Ablation index-guided cavotricuspid isthmus ablation with contiguous lesions using fluoroscopy integrated 3D mapping in atrial flutter

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Contact Force-Guided versus Contact Force-Blinded Cavo-Tricuspid Isthmus Ablation for Atrial Flutter: A Systematic Review and Meta-Analysis

Contact force (CF) is a novel approach developed to increase the safety and efficacy of catheter ablation. However, the value of CF-sensing technology for atrial flutter (AFL) cavo-tricuspid isthmus ablation (CTIA) is inconclusive. To generate a comprehensive assessment of optimal extant data on CF for AFL, we synthesized randomized controlled trials (RCTs) and observational studies from Web of Science, SCOPUS, EMBASE, PubMed, and Cochrane until 29 November 2022, using the odds ratio (OR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with a corresponding 95% confidence interval (CI). Two RCTs and three observational studies with a total of 376 patients were included in our analysis. CF-guided ablation was associated with (A) a higher rate of AFL recurrence (OR: 2.26 with 95% CI [1.05, 4.87]) and total CF (MD: 2.71 with 95% CI [1.28, 4.13]); (B) no effect on total procedure duration (MD: -2.88 with 95% CI [-7.48, 1.72]), fluoroscopy duration (MD: -0.96 with 95% CI [-2.24, 0.31]), and bidirectional isthmus block (BDIB) (OR: 1.50 with 95% CI [0.72, 3.11]); and (C) decreased radiofrequency (RF) duration (MD: -1.40 with 95% CI [-2.39, -0.41]). We conclude that although CF-guided CTIA was associated with increased AFL recurrence and total CF and reduced RF duration, it did not affect total procedure duration, fluoroscopy duration, or BDIB. Thus, CF-guided CTIA may not be the optimal intervention for AFL. These findings indicate the need for (A) providers to balance the benefits and risks of CF when utilizing precision medicine to develop treatment plans for individuals with AFL and (B) clinical trials investigating CF-guided catheter ablation for AFL to provide definitive evidence of optimal CF-sensing technology.

Impact of tag index and local electrogram for successful first-pass cavotricuspid isthmus ablation

Background

The optimal ablation index (AI) value for cavotricuspid isthmus (CTI) ablation is unknow.

Objective

This study investigated the optimal AI value and whether preassessment of local electrogram voltage of CTI could predict first-pass success of ablation.

Methods

Voltage maps of CTI were created before ablation. In the preliminary group, the procedure was performed in 50 patients targeting an AI ≥450 on the anterior side (two-thirds segment of CTI) and AI ≥400 on the posterior side (one-third segment of CTI). The modified group also included 50 patients, but the target AI for the anterior side was modified to ≥500.

Results

In the modified group, the first-pass rate of success was higher (88% vs 62%; P < .01) than in the preliminary group, and there were no differences in the average bipolar and unipolar voltages at the CTI line. Multivariate logistic regression analysis revealed that ablation with an AI ≥500 on the anterior side was the only independent predictor (odds ratio 4.17; 95% confidence interval 1.44-12.05; P < .01). The bipolar and unipolar voltages were higher at sites without conduction block than at sites with conduction block (both P < .01). The cutoff values for predicting conduction gap were ≥1.94 mV and ≥2.33 mV with areas under the curve of 0.655 and 0.679, respectively.

Conclusions

CTI ablation with a target AI >500 on the anterior side was shown to be more effective than an AI >450, and local voltage at a conduction gap was higher than without a conduction gap.

Lesion size index-guided cavotricuspid isthmus linear ablation

BACKGROUND

The lesion size index (LSI) predicts radiofrequency (RF) ablation lesion size and is an established parameter for pulmonary vein isolation. However, the effectiveness and safety of LSI for cavotricuspid isthmus (CTI) linear ablation remain unclear.

METHODS

This single-center retrospective study included 50 of patients (67 ± 10 years, 68% male) who underwent de novo CTI linear ablation between July 2020 and December 2020. The LSI target was set at 5.0 and 4.0 for the anterior ^2/3 and posterior ^1/3 segments, respectively. Acute procedural parameters of ablation were evaluated.

RESULTS

Acute bidirectional CTI block was achieved in all patients with an RF application time of 4.0 min (3.1-5.0 min), RF application number of 15 ± 7, and length of CTI of 36.9 ± 9.3 mm. First-pass bidirectional conduction block of the CTI was achieved in 39/50 (78%) patients. No major complications were observed. The contact force (CF) per application was significantly lower in the gap tag group than in the non-gap tag group (7 g [7-8 g] vs. 10 g [7-12 g], P = 0.0284).

CONCLUSIONS

LSI-guided CTI linear ablation is an effective and safe treatment approach. CF affects gap formation, even when the target LSI is the same.

Cavotricuspid isthmus ablation for atrial flutter guided by contact force related parameters: A systematic review and meta-analysis

Background

Contact force (CF) and related parameters have been evaluated as an effective guide mark for pulmonary vein isolation, yet not for linear ablation of the cavotricuspid isthmus (CTI) dependent atrial flutter (AFL). We thus studied the efficacy and safety of CF related parameter-guided ablation for CTI-AFL.

Methods

Systematic search was performed on databases involving PubMed, EMbase, Cochrane Library and Web of Science (through June 2022). Original articles comparing CF related parameter-guided ablation and conventional parameter-guided ablation for CTI-AFL were included. One-by-one elimination, subgroup analysis and meta-regression were used for heterogeneity test between studies.

Results

Ten studies reporting on 761 patients were identified after screening with inclusion and exclusion criteria. Radiofrequency (RF) duration was significantly shorter in CF related parameter-guided group (p = 0.01), while procedural time (p = 0.13) and fluoroscopy time (p = 0.07) were no significant difference between two groups. CF related parameter-guided group had less RF lesions (p = 0.0003) and greater CF of catheter-tissue (p = 0.0002). Touch-up needed after first ablation line was less in CF related parameter-guided group (p = 0.004). In addition, there were no statistical significance between two groups on acute conduction recovery rates (p = 0.25), recurrence rates (p = 0.92), and complication rates (p = 0.80). Meta-regression analysis revealed no specific covariate as an influencing factor for above results (p > 0.10).

Conclusion

CF related parameters guidance improves the efficiency of CTI ablation, with the better catheter-tissue contact, the lower RF duration and the comparable safety as compared with conventional method, but does not improve the acute success rate and long-term outcome.

Typical Atrial Flutter Mapping and Ablation

Isthmus-dependent flutter represents a defeated arrhythmia. Possibly one of the most outstanding successes in terms of understanding the mechanism behind it has led to an effective, relatively simple, and safe targeted therapy. Technology, fulfilling a number of the clinical electrophysiologist's dreams, has linked diagnosis and therapy in computerized systems showing real-time imagines of the right atrium, the arrhythmia circuit, and the ablation target. The entire history of clinical electrophysiology is contained in its path and atrial flutter needs to be regarded with immense respect for a large amount of knowledge that its study always engenders."