bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

Abstract

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&lt;0.01), independent of established predictors as persistent AF type (HR=2.075; 95%CI 1.584-2.738; p&lt;0.01), left atrial diameter (HR=1.050; 95%CI 1.028-1.072; p&lt;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&lt;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

Abstract

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&lt;0,0001). Fluoroscopy time was 17±7 in the X-ray group vs. 20±6 in the 3D group, respectively (p&lt;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

Abstract

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

Abstract

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&lt;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

Abstract

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

Abstract

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 &gt;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&lt;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

Abstract

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

Abstract

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&lt;0.001), but not in patients treated with RF-PVI or HPSD-PVI (both p&gt;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&gt;0.05). The ΔNSE/ΔhsTnT ratio (p&lt;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

Abstract

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.