Pulsed-field ablation combined with ultrahigh-density mapping in patients undergoing catheter ablation for atrial fibrillation: Practical and electrophysiological considerations.
atrial fibrillation
left posterior wall isolation
pulmonary vein isolation
pulsed-field ablation
ultrahigh-density mapping
Journal
Journal of cardiovascular electrophysiology
ISSN: 1540-8167
Titre abrégé: J Cardiovasc Electrophysiol
Pays: United States
ID NLM: 9010756
Informations de publication
Date de publication:
03 2022
03 2022
Historique:
revised:
14
10
2021
received:
25
08
2021
accepted:
08
11
2021
pubmed:
4
1
2022
medline:
17
3
2022
entrez:
3
1
2022
Statut:
ppublish
Résumé
Pulsed-field ablation (PFA) yields a novel ablation technology for atrial fibrillation (AF). PFA lesions promise to be highly durable, however clinical data on lesion characteristics are still limited. This study sought to investigate PFA lesion creation with ultrahigh-density (UHDx) mapping. Consecutive AF patients underwent PFA-based pulmonary vein isolation (PVI) using a multispline catheter (Farwave, Farapulse Inc.). Additional ablation, including left atrial posterior wall isolation (LAPWI) and mitral isthmus ablation (MI) were performed in a subset of persistent AF patients. The extent of PFA-lesions and decrease of LA-voltage were assessed with pre- and post PFA UHDx-mapping (Orion™ catheter and Rhythmia™ 3D-mapping system, Boston Scientific). In 20 patients, acute PVI was achieved in 80/80 PVs, LAPW isolation in 9/9 patients, MI ablation in 2/2 (procedure time: 123 ± 21.6 min, fluoroscopy time: 19.2 ± 5.5 min). UHDx-mapping subsequent to PVI revealed early PV-reconnection in five case (5/80, 6.25%). Gaps were located at the anterior-superior PV ostia and were successfully targeted with additional PFA. Repeat UHDx mapping after PFA revealed a significant decrease of voltage along the PV ostia (1.67 ± 1.36 mV vs. 0.053 ± 0.038 mV, p < .0001) with almost no complex electrogram-fractionation at the lesion border zones. PFA-catheter visualization within the mapping system was feasible in 17/19 (84.9%) patients and adequate in 92.9% of ablation sites. For the first time illustrated by UHDx mapping, PFA creates wide antral circumferential lesions and homogenous LAPW isolation with depression of tissue voltage to a minimum. Although with a low incidence, early PV reconnection can still occur also in the setting of PFA.
Sections du résumé
BACKGROUND
Pulsed-field ablation (PFA) yields a novel ablation technology for atrial fibrillation (AF). PFA lesions promise to be highly durable, however clinical data on lesion characteristics are still limited.
OBJECTIVE
This study sought to investigate PFA lesion creation with ultrahigh-density (UHDx) mapping.
METHODS
Consecutive AF patients underwent PFA-based pulmonary vein isolation (PVI) using a multispline catheter (Farwave, Farapulse Inc.). Additional ablation, including left atrial posterior wall isolation (LAPWI) and mitral isthmus ablation (MI) were performed in a subset of persistent AF patients. The extent of PFA-lesions and decrease of LA-voltage were assessed with pre- and post PFA UHDx-mapping (Orion™ catheter and Rhythmia™ 3D-mapping system, Boston Scientific).
RESULTS
In 20 patients, acute PVI was achieved in 80/80 PVs, LAPW isolation in 9/9 patients, MI ablation in 2/2 (procedure time: 123 ± 21.6 min, fluoroscopy time: 19.2 ± 5.5 min). UHDx-mapping subsequent to PVI revealed early PV-reconnection in five case (5/80, 6.25%). Gaps were located at the anterior-superior PV ostia and were successfully targeted with additional PFA. Repeat UHDx mapping after PFA revealed a significant decrease of voltage along the PV ostia (1.67 ± 1.36 mV vs. 0.053 ± 0.038 mV, p < .0001) with almost no complex electrogram-fractionation at the lesion border zones. PFA-catheter visualization within the mapping system was feasible in 17/19 (84.9%) patients and adequate in 92.9% of ablation sites.
CONCLUSION
For the first time illustrated by UHDx mapping, PFA creates wide antral circumferential lesions and homogenous LAPW isolation with depression of tissue voltage to a minimum. Although with a low incidence, early PV reconnection can still occur also in the setting of PFA.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
345-356Commentaires et corrections
Type : CommentIn
Informations de copyright
© 2022 Wiley Periodicals LLC.
Références
Reddy VY, Neuzil P, Koruth JS, et al. Pulsed field ablation for pulmonary vein isolation in atrial fibrillation. J Am Coll Cardiol. 2019;74(3):315-326.
Reddy VY, Anic A, Koruth J, et al. Pulsed field ablation in patients with persistent atrial fibrillation. J Am Coll Cardiol. 2020;76(9):1068-1080.
Kawamura I, Neuzil P, Shivamurthy P, et al. Does pulsed field ablation regress over time? A quantitative temporal analysis of pulmonary vein isolation. Heart Rhythm. Published online February 27, 2021. doi:10.1016/j.hrthm.2021.02.020
Reddy VY, Dukkipati SR, Neuzil P, et al. Pulsed field ablation of paroxysmal atrial fibrillation. JACC Clin Electrophysiol. 2021;7(5):614-627.
Gunawardene MA, Eickholt C, Akbulak RÖ, et al. Ultra-high-density mapping of conduction gaps and atrial tachycardias: Distinctive patterns following pulmonary vein isolation with cryoballoon or contact-force-guided radiofrequency current. J Cardiovasc Electrophysiol. 2020;31(5):1051-1061.
Alken FA, Klatt N, Muenkler P, et al. Advanced mapping strategies for ablation therapy in adults with congenital heart disease. Cardiovasc Diagn Ther. 2019;9(Suppl 2):247-S263.
Gunawardene MA, Schaeffer BN, Jularic M, et al. Coronary spasm during pulsed field ablation of the mitral isthmus line. JACC Clin Electrophysiol. Published online September 23, 2021.
García-Bolao I, Ballesteros G, Ramos P, et al. Identification of pulmonary vein reconnection gaps with high-density mapping in redo atrial fibrillation ablation procedures. EP Eur. 2017;0:1-8.
Anter E, Tschabrunn CM, Josephson ME. High-resolution mapping of scar-related atrial arrhythmias using smaller electrodes with closer interelectrode spacing. Circ Arrhythm Electrophysiol. 2015;8(3):537-545.
Kiuchi K, Kircher S, Watanabe N, et al. Quantitative analysis of isolation area and rhythm outcome in patients with paroxysmal atrial fibrillation after circumferential pulmonary vein antrum isolation using the pace-and-ablate technique. Circ Arrhythm Electrophysiol. 2012;5(4):667-675.
Kawamura I, Neuzil P, Shivamurthy P, et al. How does the level of pulmonary venous isolation compare between pulsed field ablation and thermal energy ablation (radiofrequency, cryo, or laser)? Europace. 2021;0:1-10.
Koruth J, Kuroki K, Iwasawa J, et al. Preclinical evaluation of pulsed field ablation. Circ Arrhythm Electrophysiol. 2019;12:e007781.
Sun X, Niu G, Lin J, Suo N. The incidence and location of epicardial connections in the era of contact force guided ablation for pulmonary vein isolation. J Cardiovasc Electrophysiol. 2021;32(9):2381-2390.
Ouyang F, Antz M, Ernst S, et al. Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins: lessons from double lasso technique. Circulation. 2005;111:127-135.
De Pooter J, Strisciuglio T, El Haddad M, et al. Pulmonary vein reconnection no longer occurs in the majority of patients after a single pulmonary vein isolation procedure. JACC Clin Electrophysiol. 2019;5(3):295-305.
Reddy VY, Sediva L, Petru J, et al. Durability of pulmonary vein isolation with cryoballoon ablation: results from the Sustained PV Isolation with Arctic Front Advance (SUPIR) Study. J Cardiovasc Electrophysiol. 2015;26(5):493-500.
Ciconte G, Velagić V, Mugnai G, et al. Electrophysiological findings following pulmonary vein isolation using radiofrequency catheter guided by contact-force and second-generation cryoballoon: Lessons from repeat ablation procedures. Europace. 2015;18(1):71-77.
Ruiz-Granell R, Ballesteros G, Andreu D, et al. Differences in scar lesion formation between radiofrequency and cryoballoon in atrial fibrillation ablation: a comparison study using ultra-high-density mapping. Europace. 2019;21(2):250-258.
Hindricks G, Potpara T, Serbia C, et al. ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the EuropeanAssociation of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020;2020(0):1-126.
Winkle RA. High - power short - duration ablation: turn up the heat to cool down the esophagus. J Cardiovasc Electrophysiol. 2019;30:1884-1885.
Chen S, Schmidt B, Seeger A, et al. Catheter ablation of atrial fibrillation using ablation index-guided high power (50 W) for pulmonary vein isolation with or without esophageal temperature probe (the AI-HP ESO II). Heart Rhythm. 2020; 17(11):1833-1840.
Chen S, Chun KRJ, Tohoku S, et al. Esophageal endoscopy after catheter ablation of atrial fibrillation using Ablation-Index Guided High-Power: Frankfurt AI-HP ESO-I. JACC Clin Electrophysiol. 2020;6(10):1253-1261.
Winkle RA, Mohanty S, Patrawala RA, et al. Low complication rates using high power (45-50 W) for short duration for atrial fibrillation ablations. Heart Rhythm. 2019;16(2):165-169. doi:10.1016/j.hrthm.2018.11.031
Koruth JS, Kuroki K, Kawamura I, et al. Pulsed field ablation versus radiofrequency ablation. Circ: Arrythym Electrophysiol. 2020;13(3):e008303.
Cochet H, Nakatani Y, Sridi-cheniti S, et al. Pulsed field ablation selectively spares the oesophagus during pulmonary vein isolation for atrial fibrillation. Europace. 2021;0:1-9.
Kotnik T, Rems L, Tarek M, Miklavčič D. Membrane electroporation and electropermeabilization: mechanisms and models. Annu Rev Biophys. 2019;48:63-91.