Predictors of first pass isolation of the pulmonary veins in real world ablations: An analysis of 2671 patients from the REAL-AF registry

Optimized workflow for paroxysmal atrial fibrillation ablation using very high power short duration

Background

wide antral pulmonary vein isolation (PVI) is effective for treating paroxysmal atrial fibrillation (PAF), although time-demanding. We investigated the impact of a standardized ablation protocol by using a bidirectional transeptal steerable sheath, high-density mapping and very high-power-short-duration (vHPSD) catheters on procedure timing, efficacy, and safety.

Methods

consecutive PAF patients free from previous ablations undergoing PVI alone between January 2022 and March 2023 were prospectively enrolled. The standardized workflow included general anesthesia, a single transeptal puncture trough with a bidirectional, steerable visualizable sheath introduced into the left atrium accommodated a high density, penta-spline mapping catheter and a contact force sensor ablation catheter enabled to deliver vHPSD. Procedural data and electrophysiology (EP) laboratory times were systematically collected and analyzed. The primary endpoint was any AF or atrial tachycardia recurrence at 12 and 24 month follow up.

Results

the study cohort was composed by 138 patients (mean age was 59 ± 11 years, 38% female) and successful PVI was achieved in 100% of cases. Overall, first pass isolation (PFI) was 93%, with a LA dwell time of 32 ± 4 min. Significant complications were reported in 3% of patients. Skin-to-skin time and total EP laboratory time were 58 ± 5 min and 85 ± 7 min, respectively. The primary endpoint was achieved by 9% and 12% of cases at 12 and 24 month follow up, respectively. Upper limit skin-to-skin time and missed FPI resulted predictors of the primary endpoint.

Conclusion

This standardized workflow resulted in low procedural times and arrhythmias recurrence without compromising the safety.

Proactive esophageal cooling during radiofrequency cardiac ablation: data update including applications in very high-power short duration ablation

INTRODUCTION

Proactive esophageal cooling reduces injury during radiofrequency (RF) ablation of the left atrium (LA) for the treatment of atrial fibrillation (AF). New catheters are capable of higher wattage settings up to 90 W (very high-power short duration, vHPSD) for 4 s. Varying power and duration, however, does not eliminate the risk of thermal injury. Furthermore, alternative energy sources such as pulsed field ablation (PFA) also exhibit thermal effects, with clinical data showing esophageal temperatures up to 40.3°C. The ensoETM esophageal cooling device (Attune Medical, now a part of Haemonetics, Boston, MA, U.S.A.) is commercially available and FDA-cleared to reduce thermal injury to the esophagus during RF ablation for AF and is recommended in the 2024 expert consensus statement on catheter and surgical ablation of AF.

AREAS COVERED

This review summarizes growing evidence of esophageal cooling during high power RF ablation for AF treatment, including data relating to procedural efficacy, safety, and efficiency, and techniques to enhance operator success while providing directions for further research.

EXPERT OPINION

Proactive esophageal cooling reduces injury to the esophagus during high power RF ablation, and utilizing this approach may result in increased success in first-pass isolation, procedural efficiency, and long-term efficacy.

Catheter Ablation in Atrial Fibrillation: Recent Advances

Atrial fibrillation (AF) is the leading cause of arrhythmia-related morbidity and mortality. Recurrent symptoms, hospitalizations, and cost burden to patients have necessitated treatments beyond antiarrhythmic drugs (AADs) for patients with AF. Catheter ablation has proven to be effective over medical therapy alone; however the recurrence rates for atrial tachyarrhythmias post-ablation remain significant, particularly in patients with persistent and long-standing persistent AF. Hence, new techniques for catheter ablation have arisen, such as non-thermal energy sources, novel catheters, electroanatomical mapping, and ablation of additional targets. In this review, we discuss the recent advances in the field of catheter ablation, including newer modalities for the prevention of adverse events and future perspectives.

A negative relationship between first-pass pulmonary vein isolation and body mass index in ablation index-guided pulmonary vein isolation

Background

We previously reported the relationship between first-pass pulmonary vein isolation (FPI) and pulmonary vein isolation (PVI) durability in ablation index-guided atrial fibrillation ablation. Obesity is a worsening factor for atrial tachyarrhythmia (AT) recurrence. However, the impact of obesity on FPI has been scarcely reported. General anesthesia (GA) facilitates completing PVI by preventing airway obstruction caused by sedative drug use. However, the impact of GA on the relationship also has not been elucidated.

Objective

The study sought to evaluate the impact of obesity and its relationship with GA on FPI.

Methods

We retrospectively studied 2187 consecutive patients undergoing ablation index-guided first atrial fibrillation ablation (conscious sedation in 1969 and GA in 218). We divided them into 4 groups according to body mass index (BMI): underweight (BMI < 18.5 kg/m2) (n = 80), normal (18.5 kg/m2 ≤ BMI < 25 kg/m2) (n = 1,160), overweight (25 kg/m2 ≤ BMI < 30 kg/m2) (n = 763), and obesity (BMI ≥30 kg/m2) (n = 184).

Results

FPI rate decreased as BMI increased in both conscious sedation (68.1% in underweight, 61.5% in normal, 48.7% in overweight, and 39.0% in obesity; P < .001) and GA (87.5%, 67.1%, 61.3%, and 44.7%, respectively; P = .01). Multivariate analysis revealed overweight (odds ratio 0.65, 95% confidence interval [CI] 0.53-0.79, P < .001, vs normal) and obesity (OR 0.44, 95% CI 0.31-0.62 P < .001, vs normal) as independent predictors for FPI and obesity as an AT recurrence predictor (hazard ratio 1.35, 95% CI 1.01-1.81, P = .04).

Conclusion

BMI increase was negatively related to the FPI rate. Notably, the FPI rate in obese patients, even under GA, was low, which might be related to their high AT recurrence.