , Solimene F , Schillaci V , Arestia A , Shopova G , Salito A , Bottaro G , Marano G , Coltorti F , Poggi S , Iuliano A , Agresta A , Stabile G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The very high-power short-duration (vHPSD) temperature-controlled ablation (vHPSD) improves the efficiency of pulmonary vein isolation (PVI) procedures.

Aims

We evaluated the procedural and 12-months outcomes in atrial fibrillation (AF) patients undergoing PVI by means of vHPSD ablation. In patients with AF or atrial tachy-arrythmia (AT) recurrence undergoing a redo procedure the durability of the PVI was investigated.

Methods

Consecutive paroxysmal/persistent AF patients undergoing PVI with the vHPSD ablation strategy (90 W, for 4 s) were enrolled. The rate of PVI, first pass isolation, acute reconnection, and procedural complications were evaluated. Follow-up examinations and EKG were scheduled at 1,6, and 12 months. In case of AF/AT recurrence, patients underwent a redo procedure.

Results

Overall, 163 AF patients (29 persistent and 134 paroxysmal) were enrolled. The PVI was reached in 100% of patients (88% at first pass). The rate of acute reconnection was 2%. The radiofrequency, fluoroscopy and procedural times were respectively 5,5±1 min, 9±1 min and 75±20 min. No death, tamponade nor steam pops occurred, however 5 patients had vascular complications. The 12-months freedom from AF/AT recurrence was 84% in paroxysmal patients and 71% in persistent. Overall, 9 patients underwent a redo procedure, and in 4 all veins were still isolated, whereas in 5 pulmonary vein reconnections were found. The PVI durability was 83%. No overt complications were observed in the follow-up.

Conclusions

The vHPSD ablation represents an effective and safe ablation strategy to achieve PVI. The 12-months follow-up showed high freedom from AF/AT recurrence and a good safety profile.