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De Smet MAJ, Wielandts JY, El Haddad M, De Becker B, François C, Tavernier R, le Polain de Waroux JB, Duytschaever M, Knecht S. Risk assessment of esophageal ulceration following left atrial radiofrequency linear ablation. J Cardiovasc Electrophysiol 2024. [PMID: 38818534 DOI: 10.1111/jce.16330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/10/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Esophageal safety following radiofrequency (RF) left atrial (LA) linear ablation has not been established. To determine the esophageal safety profile of LA linear RF lesions, we performed systematic esophagogastroduodenoscopy in all patients with intraesophageal temperature rise (ITR) ≥ 38.5°C. METHODS AND RESULTS Between December 2021 and July 2023, a total of 200 consecutive patients with atrial tachyarrhythmia (ATA) underwent linear ablation with posterior dome (roof or floor) or posterior mitral isthmus line transection. Patients with ITR ≥ 38.5°C were scheduled for esophageal endoscopy ~3 weeks after ablation. Patient and ATA characteristics, procedural parameters, endoscopy findings and ablation lesion data were collected and analyzed. One hundred thirty-three out of 200 (67%) patients showed ITR ≥ 38.5°C during LA linear ablation. ITR (with maximal temperature of 45.7°C) was more frequently observed during floor line ablation (82% of cases). ITR was less observed during roof line ablation (34%) and posterior mitral isthmus ablation (4%). Endoscopy, performed in 115 patients after 24 ± 10 days, showed esophageal ulceration in four patients (two patients Kansas City classification [KCC] 2a and two patients KCC 2b). No patient showed esophageal perforation or fistula. CONCLUSION Temperature rise during LA linear ablation is frequent and ulceration risk exists, particularly when floor line is performed. Safety measures are needed to avoid potential severe complications like esophageal perforation and fistula.
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Affiliation(s)
| | | | - Milad El Haddad
- Department of Cardiology, AZ Sint-Jan Hospital Bruges, Bruges, Belgium
| | | | - Clara François
- Department of Cardiology, AZ Sint-Jan Hospital Bruges, Bruges, Belgium
| | - Rene Tavernier
- Department of Cardiology, AZ Sint-Jan Hospital Bruges, Bruges, Belgium
| | | | | | - Sébastien Knecht
- Department of Cardiology, AZ Sint-Jan Hospital Bruges, Bruges, Belgium
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Baumgartner A, Martinek M, Derndorfer M, Kollias G, Ammann P, Pürerfellner H, Seidl S. Pulmonary Vein Isolation for Atrial Fibrillation: Comparison of a Very High-Power Very Short-Duration (vHPvSD) Ablation Protocol versus a Hybrid Ablation Approach-Procedural and Mid-Term Outcome Data. J Clin Med 2024; 13:2879. [PMID: 38792421 PMCID: PMC11121963 DOI: 10.3390/jcm13102879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Pulmonary vein isolation (PVI) using radiofrequency ablation (RFA) is a standard-of-care treatment in the rhythm control strategy of symptomatic atrial fibrillation (AF). Ablation protocols, varying in the power and duration of energy delivery, have changed rapidly in recent years. Very high-power very short-duration ablation (vHPvSD) is expected to shorten procedural times compared to conventional ablation approaches. However, the existing data suggest that this might come at the cost of lower first-pass isolation rates, a predictor of poor ablation long-term outcomes. This study aims to compare a vHPvSD protocol to a hybrid strategy, in which the power and duration of the energy transfer are adapted depending on the anatomical location. Methods: We retrospectively analyzed procedural and outcome data from 93 patients (55 vHPvSD vs. 38 hybrid) scheduled for de novo pulmonary vein isolation. A vHPvSD ablation protocol (90 Watt (W), 4 s) was compared to a hybrid protocol using vHPvSD on the posterior wall and 50 W HPSD (high-power short-duration) ablation guided by the Ablation Index along the remaining spots. Results: Ablation times were significantly shorter in the vHPvSD cohort (5.4 min. vs. 14.2 min, p < 0.001), thus resulting in a significant reduction in the overall procedural duration (91 min vs. 106 min, p = 0.003). The non-significant slightly higher first-pass isolation rates in the vHPvSD cohort (85% vs. 76%, p = 0.262) did not affect freedom from AF 6 months after the procedure (83% vs. 87%, p = 0.622). Conclusions: vHPvSD helps in shortening the PVI procedural duration, thus neither affecting first-pass isolation rates nor freedom from atrial tachyarrhythmia recurrence at 6 months after the index procedure.
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Affiliation(s)
| | - Martin Martinek
- Department of Cardiology, Ordensklinikum Linz GmbH, 4020 Linz, Austria; (M.M.); (M.D.); (G.K.); (H.P.)
| | - Michael Derndorfer
- Department of Cardiology, Ordensklinikum Linz GmbH, 4020 Linz, Austria; (M.M.); (M.D.); (G.K.); (H.P.)
| | - Georgios Kollias
- Department of Cardiology, Ordensklinikum Linz GmbH, 4020 Linz, Austria; (M.M.); (M.D.); (G.K.); (H.P.)
| | - Peter Ammann
- Department of Cardiology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland;
| | - Helmut Pürerfellner
- Department of Cardiology, Ordensklinikum Linz GmbH, 4020 Linz, Austria; (M.M.); (M.D.); (G.K.); (H.P.)
| | - Sebastian Seidl
- Department of Cardiology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland;
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De Potter TJR, De Becker B, Duytschaever M. Durable pulmonary vein isolation with optimized high-power and very high-power short-duration temperature-controlled ablation: A step-by-step guide. J Cardiovasc Electrophysiol 2024; 35:886-894. [PMID: 38433316 DOI: 10.1111/jce.16217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/24/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Through systematic scientific rigor, the CLOSE guided workflow was developed and has been shown to improve pulmonary vein isolation durability. However, this technique was developed at a time when using power-controlled ablation catheters with conventional power ranges was the norm. There has been increased adoption of a high-power and very high-power short-duration ablation practice propelled by the availability of the temperature-controlled radiofrequency QDOT MICRO catheter. METHODS There are fundamental differences in biophysics between very high-powered temperature guided ablation and conventional ablation strategy that may impact patient outcomes. The catheter's design and ablation modes offer flexibility in technique while accommodating the individual operator's clinical discretion and preference to deliver a durable, transmural, and contiguous lesion set. RESULTS Here, we provide recommendations for 3 different workflows using the QDOT MICRO catheter in a step-by-step manner for pulmonary vein isolation based on our cumulative experience as early adopters of the technology and the data available in the scientific literature. CONCLUSIONS With standardization, temperature-controlled ablation with the QDOT MICRO catheter provides operators the flexibility of implementing different ablation strategies to ensure durable contiguous pulmonary vein isolation depending on patient characteristics.
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Affiliation(s)
- Tom J R De Potter
- Cardiovascular Center, Division of Cardiology, Onze Lieve Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Benjamin De Becker
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove, Brugge, Belgium
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 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. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01771-5. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
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.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Calvert P, Koniari I, Mills MT, Ashrafi R, Snowdon R, Gupta D, Luther V. Lesion metrics and 12-month outcomes of very-high power short duration radiofrequency ablation (90W/4 s) under mild conscious sedation. J Cardiovasc Electrophysiol 2024. [PMID: 38571287 DOI: 10.1111/jce.16269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/04/2024] [Accepted: 03/21/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Pulmonary vein isolation (PVI) is often performed under general anaesthesia (GA) or deep sedation. Anaesthetic availability is limited in many centers, and deep sedation is prohibited in some countries without anaesthetic support. Very high-power short duration (vHPSD-90W/4 s) PVI using the Q-Dot catheter is generally well tolerated under mild conscious sedation (MCS) though an understanding of catheter stability and long-term effectiveness is lacking. We analyzed lesion metrics and 12-month freedom from atrial arrythmia with this approach. METHODS Our approach to radiofrequency (RF) PVI under MCS is standardized and includes a single catheter approach with a steerable sheath. We identified patients undergoing Q-Dot RF PVI between March 2021 and December 2022 in our center, comparing those undergoing vHPSD ablation under MCS (90W/MCS) against those undergoing 50 W ablation under GA (50 W/GA) up to 12 months of follow-up. Data were extracted from clinical records and the CARTO system. RESULTS Eighty-three patients met our inclusion criteria (51 90W/MCS; 32 50 W/GA). Despite shorter ablation times (353 vs. 886 s; p < .001), the 90 W/MCS group received more lesions (median 87 vs. 58, p < .001), resulting in similar procedure times (149.3 vs. 149.1 min; p = .981). PVI was achieved in all cases, and first pass isolation rates were similar (left wide antral circumferential ablation [WACA] 82.4% vs. 87.5%, p = .758; right WACA 74.5% vs. 78.1%, p = .796; 90 W/MCS vs. 50 W/GA respectively). Analysis of 6647 ablation lesions found similar mean impedance drops (10.0 ± 1.9 Ω vs. 10.0 ± 2.2 Ω; p = .989) and mean contact force (14.6 ± 2.0 g vs. 15.1 ± 1.6 g; p = .248). Only median 2.5% of lesions in the 90 W/MCS cohort failed to achieve ≥ 5 Ω drop. In the 90 W/MCS group, there were no procedural related complications, and 12-month freedom from atrial arrhythmia was observed in 78.4%. CONCLUSION vHPSD PVI is feasible under MCS, with encouraging acute and long-term procedural outcomes. This provides a compelling option for centers with limited anaesthetic support.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | | | | | | | | | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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Dai M, Barbhaiya C. One shot to challenge single-shot. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01787-x. [PMID: 38557947 DOI: 10.1007/s10840-024-01787-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Matthew Dai
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1St Avenue, New York, NY, 10016, USA
| | - Chirag Barbhaiya
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1St Avenue, New York, NY, 10016, USA.
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7
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Macle L, Nair GM, Skanes A, Aguilar M, Pantano A, Khaykin Y, Verma A. Safety and acute performance of atrial fibrillation ablation using a temperature-controlled, very high-power short-duration catheter and a new radiofrequency generator. J Interv Card Electrophysiol 2024; 67:453-455. [PMID: 37930503 PMCID: PMC11015997 DOI: 10.1007/s10840-023-01652-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/17/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Laurent Macle
- Montreal Heart Institute, Montreal, QC, Canada
- Université de Montréal, Montreal, QC, Canada
| | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Allan Skanes
- London Health Sciences Centre, London, ON, Canada
| | | | | | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada.
- McGill University Health Centre, Montreal, QC, Canada.
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Hirata M, Nagashima K, Watanabe R, Wakamatsu Y, Hirata S, Kurokawa S, Okumura Y. Where is the gap after a 90 W/4 s very-high-power short-duration ablation of atrial fibrillation?: Association with the left atrial-pulmonary vein voltage and wall thickness. J Arrhythm 2024; 40:256-266. [PMID: 38586851 PMCID: PMC10995583 DOI: 10.1002/joa3.13009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/19/2024] [Accepted: 01/31/2024] [Indexed: 04/09/2024] Open
Abstract
Background Although pulmonary vein isolation (PVI) for atrial fibrillation (AF) utilizing radiofrequency (RF) applications with a very high-power and short-duration (vHPSD) has shortened the procedure time, the determinants of pulmonary vein (PV) gaps in the first-pass PVI and acute PV reconnections are unclear. Methods An extensive encircling PVI was performed with the QDOT MICRO catheter with a vHPSD (90 W-4 s) in 30 patients with AF (19 men, 64 ± 10 years). The association of the PV gap sites (first-pass PVI failure, acute PV reconnections [spontaneous reconnections or dormant conduction provoked by adenosine triphosphate] or both) with the left atrial (LA) wall thickness and LA bipolar voltage on the PVI line and ablation-related parameters were assessed. Results PV gaps were observed in 29 (6%) of 480 segments (16 segments per patient) in 17 patients (56%). The PV gaps were associated with the LA wall thickness, bipolar voltage, and the number of RF points (LA wall thickness, 2.5 ± 0.5 vs. 1.9 ± 0.4 mm, p < .001; bipolar voltage, 2.59 ± 1.62 vs. 1.34 ± 1.14 mV, p < .001; RF points, 6 ± 2 vs. 4 ± 2, p = .008) but were not with the other ablation-related parameters. Receiver operating characteristic curves yielded that an LA wall thickness ≥2.3 mm and bipolar voltage ≥2.40 mV were determinants of PV gaps with an area under the curve of 0.82 and 0.73, respectively. Conclusions The LA voltage and wall thickness on the PV-encircling ablation line were highly associated with PV gaps using the 90 W/4 s-vHPSD ablation.
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Affiliation(s)
- Moyuru Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Koichi Nagashima
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Ryuta Watanabe
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Shu Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yasuo Okumura
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
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Falasconi G, Penela D, Soto-Iglesias D, Francia P, Saglietto A, Turturiello D, Viveros D, Bellido A, Alderete J, Zaraket F, Franco-Ocaña P, Huguet M, Cámara Ó, Vătășescu R, Ortiz-Pérez JT, Martí-Almor J, Berruezo A. Personalized pulmonary vein isolation with very high-power short-duration lesions guided by left atrial wall thickness: the QDOT-by-LAWT randomized trial. Europace 2024; 26:euae087. [PMID: 38652090 PMCID: PMC11036893 DOI: 10.1093/europace/euae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using very high-power short-duration (vHPSD) radiofrequency (RF) ablation proved to be safe and effective. However, vHPSD applications result in shallower lesions that might not be always transmural. Multidetector computed tomography-derived left atrial wall thickness (LAWT) maps could enable a thickness-guided switching from vHPSD to the standard-power ablation mode. The aim of this randomized trial was to compare the safety, the efficacy, and the efficiency of a LAWT-guided vHPSD PVI approach with those of the CLOSE protocol for PAF ablation (NCT04298177). METHODS AND RESULTS Consecutive patients referred for first-time PAF ablation were randomized on a 1:1 basis. In the QDOT-by-LAWT arm, for LAWT ≤2.5 mm, vHPSD ablation was performed; for points with LAWT > 2.5 mm, standard-power RF ablation titrating ablation index (AI) according to the local LAWT was performed. In the CLOSE arm, LAWT information was not available to the operator; ablation was performed according to the CLOSE study settings: AI ≥400 at the posterior wall and ≥550 at the anterior wall. A total of 162 patients were included. In the QDOT-by-LAWT group, a significant reduction in procedure time (40 vs. 70 min; P < 0.001) and RF time (6.6 vs. 25.7 min; P < 0.001) was observed. No difference was observed between the groups regarding complication rate (P = 0.99) and first-pass isolation (P = 0.99). At 12-month follow-up, no significant differences occurred in atrial arrhythmia-free survival between groups (P = 0.88). CONCLUSION LAWT-guided PVI combining vHPSD and standard-power ablation is not inferior to the CLOSE protocol in terms of 1-year atrial arrhythmia-free survival and demonstrated a reduction in procedural and RF times.
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Affiliation(s)
- Giulio Falasconi
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
- Arrhythmology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Diego Penela
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Arrhythmology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - David Soto-Iglesias
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Pietro Francia
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Division of Cardiology, Department of Clinical and Molecular Medicine, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Andrea Saglietto
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Dario Turturiello
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Open Heart Foundation, Barcelona, Spain
| | - Daniel Viveros
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
| | - Aldo Bellido
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Jose Alderete
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
- Open Heart Foundation, Barcelona, Spain
| | - Fatima Zaraket
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Paula Franco-Ocaña
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Marina Huguet
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | | | - Radu Vătășescu
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | | | - Julio Martí-Almor
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Antonio Berruezo
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 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. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
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 .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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11
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Amin AM, Ghaly R, Ibrahim AA, Ali MA, Almaadawy O, Elzahaby A, Abuelazm M, Abdelazeem B, Munir MB. Efficacy and safety of high-power short-duration ablation for atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01782-2. [PMID: 38460090 DOI: 10.1007/s10840-024-01782-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/01/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND High-power short-duration (HPSD) ablation has emerged as an alternative to conventional standard-power long-duration (SPLD) ablation. We aim to assess the efficacy and safety of HPSD versus SPLD for atrial fibrillation (AF) ablation. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL were performed through August 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). PROSPERO ID CRD42023471797. RESULTS We included six RCTs with a total of 694 patients. HPSD was significantly associated with a decreased total procedure time (MD: -22.88 with 95% CI [-36.13, -9.63], P = 0.0007), pulmonary vein isolation (PVI) time (MD: -19.73 with 95% CI [-23.93, -15.53], P < 0.00001), radiofrequency time (MD: -10.53 with 95% CI [-12.87, -8.19], P < 0.00001). However, there was no significant difference between HPSD and SPLD ablation with respect to the fluoroscopy time (MD: -0.69 with 95% CI [-2.00, 0.62], P = 0.30), the incidence of esophageal lesions (RR: 1.15 with 95% CI [0.43, 3.07], P = 0.77), and the incidence of first pass isolation (RR: 0.98 with 95% CI [0.88, 1.08], P = 0.65). CONCLUSION HPSD ablation was significantly associated with decreased total procedure time, PVI time, and radiofrequency time compared with SPLD ablation. On the contrary, SPLD ablation was significantly associated with low maximum temperature.
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Affiliation(s)
| | - Ramy Ghaly
- Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | | | | | - Amr Elzahaby
- Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
| | - Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, Department of Medicine, University of California Davis, Sacramento, CA, USA
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12
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Fink T, Sciacca V, Nischik F, Bergau L, Guckel D, El Hamriti M, Khalaph M, Braun M, Winnik S, Didenko M, Imnadze G, Sommer P, Sohns C. Atrial fibrillation ablation workflow optimization facilitated by high-power short-duration ablation and high-resolution mapping. Europace 2024; 26:euae067. [PMID: 38516791 DOI: 10.1093/europace/euae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/19/2024] [Indexed: 03/23/2024] Open
Abstract
AIMS Pulmonary vein isolation (PVI) for catheter ablation of atrial fibrillation (AF) is a time-demanding procedure. High-power short-duration (HPSD) ablation protocols and high-density mapping catheters have recently been introduced to clinical practice. We investigated the impact of high-density mapping and HPSD ablation protocols on procedural timing, efficacy, and safety by comparing different standardized set-ups. METHODS AND RESULTS Three electrophysiology (EP) laboratory set-ups were analysed: (i) circular catheter for mapping and HPSD ablation with 30/35 W guided by an ablation index (AI); (ii) pentaspline catheter for mapping an HPSD ablation with 50 W guided by an AI; and (iii) pentaspline catheter for mapping and HPSD ablation with 90 W over 4 s using a novel ablation catheter. All patients underwent PVI without additional left atrial ablation strategies. Procedural data and operating intervals in the EP laboratory were systematically analysed. Three hundred seven patients were analysed (30/35 W AI: n = 102, 50 W AI: n = 102, 90 W/4 s: n = 103). Skin-to-skin times [105.3 ± 22.7 (30/35 W AI) vs. 81.4 ± 21.3 (50 W AI) vs. 69.5 ± 12.2 (90 W/4 s) min, P ≤ 0.001] and total laboratory times (132.8 ± 42.1 vs. 107.4 ± 25.7 vs. 95.2 ± 14.0 min, P < 0.001) significantly differed among the study groups. Laboratory interval analysis revealed significant shortening of mapping and ablation times. Arrhythmia-free survival after 12 months was not different among the study groups (log-rank P = 0.96). CONCLUSION The integration of high-density mapping and HPSD protocols into an institutional AF ablation process resulted in reduced procedure times without compromising safety or efficacy.
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Affiliation(s)
- Thomas Fink
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Flemming Nischik
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Leonard Bergau
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Denise Guckel
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Mustapha El Hamriti
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Moneeb Khalaph
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Martin Braun
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Stephan Winnik
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Maxim Didenko
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Guram Imnadze
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Georgstraße 11, 32545 Bad Oeynhausen, Germany
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13
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De Becker B, El Haddad M, De Smet M, François C, Tavernier R, le Polain de Waroux JB, Knecht S, Duytschaever M. Procedural performance and outcome after pulsed field ablation for pulmonary vein isolation: comparison with a reference radiofrequency database. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae014. [PMID: 38487367 PMCID: PMC10939121 DOI: 10.1093/ehjopen/oeae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Abstract
Aims Pulsed field ablation (PFA) is a promising ablation technique for pulmonary vein isolation (PVI) with appealing advantages over radiofrequency (RF) including speed, tissue selectivity, and the promise of enhanced durability. In this study, we determine the procedural performance, efficacy, safety, and durability of PFA and compare its performance with a dataset of optimized RF ablation. Methods and results After propensity score matching, we compared 161 patients who received optimized RF-guided PVI in the PowerPlus study (CLOSE protocol) with 161 patients undergoing PFA-guided PVI for paroxysmal or persistent atrial fibrillation (AF; pentaspline basket catheter). The median age was 65 years with 78% paroxysmal AF in the PFA group (comparable characteristics in the RF group). Pulsed field ablation-guided PVI was obtained in all patients with a procedure time of 47 min (vs. 71 min in RF, P < 0.0001) and a fluoroscopy time of 15 min (vs. 11 min in RF, P < 0.0001). One serious adverse event [transient ischaemic attack] occurred in a patient with thrombocytosis (0.6 vs. 0% in RF). During the 6-month follow-up, 24 and 27 patients experienced a recurrence with 20 and 11 repeat procedures in the PFA and the RF groups, respectively (P = 0.6 and 0.09). High-density mapping revealed a status of 4 isolated veins in 7/20 patients in the PFA group and in 2/11 patients in the RF group (35 vs. 18%, P = 0.3). Conclusion Pulsed field ablation fulfils the promise of offering a short and safe PVI procedure, even when compared with optimized RF in experienced hands. Pulmonary vein reconnection is the dominant cause of recurrence and tempers the expectation of a high durability rate with PFA.
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Affiliation(s)
- Benjamin De Becker
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove 10, 8000 Bruges, Belgium
| | - Milad El Haddad
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove 10, 8000 Bruges, Belgium
| | - Maarten De Smet
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove 10, 8000 Bruges, Belgium
| | - Clara François
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove 10, 8000 Bruges, Belgium
| | - Rene Tavernier
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove 10, 8000 Bruges, Belgium
| | | | - Sébastien Knecht
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove 10, 8000 Bruges, Belgium
| | - Mattias Duytschaever
- Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove 10, 8000 Bruges, Belgium
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14
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Bertaglia E. How to improve the efficacy of point-by-point radiofrequency ablation. J Cardiovasc Electrophysiol 2024; 35:451-452. [PMID: 38369698 DOI: 10.1111/jce.16218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Emanuele Bertaglia
- Cardiology Unit-Ospedale di Camposampiero, AULSS 6 Euganea, Camposampiero, Padova, Italy
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15
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Liuba I, Santangeli P. High-power short-duration ablation of atrial fibrillation: learning to master the power. J Interv Card Electrophysiol 2024; 67:227-229. [PMID: 37897536 DOI: 10.1007/s10840-023-01666-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Ioan Liuba
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.
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16
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Heeger CH, Kuck KH, Tilz RR. Very high-power short-duration catheter ablation for treatment of cardiac arrhythmias: Insights from the FAST and FURIOUS study series. J Cardiovasc Electrophysiol 2024; 35:547-556. [PMID: 37855621 DOI: 10.1111/jce.16113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 09/27/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
The QDOT MICRO™ Catheter is a novel open-irrigated contact force-sensing radiofrequency ablation catheter. It offers very high-power short-duration (vHPSD) ablation with 90 W for 4 s to improve safety and efficacy of catheter ablation procedures. Although the QDOT MICRO™ Catheter was mainly designed for pulmonary vein isolation (PVI) its versatility to treat atrial fibrillation (AF) and other types of arrhythmias was recently evaluated by the FAST and FURIOUS study series and other studies and will be presented in this article. Available study and registry data as well as case reports concerning utilization of the QDOT MICRO™ Catheter for the treatment of cardiac arrhythmias including AF, focal and macroreentry atrial tachycardia, typical atrial flutter by cavotricuspid isthmus block, premature ventricular contractions, and accessory pathways were reviewed and summarized. In summary, the QDOT MICRO™ Catheter showed safety and efficacy for PVI and is able to treat also other types of arrhythmias as is was recently evaluated by case reports and the FAST and FURIOUS studies.
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Affiliation(s)
- Christian-H Heeger
- Department of Rhythmology, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Lubeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Karl-Heinz Kuck
- Department of Rhythmology, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Lubeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Roland R Tilz
- Department of Rhythmology, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Lubeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
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17
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Bortone AA, Ramirez FD, Combes S, Laborie G, Albenque JP, Sebag FA, Limite LR. Optimized workflow for pulmonary vein isolation using 90-W radiofrequency applications: a comparative study. J Interv Card Electrophysiol 2024; 67:353-361. [PMID: 37639157 DOI: 10.1007/s10840-023-01630-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Ninety-watt applications are more sensitive to catheter instability and produce lesions that are shallower and smaller in diameter than 50-W applications. These characteristics were considered for the development of a combined (90-50 W) pulmonary vein isolation (PVI) strategy which was prospectively compared to a 50 W-only ablation index (AI)-guided PVI strategy. METHODS One hundred fifty consecutive paroxysmal AF patients underwent PVI under general anesthesia using CARTO. In the first 75 patients, PVI was performed with a combined (90-50 W) strategy using the QDOT-MICRO catheter in a temperature-controlled mode. This strategy consisted of 90 W-4 s applications on the posterior LA wall (at sites of catheter stability and expectedly thin atrial tissue) with an interlesion distance (ILD) ≤ 4 mm and 50-W applications elsewhere (at sites of catheter instability or expectedly thick atrial tissue) with ILD < 6 mm. In the subsequent 75 patients, PVI was performed with a 50 W-only AI-guided strategy using the SmartTouch-SF catheter in a power-controlled mode. RESULTS Both groups of patients had similar clinical characteristics and LA dimensions (123.1 ± 24.9 ml vs 119 ± 26.8 ml, P = 0.33). Total procedural times (61 [56-70] vs 65 [60-75] min, P = 0.12), first-pass PVI (82.6 vs 80%, P = 0.81), acute PV reconnection (0 vs 6.6%, P = 0.05), and 1-year SR maintenance (93.3 vs 90.6%, P = 0.57) rates were also similar in both groups of patients. There were no complications in the combined (90-50 W) group while only 2 groin hematomas were reported in the 50 W group. CONCLUSIONS In paroxysmal AF patients, a combined (90-50 W) strategy for PVI did not improve safety, efficiency, or effectiveness compared to a 50 W-only AI-guided strategy.
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Affiliation(s)
| | - F Daniel Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Stéphane Combes
- Département de Rythmologie, Clinique Pasteur, Toulouse, France
| | - Guillaume Laborie
- Service de Cardiologie, Hôpital Privé Les Franciscaines, ELSAN, Nîmes, France
| | | | - Frédéric A Sebag
- Service de Cardiologie, Institut Mutualiste Montsouris, Paris, France
| | - Luca Rosario Limite
- Service de Cardiologie, Hôpital Privé Les Franciscaines, ELSAN, Nîmes, France
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18
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Szegedi N, Salló Z, Nagy VK, Osztheimer I, Hizoh I, Lakatos B, Boussoussou M, Orbán G, Boga M, Ferencz AB, Komlósi F, Tóth P, Perge P, Kovács A, Merkely B, Gellér L. Long-Term Durability of High- and Very High-Power Short-Duration PVI by Invasive Remapping: The HPSD Remap Study. Circ Arrhythm Electrophysiol 2024; 17:e012402. [PMID: 38284286 PMCID: PMC10876176 DOI: 10.1161/circep.123.012402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND High-power short-duration ablation has shown impressive efficacy and safety for pulmonary vein isolation (PVI); however, initial efficacy results with very high power short-duration ablation were discouraging. This study compared the long-term durability of PVI performed with a 90- versus 50-W power setting. METHODS Patients were randomized 1:1 to undergo PVI with the QDOT catheter using a power setting of 90 or 50 W. Three months after the index procedure, patients underwent a repeat electrophysiology study to identify pulmonary vein reconnections. Patients were followed for 12 months to detect AF recurrences. RESULTS We included 46 patients (mean age, 64 years; women, 48%). Procedure (76 versus 84 minutes; P =0.02), left atrial dwell (63 versus 71 minutes; P =0.01), and radiofrequency (303 versus 1040 seconds; P <0.0001) times were shorter with 90- versus 50-W procedures, while the number of radiofrequency applications was higher with 90 versus 50 W (77 versus 67; P =0.01). There was no difference in first-pass isolation (83% versus 82%; P =1.0) or acute reconnection (4% versus 14%; P =0.3) rates between 90 and 50 W. Forty patients underwent a repeat electrophysiology study. Durable PVI on a per PV basis was present in 72/78 (92%) versus 68/77 (88%) PVs in the 90- and 50-W energy setting groups, respectively; effect size: 72/78-68/77=0.040, lower 95% CI=-0.051 (noninferiority limit=-0.1, ie, noninferiority is met). No complications occurred. There was no difference in 12-month atrial fibrillation-free survival between the 90- and 50-W groups (P =0.2). CONCLUSIONS Similarly high rates of durable PVI and arrhythmia-free survival were achieved with 90 and 50 W. Procedure, left atrial dwell, and radiofrequency times were shorter with 90 W compared with 50 W. The sample size is too small to conclude the safety and long-term efficacy of the high and very high-power short-duration PVI; further studies are needed to address this topic. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05459831.
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Affiliation(s)
- Nándor Szegedi
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Salló
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Vivien Klaudia Nagy
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - István Osztheimer
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - István Hizoh
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Lakatos
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Melinda Boussoussou
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Gábor Orbán
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Márton Boga
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Arnold Béla Ferencz
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ferenc Komlósi
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Patrik Tóth
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Péter Perge
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Kovács
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - László Gellér
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Ahmad A, Karnik AA, Doshi R. A Year in Review: Atrial Fibrillation 2023. J Innov Card Rhythm Manag 2024; 15:5704-5708. [PMID: 38304091 PMCID: PMC10829408 DOI: 10.19102/icrm.2024.15017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Affiliation(s)
- Amier Ahmad
- Department of Clinical Cardiac Electrophysiology, Scottsdale, AZ, USA
| | - Ankur A. Karnik
- Department of Clinical Cardiac Electrophysiology, Scottsdale, AZ, USA
| | - Rahul Doshi
- Department of Clinical Cardiac Electrophysiology, Scottsdale, AZ, USA
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20
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Berte B, Pürerfellner H, Roten L, Rissotto S, Mahida S, Reichlin T, Kobza R. Combined complex electrophysiological interventions due to improved standardization and efficiency: proof of concept. Europace 2023; 26:euae014. [PMID: 38227808 PMCID: PMC10810277 DOI: 10.1093/europace/euae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/18/2024] Open
Affiliation(s)
- Benjamin Berte
- Heart Center, Hirslanden St Anna, Zentralstrasse 1, 6003 Lucerne, Switzerland
| | | | - Laurent Roten
- Cardiology Department, Inselspital Bern, Bern, Switzerland
| | | | - Saagar Mahida
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | - Richard Kobza
- Heart Center, Hirslanden St Anna, Zentralstrasse 1, 6003 Lucerne, Switzerland
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21
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Pranata R, Karwiky G, Iqbal M. Very-high-power Short-duration Ablation versus Conventional Ablation for Pulmonary Vein Isolation in Atrial Fibrillation: Systematic Review and Meta-analysis. Arrhythm Electrophysiol Rev 2023; 12:e30. [PMID: 38173799 PMCID: PMC10762667 DOI: 10.15420/aer.2023.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/02/2023] [Indexed: 01/05/2024] Open
Abstract
The aim of this study was to compare the effectiveness and safety of very-high-power short-duration (VHPSD) ablation (70-90 W/4-7 s) with conventional ablation (30-40 W/>20 s, 50 W/7-11 s) for pulmonary vein isolation (PVI) in patients with AF. A total of 13 studies were included in this analysis (1,527 patients). AF recurrence occurred in 14% (95% CI [11-18%]) of the VHPSD group. VHPSD was associated with lower AF recurrence (OR 0.65; 95% CI [0.48-0.89]; p=0.006) compared with the conventional ablation group. Subgroup analysis showed that additional ablation beyond PVI had a similar rate of AF recurrence (16% versus 10%) compared with PVI alone. Procedure and ablation durations were significantly shorter in the VHPSD group with a mean differences of -14.4 minutes (p=0.017) and -14.1 minutes (p<0.001), respectively. Complications occurred in 6% (95% CI [3-9%]) of the VHPSD group, and the rate was similar between the two groups (OR 1.03; 95% CI [0.60-1.80]; p=0.498). VHPSD ablation resulted in less AF recurrence and a shorter procedure time. Additional ablation beyond PVI alone in VHPSD may not provide additional benefits.
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Affiliation(s)
- Raymond Pranata
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital Bandung, Indonesia
| | - Giky Karwiky
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital Bandung, Indonesia
| | - Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital Bandung, Indonesia
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22
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Boga M, Suhai FI, Orbán G, Salló Z, Nagy KV, Szegedi L, Jokkel Z, Csőre J, Osztheimer I, Perge P, Gupta D, Merkely B, Gellér L, Szegedi N. Incidence and predictors of stroke and silent cerebral embolism following very high-power short-duration atrial fibrillation ablation. Europace 2023; 25:euad327. [PMID: 37931067 PMCID: PMC10653180 DOI: 10.1093/europace/euad327] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/22/2023] [Accepted: 10/02/2023] [Indexed: 11/08/2023] Open
Abstract
AIMS Cerebral thrombo-embolism is a dreaded complication of pulmonary vein isolation (PVI) for atrial fibrillation; its surrogate, silent cerebral embolism (SCE) can be detected by diffusion-weighted brain magnetic resonance imaging (bMRI). Initial investigations have raised a concern that very high-power, short-duration (vHPSD; 90 W/4 s) temperature-controlled PVI with the QDOT Micro catheter may be associated with a higher incidence of SCE compared with low-power long-duration ablation. We aimed to assess the incidence of procedural complications of vHPSD PVI with an emphasis on cerebral safety. METHODS AND RESULTS We enrolled 328 consecutive patients undergoing their PVI procedure using vHPSD. A subgroup of 61 consecutive patients underwent diffusion-weighted bMRI within 24 h of the procedure, and incidence and predictors of SCE were studied. The mean procedure time and left atrial dwell time for the overall cohort were 69.6 ± 24.1 and 46.5 ± 21.5 min, respectively. First-pass isolation was achieved in 82%. No stroke or transient ischaemic attack occurred. Silent cerebral embolism was identified in 5 of 61 patients (8.2%). Silent cerebral embolism following procedures was significantly associated with lower baseline generator impedance (105.8 vs. 112.6 Ω, P < 0.0001) and with intermittent loss of catheter-tissue contact during ablation (14.1% vs. 6.1%, P < 0.0001). CONCLUSION Very high-power, short-duration PVI is a safe technique with an excellent acute success rate. Silent cerebral embolism incidence in our cohort was below the previously reported range, with no clinically overt cerebral complications. Lower baseline generator impedance and loss of contact during ablation may contribute to a higher risk of SCEs.
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Affiliation(s)
- Márton Boga
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Ferenc Imre Suhai
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Gábor Orbán
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Zoltán Salló
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Klaudia Vivien Nagy
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Levente Szegedi
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Zsófia Jokkel
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Judit Csőre
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - István Osztheimer
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Péter Perge
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, UK
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Nándor Szegedi
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
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23
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Bortone AA, Ramirez FD, Constantin M, Bortone C, Hébert C, Constantin J, Bialas P, Limite LR. Optimal interlesion distance for 90 and 50 watt radiofrequency applications with low ablation index values: experimental findings in a chronic ovine model. Europace 2023; 25:euad310. [PMID: 37851513 PMCID: PMC10629717 DOI: 10.1093/europace/euad310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/14/2023] [Indexed: 10/20/2023] Open
Abstract
AIMS The optimal interlesion distance (ILD) for 90 and 50 W radiofrequency applications with low ablation index (AI) values in the atria has not been established. Excessive ILDs can predispose to interlesion gaps, whereas restrictive ILDs can predispose to procedural complications. The present study sought, therefore, to experimentally determine the optimal ILD for 90 W-4 s and 50 W applications with low AI values to optimize catheter ablation outcomes in humans. METHODS AND RESULTS Posterior intercaval lines were created in eight adult sheep using CARTO and the QDOT-MICRO catheter in a temperature-controlled mode. In four animals, the lines were created with 50 W applications, a target AI value ≥350, and ILDs of 6, 5, 4, and 3 mm, respectively. In the other four animals, the lines were created with 90 W-4 s applications and ILDs of 6, 5, 4, and 3 mm, respectively. Activation maps were created immediately after ablation and at 21 days to assess linear block prior to gross and histological analyses. All eight lines appeared transmural and continuous on histology. However, for 50 W-only applications with an ILD of 3 mm resulted in durable linear electrical block, whereas for 90 W applications, only the lines with ILDs of 4 and 3 mm were blocked. No complications were detected during ablation procedures, but all power and ILD combinations except 50 W-6 mm resulted in asymptomatic shallow lung lesions. CONCLUSION In the intercaval region in sheep, for 50 W applications with an AI value of ∼370, the optimal ILD is 3 mm, whereas for 90 W-4 s applications, the optimal ILD is 3-4 mm.
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Affiliation(s)
- Agustín Alfonso Bortone
- ELSAN, Service de Cardiologie, Hôpital Privé Les Franciscaines, 3 Rue Jean Bouin, 30000 Nîmes, France
| | - F Daniel Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Marion Constantin
- L’Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, 33600 Pessac, France
- Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
| | - Clara Bortone
- Faculté de Médecine, Université de Montpellier, Montpellier, France
| | - Caroline Hébert
- Biosense-Webster France, Johnson & Johnson, 92787 Issy-les-Moulineaux, France
| | - Justine Constantin
- Biosense-Webster France, Johnson & Johnson, 92787 Issy-les-Moulineaux, France
| | - Patric Bialas
- Department of Anesthesiology, Saarland Medical University, Homburg, Germany
| | - Luca Rosario Limite
- ELSAN, Service de Cardiologie, Hôpital Privé Les Franciscaines, 3 Rue Jean Bouin, 30000 Nîmes, France
- Service de Cardiologie, ELSAN, Clinique Saint Pierre, Perpignan, France
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Demolder A, O'Neill L, El Haddad M, Scherr D, Vijgen J, Wolf M, Berte B, Bisbal F, Johannessen A, Rivero-Ayerza M, De Potter T, De Becker B, Polain de Waroux JBL, Knecht S, Tavernier R, Duytschaever M. No Effect of Continued Antiarrhythmic Drug Treatment on Top of Optimized Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation: Results From the POWDER-AF2 Trial. Circ Arrhythm Electrophysiol 2023; 16:e012043. [PMID: 37921006 DOI: 10.1161/circep.123.012043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND In patients with persistent atrial fibrillation (PersAF), catheter ablation aiming for pulmonary vein isolation (PVI) is associated with moderate clinical effectiveness. We investigated the benefit of continuing previously ineffective class 1C or 3 antiarrhythmic drug therapy (ADT) in the setting of a standardized PVI-only ablation strategy. METHODS In this multicenter, randomized controlled study, patients with PersAF (≥7 days and <12 months) despite ADT were prospectively randomized 1:1 to PVI with ADT continued versus discontinued beyond the blanking period (ADT ON versus ADT OFF). Standardized catheter ablation was performed aiming for durable isolation with stable, contiguous, and optimized radio frequency applications encircling the pulmonary veins (CLOSE protocol). Clinical visits and 1-to-7-day Holter were performed at 3, 6, and 12 months. The primary end point was any documented atrial tachyarrhythmia lasting >30 seconds beyond 3 months. Prospectively defined secondary end points included repeat ablations, unscheduled arrhythmia-related visits, and quality of life among groups. RESULTS Of 200 PersAF patients, 98 were assigned to ADT OFF and 102 to ADT ON. The longest atrial fibrillation episode qualifying for PersAF was 28 (10-90) versus 30 (11-90) days. Clinical characteristics and procedural characteristics were similar. Recurrence of atrial tachyarrhythmia was comparable in both groups (20% OFF versus 21.2% ON). No differences were observed in repeat ablations and unscheduled arrhythmia-related visits. Marked improvement in quality of life was observed in both groups. CONCLUSIONS In patients with PersAF, there is no benefit in continuing previously ineffective ADT beyond the blanking period after catheter ablation. The high success rate of PVI-only might be explained by the high rate of durable isolation after optimized PVI and the early stage of PersAF (POWDER-AF2). REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03437356.
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Affiliation(s)
- Anthony Demolder
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium (A.D., L.O., M.E.H., B.D.B., J.-B.L.P.D.W., S.K., R.T., M.D.)
| | - Louisa O'Neill
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium (A.D., L.O., M.E.H., B.D.B., J.-B.L.P.D.W., S.K., R.T., M.D.)
| | - Milad El Haddad
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium (A.D., L.O., M.E.H., B.D.B., J.-B.L.P.D.W., S.K., R.T., M.D.)
| | - Daniel Scherr
- Department of Cardiology, Medical University of Graz, Austria (D.S.)
| | - Johan Vijgen
- Department of Cardiology, Jessa Hospitals, Hasselt, Belgium (J.V.)
| | - Michael Wolf
- Department of Cardiology, ZNA Middelheim, Antwerp, Belgium (M.W.)
| | - Benjamin Berte
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland (B.B.)
| | - Felipe Bisbal
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (F.B.)
| | - Arne Johannessen
- Department of Cardiology, Herlev & Gentofte Hospital, Hellerup, Denmark (A.J.)
| | | | - Tom De Potter
- Department of Cardiology, OLV Hospital, Aalst, Belgium (T.D.P.)
| | - Benjamin De Becker
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium (A.D., L.O., M.E.H., B.D.B., J.-B.L.P.D.W., S.K., R.T., M.D.)
| | - Jean-Benoît le Polain de Waroux
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium (A.D., L.O., M.E.H., B.D.B., J.-B.L.P.D.W., S.K., R.T., M.D.)
| | - Sebastien Knecht
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium (A.D., L.O., M.E.H., B.D.B., J.-B.L.P.D.W., S.K., R.T., M.D.)
| | - Rene Tavernier
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium (A.D., L.O., M.E.H., B.D.B., J.-B.L.P.D.W., S.K., R.T., M.D.)
| | - Mattias Duytschaever
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium (A.D., L.O., M.E.H., B.D.B., J.-B.L.P.D.W., S.K., R.T., M.D.)
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