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Chun KRJ, Miklavčič D, Vlachos K, Bordignon S, Scherr D, Jais P, Schmidt B. State-of-the-art pulsed field ablation for cardiac arrhythmias: ongoing evolution and future perspective. Europace 2024; 26:euae134. [PMID: 38848447 PMCID: PMC11160504 DOI: 10.1093/europace/euae134] [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: 03/11/2024] [Accepted: 05/07/2024] [Indexed: 06/09/2024] Open
Abstract
Pulsed field ablation (PFA) is an innovative approach in the field of cardiac electrophysiology aimed at treating cardiac arrhythmias. Unlike traditional catheter ablation energies, which use radiofrequency or cryothermal energy to create lesions in the heart, PFA utilizes pulsed electric fields to induce irreversible electroporation, leading to targeted tissue destruction. This state-of-the-art review summarizes biophysical principles and clinical applications of PFA, highlighting its potential advantages over conventional ablation methods. Clinical data of contemporary PFA devices are discussed, which combine predictable procedural outcomes and a reduced risk of thermal collateral damage. Overall, these technological developments have propelled the rapid evolution of contemporary PFA catheters, with future advancements potentially impacting patient care.
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Affiliation(s)
- Kyoung-Ryul Julian Chun
- CCB Frankfurt, Med. Klinik III, Markuskrankenhaus, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
- Klinik für Rhythmologie, UKSH, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, Laboratory of Biocybernetics, University of Ljubljana, Trzaska cesta 25, SI-1000 Ljubljana, Slovenia
| | - Konstantinos Vlachos
- Site Hôpital Xavier Arnozan, Bordeaux University Hospital, University of Bordeaux, Avenue du Haut-Lévêque, –Pessac, France
| | - Stefano Bordignon
- CCB Frankfurt, Med. Klinik III, Markuskrankenhaus, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - Daniel Scherr
- Klinische Abteilung für Kardiologie, Medizinische Universität Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Pierre Jais
- Site Hôpital Xavier Arnozan, Bordeaux University Hospital, University of Bordeaux, Avenue du Haut-Lévêque, –Pessac, France
| | - Boris Schmidt
- CCB Frankfurt, Med. Klinik III, Markuskrankenhaus, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
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Malyshev Y, Neuzil P, Petru J, Funasako M, Hala P, Kopriva K, Schneider C, Achyutha A, Vanderper A, Musikantow D, Turagam M, Dukkipati SR, Reddy VY. Nitroglycerin to Ameliorate Coronary Artery Spasm During Focal Pulsed-Field Ablation for Atrial Fibrillation. JACC Clin Electrophysiol 2024; 10:885-896. [PMID: 38385916 DOI: 10.1016/j.jacep.2023.12.015] [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: 10/24/2023] [Revised: 12/21/2023] [Accepted: 12/24/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND In treating atrial fibrillation, pulsed-field ablation (PFA) has comparable efficacy to conventional thermal ablation, but with important safety advantages: no esophageal injury or pulmonary vein stenosis, and rare phrenic nerve injury. However, when PFA is delivered in proximity to coronary arteries using a pentaspline catheter, which generates a broad electrical field, severe vasospasm can be provoked. OBJECTIVES The authors sought to study the vasospastic potential of a focal PFA catheter with a narrower electrical field and develop a preventive strategy with nitroglycerin. METHODS During atrial fibrillation ablation, a focal PFA catheter was used for cavotricuspid isthmus ablation. Angiography of the right coronary artery (some with fractional flow reserve measurement) was performed before, during, and after PFA. Beyond no nitroglycerin (n = 5), and a few testing strategies (n = 8), 2 primary nitroglycerin administration strategies were studied: 1) multiple boluses (3-2 mg every 2 min) into the right atrium (n = 10), and 2) a bolus (3 mg) into the right atrium with continuous peripheral intravenous infusion (1 mg/min; n = 10). RESULTS Without nitroglycerin, cavotricuspid isthmus ablation provoked moderate-severe vasospasm in 4 of 5 (80%) patients (fractional flow reserve 0.71 ± 0.08). With repetitive nitroglycerin boluses, severe spasm did not occur, and mild-moderate vasospasm occurred in only 2 of 10 (20%). Using the bolus + infusion strategy, severe and mild-moderate spasm occurred in 1 and 3 of 10 patients (aggregate 40%). No patient had ST-segment changes. CONCLUSIONS Ablation of the cavotricuspid isthmus using a focal PFA catheter routinely provokes right coronary vasospasm. Pretreatment with high doses of parenteral nitroglycerin prevents severe spasm.
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Affiliation(s)
- Yury Malyshev
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jan Petru
- Homolka Hospital, Prague, Czech Republic
| | | | - Pavel Hala
- Homolka Hospital, Prague, Czech Republic
| | | | | | - Anitha Achyutha
- Farapulse-Boston Scientific, Inc, Menlo Park, California, USA
| | | | | | - Mohit Turagam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Homolka Hospital, Prague, Czech Republic.
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3
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Aldaas OM, Malladi C, Han FT, Hoffmayer KS, Krummen D, Ho G, Raissi F, Birgersdotter-Green U, Feld GK, Hsu JC. Pulsed field ablation versus thermal energy ablation for atrial fibrillation: a systematic review and meta-analysis of procedural efficiency, safety, and efficacy. J Interv Card Electrophysiol 2024; 67:639-648. [PMID: 37855992 PMCID: PMC11016003 DOI: 10.1007/s10840-023-01660-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Pulsed field ablation (PFA) induces cell death through electroporation using ultrarapid electrical pulses. We sought to compare the procedural efficiency characteristics, safety, and efficacy of ablation of atrial fibrillation (AF) using PFA compared with thermal energy ablation. METHODS We performed an extensive literature search and systematic review of studies that compared ablation of AF with PFA versus thermal energy sources. Risk ratio (RR) 95% confidence intervals (CI) were measured for dichotomous variables and mean difference (MD) 95% CI were measured for continuous variables, where RR < 1 and MD < 0 favor the PFA group. RESULTS We included 6 comparative studies for a total of 1012 patients who underwent ablation of AF: 43.6% with PFA (n = 441) and 56.4% (n = 571) with thermal energy sources. There were significantly shorter procedures times with PFA despite a protocolized 20-min dwell time (MD - 21.95, 95% CI - 33.77, - 10.14, p = 0.0003), but with significantly longer fluroscopy time (MD 5.71, 95% CI 1.13, 10.30, p = 0.01). There were no statistically significant differences in periprocedural complications (RR 1.20, 95% CI 0.59-2.44) or recurrence of atrial tachyarrhythmias (RR 0.64, 95% CI 0.31, 1.34) between the PFA and thermal ablation cohorts. CONCLUSIONS Based on the results of this meta-analysis, PFA was associated with shorter procedural times and longer fluoroscopy times, but no difference in periprocedural complications or rates of recurrent AF when compared to ablation with thermal energy sources. However, larger randomized control trials are needed.
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Affiliation(s)
- Omar Mahmoud Aldaas
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Chaitanya Malladi
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Frederick T Han
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Kurt S Hoffmayer
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - David Krummen
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Gordon Ho
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Farshad Raissi
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Ulrika Birgersdotter-Green
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Gregory K Feld
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA
| | - Jonathan C Hsu
- Division of Cardiac Electrophysiology at the University of California San Diego Health System, 9452 Medical Center Drive, La Jolla, CA, 92037, USA.
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of CA - San Diego, 9452 Medical Center Drive, 3rd Floor, Room 3E-417, La Jolla, CA, 92037, USA.
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4
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Chinyere IR, Mori S, Hutchinson MD. Cardiac blood vessels and irreversible electroporation: findings from pulsed field ablation. VESSEL PLUS 2024; 8:7. [PMID: 38646143 PMCID: PMC11027649 DOI: 10.20517/2574-1209.2023.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
The clinical use of irreversible electroporation in invasive cardiac laboratories, termed pulsed field ablation (PFA), is gaining early enthusiasm among electrophysiologists for the management of both atrial and ventricular arrhythmogenic substrates. Though electroporation is regularly employed in other branches of science and medicine, concerns regarding the acute and permanent vascular effects of PFA remain. This comprehensive review aims to summarize the preclinical and adult clinical data published to date on PFA's effects on pulmonary veins and coronary arteries. These data will be contrasted with the incidences of iatrogenic pulmonary vein stenosis and coronary artery injury secondary to thermal cardiac ablation modalities, namely radiofrequency energy, laser energy, and liquid nitrogen-based cryoablation.
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Affiliation(s)
- Ikeotunye Royal Chinyere
- Sarver Heart Center, University of Arizona, Tucson, AZ 85724, USA
- Banner University Medicine, Banner Health, Tucson, AZ 85719, USA
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Mathew D. Hutchinson
- Sarver Heart Center, University of Arizona, Tucson, AZ 85724, USA
- Banner University Medicine, Banner Health, Tucson, AZ 85719, USA
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Turagam MK, Neuzil P, Schmidt B, Reichlin T, Neven K, Metzner A, Hansen J, Blaauw Y, Maury P, Arentz T, Sommer P, Anic A, Anselme F, Boveda S, Deneke T, Willems S, van der Voort P, Tilz R, Funasako M, Scherr D, Wakili R, Steven D, Kautzner J, Vijgen J, Jais P, Petru J, Chun J, Roten L, Füting A, Lemoine MD, Ruwald M, Mulder BA, Rollin A, Lehrmann H, Fink T, Jurisic Z, Chaumont C, Adelino R, Nentwich K, Gunawardene M, Ouss A, Heeger CH, Manninger M, Bohnen JE, Sultan A, Peichl P, Koopman P, Derval N, Kueffer T, Reddy VY. Clinical Outcomes by Sex After Pulsed Field Ablation of Atrial Fibrillation. JAMA Cardiol 2023; 8:1142-1151. [PMID: 37910101 PMCID: PMC10620676 DOI: 10.1001/jamacardio.2023.3752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/10/2023] [Indexed: 11/03/2023]
Abstract
Importance Previous studies evaluating the association of patient sex with clinical outcomes using conventional thermal ablative modalities for atrial fibrillation (AF) such as radiofrequency or cryoablation are controversial due to mixed results. Pulsed field ablation (PFA) is a novel AF ablation energy modality that has demonstrated preferential myocardial tissue ablation with a unique safety profile. Objective To compare sex differences in patients undergoing PFA for AF in the Multinational Survey on the Methods, Efficacy, and Safety on the Postapproval Clinical Use of Pulsed Field Ablation (MANIFEST-PF) registry. Design, Setting, and Participants This was a retrospective cohort study of MANIFEST-PF registry data, which included consecutive patients undergoing postregulatory approval treatment with PFA to treat AF between March 2021 and May 2022 with a median follow-up of 1 year. MANIFEST-PF is a multinational, retrospectively analyzed, prospectively enrolled patient-level registry including 24 European centers. The study included all consecutive registry patients (age ≥18 years) who underwent first-ever PFA for paroxysmal or persistent AF. Exposure PFA was performed on patients with AF. All patients underwent pulmonary vein isolation and additional ablation, which was performed at the discretion of the operator. Main Outcomes and Measures The primary effectiveness outcome was freedom from clinically documented atrial arrhythmia for 30 seconds or longer after a 3-month blanking period. The primary safety outcome was the composite of acute (<7 days postprocedure) and chronic (>7 days) major adverse events (MAEs). Results Of 1568 patients (mean [SD] age, 64.5 [11.5] years; 1015 male [64.7%]) with AF who underwent PFA, female patients, as compared with male patients, were older (mean [SD] age, 68 [10] years vs 62 [12] years; P < .001), had more paroxysmal AF (70.2% [388 of 553] vs 62.4% [633 of 1015]; P = .002) but had fewer comorbidities such as coronary disease (9% [38 of 553] vs 15.9% [129 of 1015]; P < .001), heart failure (10.5% [58 of 553] vs 16.6% [168 of 1015]; P = .001), and sleep apnea (4.7% [18 of 553] vs 11.7% [84 of 1015]; P < .001). Pulmonary vein isolation was performed in 99.8% of female (552 of 553) and 98.9% of male (1004 of 1015; P = .90) patients. Additional ablation was performed in 22.4% of female (124 of 553) and 23.1% of male (235 of 1015; P = .79) patients. The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was similar in male and female patients (79.0%; 95% CI, 76.3%-81.5% vs 76.3%; 95% CI, 72.5%-79.8%; P = .28). There was also no significant difference in acute major AEs between groups (male, 1.5% [16 of 1015] vs female, 2.5% [14 of 553]; P = .19). Conclusion and Relevance Results of this cohort study suggest that after PFA for AF, there were no significant sex differences in clinical effectiveness or safety events.
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Affiliation(s)
- Mohit K. Turagam
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Petr Neuzil
- Cardiology Department, Na Homolce Hospital, Homolka Hospital, Prague, Czechia
| | - Boris Schmidt
- Medizinisches Versorgungszentrum Cardioangiologisches Centrum Bethanien Frankfurt und Main-Taunus GbR, Frankfurt, Germany
| | - Tobias Reichlin
- Inselspital—Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kars Neven
- Department of Medicine, Witten/Herdecke University, Witten, Germany
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
| | - Andreas Metzner
- University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jim Hansen
- Department of Cardiology, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Yuri Blaauw
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Philippe Maury
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
- I2MC Institute, INSERM UMR 1297, Toulouse, France
| | - Thomas Arentz
- Department of Cardiology and Angiology, Medical Center and Faculty of Medicine—University of Freiburg, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum North Rhine Westfalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Ante Anic
- Department for Cardiovascular Diseases, University Hospital Center Split, Split, Croatia
| | | | - Serge Boveda
- Heart Rhythm Department, Clinique Pasteur, Toulouse, France
- Universitair Ziekenhuis, Brussels, Belgium
| | - Tom Deneke
- Heart Center Bad Neustadt, Rhoen-Clinic Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | | | - Pepijn van der Voort
- Catharina Hospital, Eindhoven, the Netherlands instead of Catharina Ziekenhuis Eindhoven, the Netherlands
| | - Roland Tilz
- University Heart Center Lübeck, Department of Rhythmology, University Hospital Schleswig-Holstein, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Moritoshi Funasako
- Cardiology Department, Na Homolce Hospital, Homolka Hospital, Prague, Czechia
- Neuron Medical, Brno, Czech Republic
| | - Daniel Scherr
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Reza Wakili
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Duisburg, Germany
| | - Daniel Steven
- Heart Center University Hospital of Cologne, Department for Electrophysiology, Cologne, Germany
| | - Josef Kautzner
- IKEM—Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Johan Vijgen
- Department of Cardiology, Jessa Hospitals, Hasselt, Belgium
| | - Pierre Jais
- IHU LIRYC—Institute Des Maladies Du Rythme Cardiaque, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Jan Petru
- Cardiology Department, Na Homolce Hospital, Homolka Hospital, Prague, Czechia
| | - Julian Chun
- Medizinisches Versorgungszentrum Cardioangiologisches Centrum Bethanien Frankfurt und Main-Taunus GbR, Frankfurt, Germany
| | - Laurent Roten
- Inselspital—Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Füting
- Department of Medicine, Witten/Herdecke University, Witten, Germany
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
| | - Marc D. Lemoine
- University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Ruwald
- Department of Cardiology, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Bart A. Mulder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anne Rollin
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
| | - Heiko Lehrmann
- Department of Cardiology and Angiology, Medical Center and Faculty of Medicine—University of Freiburg, Germany
| | - Thomas Fink
- Clinic for Electrophysiology, Herz- und Diabeteszentrum North Rhine Westfalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Zrinka Jurisic
- Department for Cardiovascular Diseases, University Hospital Center Split, Split, Croatia
| | | | - Raquel Adelino
- Heart Rhythm Department, Clinique Pasteur, Toulouse, France
- Universitair Ziekenhuis, Brussels, Belgium
| | - Karin Nentwich
- Heart Center Bad Neustadt, Rhoen-Clinic Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | | | - Alexandre Ouss
- Catharina Hospital, Eindhoven, the Netherlands instead of Catharina Ziekenhuis Eindhoven, the Netherlands
| | - Christian-Hendrik Heeger
- University Heart Center Lübeck, Department of Rhythmology, University Hospital Schleswig-Holstein, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Martin Manninger
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jan-Eric Bohnen
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Duisburg, Germany
| | - Arian Sultan
- Heart Center University Hospital of Cologne, Department for Electrophysiology, Cologne, Germany
| | - Petr Peichl
- IKEM—Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Pieter Koopman
- Department of Cardiology, Jessa Hospitals, Hasselt, Belgium
| | - Nicolas Derval
- IHU LIRYC—Institute Des Maladies Du Rythme Cardiaque, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Thomas Kueffer
- Inselspital—Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vivek Y. Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
- Cardiology Department, Na Homolce Hospital, Homolka Hospital, Prague, Czechia
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6
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Reddy VY, Gerstenfeld EP, Natale A, Whang W, Cuoco FA, Patel C, Mountantonakis SE, Gibson DN, Harding JD, Ellis CR, Ellenbogen KA, DeLurgio DB, Osorio J, Achyutha AB, Schneider CW, Mugglin AS, Albrecht EM, Stein KM, Lehmann JW, Mansour M. Pulsed Field or Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med 2023; 389:1660-1671. [PMID: 37634148 DOI: 10.1056/nejmoa2307291] [Citation(s) in RCA: 97] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Catheter-based pulmonary vein isolation is an effective treatment for paroxysmal atrial fibrillation. Pulsed field ablation, which delivers microsecond high-voltage electrical fields, may limit damage to tissues outside the myocardium. The efficacy and safety of pulsed field ablation as compared with conventional thermal ablation are not known. METHODS In this randomized, single-blind, noninferiority trial, we assigned patients with drug-refractory paroxysmal atrial fibrillation in a 1:1 ratio to undergo pulsed field ablation or conventional radiofrequency or cryoballoon ablation. The primary efficacy end point was freedom from a composite of initial procedural failure, documented atrial tachyarrhythmia after a 3-month blanking period, antiarrhythmic drug use, cardioversion, or repeat ablation. The primary safety end point included acute and chronic device- and procedure-related serious adverse events. RESULTS A total of 305 patients were assigned to undergo pulsed field ablation, and 302 were assigned to undergo thermal ablation. At 1 year, the primary efficacy end point was met (i.e., no events occurred) in 204 patients (estimated probability, 73.3%) who underwent pulsed field ablation and 194 patients (estimated probability, 71.3%) who underwent thermal ablation (between-group difference, 2.0 percentage points; 95% Bayesian credible interval, -5.2 to 9.2; posterior probability of noninferiority, >0.999). Primary safety end-point events occurred in 6 patients (estimated incidence, 2.1%) who underwent pulsed field ablation and 4 patients (estimated incidence, 1.5%) who underwent thermal ablation (between-group difference, 0.6 percentage points; 95% Bayesian credible interval, -1.5 to 2.8; posterior probability of noninferiority, >0.999). CONCLUSIONS Among patients with paroxysmal atrial fibrillation receiving a catheter-based therapy, pulsed field ablation was noninferior to conventional thermal ablation with respect to freedom from a composite of initial procedural failure, documented atrial tachyarrhythmia after a 3-month blanking period, antiarrhythmic drug use, cardioversion, or repeat ablation and with respect to device- and procedure-related serious adverse events at 1 year. (Funded by Farapulse-Boston Scientific; ADVENT ClinicalTrials.gov number, NCT04612244.).
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Affiliation(s)
- Vivek Y Reddy
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Edward P Gerstenfeld
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Andrea Natale
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - William Whang
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Frank A Cuoco
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Chinmay Patel
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Stavros E Mountantonakis
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Douglas N Gibson
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - John D Harding
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Christopher R Ellis
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Kenneth A Ellenbogen
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - David B DeLurgio
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Jose Osorio
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Anitha B Achyutha
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Christopher W Schneider
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Andrew S Mugglin
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Elizabeth M Albrecht
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Kenneth M Stein
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - John W Lehmann
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
| | - Moussa Mansour
- From the Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai (V.Y.R., W.W.), and Lenox Hill Hospital, Northwell Health (S.E.M.) - both in New York; the University of California, San Francisco, San Francisco (E.P.G.), Scripps Clinic and Prebys Cardiovascular Institute, San Diego (D.N.G.), and Boston Scientific, Menlo Park (A.B.A., C.W.S.) - all in California; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (A.N.); Case Western Reserve University, Cleveland (A.N.); Trident Medical Center, Charleston, SC (F.A.C.); University of Pittsburgh Medical Center Pinnacle, Harrisburg (C.P.), and Doylestown Hospital, Doylestown (J.D.H.) - both in Pennsylvania; Vanderbilt University Medical Center, Nashville (C.R.E.); Virginia Commonwealth University, Richmond (K.A.E.); Emory University Hospital, Atlanta (D.B.D.); Grandview Medical Center, Birmingham, AL (J.O.); Paradigm Biostatistics, Anoka (A.S.M.), and Boston Scientific, St. Paul (E.M.A., K.M.S.) - both in Minnesota; Lehmann Consulting, Naples, FL (J.W.L.); and Massachusetts General Hospital, Boston (M.M.)
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Yu F, Dong X, Ding L, Reddy V, Tang M. Pulsed field ablation for pulmonary vein isolation: Preclinical safety and effectiveness of a novel hexaspline ablation catheter. J Cardiovasc Electrophysiol 2023; 34:2195-2202. [PMID: 37712346 DOI: 10.1111/jce.16067] [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: 01/16/2023] [Revised: 08/11/2023] [Accepted: 09/02/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Pulsed-field ablation (PFA) has emerged as a nonthermal energy source for cardiac ablation, with potential safety advantages over radiofrequency ablation (RFA) and cryoballoon ablation. OBJECTIVE To report the preclinical results of a novel hexaspline PFA catheter for pulmonary vein isolation (PVI), and to verify the influence of PFA on esophagus by comparing with RFA. METHODS This study included a total of 15 canines for the efficacy and safety study and four swine for the esophageal safety study. The 15 canines were divided into an acute cohort (n = 3), a 30-day follow-up cohort (n = 5) and a 90-day follow-up cohort (n = 7), PVI was performed with the novel hexaspline PFA ablation catheter. In the esophageal safety study, four swine were divided into PFA cohort (n = 2) and RFA cohort (n = 2), esophageal injury swine model was adopted, the esophagus was intubated with an esophageal balloon retractor, under fluoroscopy, the DV8 device was inflated with a mixture of saline and contrast and rotated to displace the esophagus rightward and anteriorly toward the ablation catheter in the inferior vena cava (IVC) and right inferior pulmonary vein (PV). Nine PFA applications were delivered at four locations on IVC and two locations on the right inferior PV in the PFA cohort, six RFA applications were delivered at each location in the RFA group. Histopathological analysis of all PVs, esophagus, IVC, and the adjacent lungs was performed. RESULTS Acute PV isolation was achieved in all 15 canines (100%), with energy delivery times of less than 3 min/animal. In the 30 and 90 days group, the overall success rates were 88.9% and 88.5% per PVs, respectively. Two right superior pulmonary veins (RSPVs) in the 30-day group, two RSPVs and one left superior PV in the 90-day group with recovered potentials. At follow-up, gross pathological examination revealed the lesions around the PVs were continuous and transmural. Masson's trichrome staining revealed the myocardial cells in the PVs became fibrotic, but small arteries and nervous tissue were preserved. Results of swine esophageal injury model revealed the esophageal luminal surface was smooth and without evidence for esophageal injury in the PFA group, whereas obvious ulceration was detected on the esophagus tunica mucosa in the RFA group. CONCLUSION In the chronic canine study, PFA-based PVI were safe and effective with demonstrable sparing of nerves and venous tissue. Compared with RFA, there was also good evidence for safety of PFA, avoiding PV stenosis and esophageal injury. This preclinical study provided the scientific basis for the first-in-human endocardial PFA studies.
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Affiliation(s)
- Fengyuan Yu
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaonan Dong
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Lei Ding
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Vivek Reddy
- Icahn School of Medicine at Mount Sinai, Helmsley Electrophysiology Center, New York, New York, USA
| | - Min Tang
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Aldaas OM, Malladi C, Aldaas AM, Han FT, Hoffmayer KS, Krummen D, Ho G, Raissi F, Birgersdotter-Green U, Feld GK, Hsu JC. Safety and acute efficacy of catheter ablation for atrial fibrillation with pulsed field ablation vs thermal energy ablation: A meta-analysis of single proportions. Heart Rhythm O2 2023; 4:599-608. [PMID: 37936671 PMCID: PMC10626185 DOI: 10.1016/j.hroo.2023.09.003] [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] [Indexed: 11/09/2023] Open
Abstract
Background Pulsed field ablation (PFA) has emerged as a novel energy source for the ablation of atrial fibrillation (AF) using ultrarapid electrical pulses to induce cell death via electroporation. Objective The purpose of this study was to compare the safety and acute efficacy of ablation for AF with PFA vs thermal energy sources. Methods We performed an extensive literature search and systematic review of studies that evaluated the safety and efficacy of ablation for AF with PFA and compared them to landmark clinical trials for ablation of AF with thermal energy sources. Freeman-Tukey double arcsine transformation was used to establish variance of raw proportions followed by the inverse with the random-effects model to combine the transformed proportions and generate the pooled prevalence and 95% confidence interval (CI). Results We included 24 studies for a total of 5203 patients who underwent AF ablation. Among these patients, 54.6% (n = 2842) underwent PFA and 45.4% (n = 2361) underwent thermal ablation. There were significantly fewer periprocedural complications in the PFA group (2.05%; 95% CI 0.94-3.46) compared to the thermal ablation group (7.75%; 95% CI 5.40-10.47) (P = .001). When comparing AF recurrence up to 1 year, there was a statistically insignificant trend toward a lower prevalence of recurrence in the PFA group (14.24%; 95% CI 6.97-23.35) compared to the thermal ablation group (25.98%; 95% CI 15.75-37.68) (P = .132). Conclusion Based on the results of this meta-analysis, PFA was associated with lower rates of periprocedural complications and similar rates of acute procedural success and recurrent AF with up to 1 year of follow-up compared to ablation with thermal energy sources.
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Affiliation(s)
- Omar M. Aldaas
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Chaitanya Malladi
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Amer M. Aldaas
- T. Still University School of Osteopathic Medicine, Mesa, Arizona
| | - Frederick T. Han
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Kurt S. Hoffmayer
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - David Krummen
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Gordon Ho
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Farshad Raissi
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Ulrika Birgersdotter-Green
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Gregory K. Feld
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
| | - Jonathan C. Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology at the University of California San Diego Health System, La Jolla, California
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Tabaja C, Younis A, Hussein AA, Taigen TL, Nakagawa H, Saliba WI, Sroubek J, Santangeli P, Wazni OM. Catheter-Based Electroporation: A Novel Technique for Catheter Ablation of Cardiac Arrhythmias. JACC Clin Electrophysiol 2023; 9:2008-2023. [PMID: 37354168 DOI: 10.1016/j.jacep.2023.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 06/26/2023]
Abstract
Catheter ablation of arrhythmias is now standard of care in invasive electrophysiology. Current ablation strategies are based on the use of thermal energy. With continuous efforts to optimize thermal energy delivery, effectiveness has greatly improved; however, safety concerns persist. This review focuses on a novel ablation technology, irreversible electroporation (IRE), also known as pulsed-field ablation which may be a safer alternative for arrhythmia management. Pulsed-field ablation is thought to be a nonthermal ablation that applies short-duration high-voltage electrical fields to ablate myocardial tissue with high selectivity and durability while sparing important neighboring structures such as the esophagus and phrenic nerves. There are multiple ongoing studies investigating the potential superior outcomes of IRE compared to radiofrequency ablation in treating patients with atrial and ventricular arrhythmias. In this review, we describe the current evidence of preclinical and clinical trials that have shown promising results of catheter-based IRE.
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Affiliation(s)
- Chadi Tabaja
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arwa Younis
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ayman A Hussein
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tyler L Taigen
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hiroshi Nakagawa
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walid I Saliba
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jakub Sroubek
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Oussama M Wazni
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
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10
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Reddy VY, Peichl P, Anter E, Rackauskas G, Petru J, Funasako M, Minami K, Koruth JS, Natale A, Jais P, Marinskis G, Aidietis A, Kautzner J, Neuzil P. A Focal Ablation Catheter Toggling Between Radiofrequency and Pulsed Field Energy to Treat Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:1786-1801. [PMID: 37227340 DOI: 10.1016/j.jacep.2023.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Because of its safety, "single-shot" pulsed field ablation (PFA) catheters have been developed for pulmonary vein isolation (PVI). However, most atrial fibrillation (AF) ablation procedures are performed with focal catheters to permit flexibility of lesion sets beyond PVI. OBJECTIVES This study sought to determine the safety and efficacy of a focal ablation catheter able to toggle between radiofrequency ablation (RFA) or PFA to treat paroxysmal or persistent AF. METHODS In a first-in-human study, a focal 9-mm lattice tip catheter was used for PFA posteriorly and either irrigated RFA (RF/PF) or PFA (PF/PF) anteriorly. Protocol-driven remapping was at ∼3 months postablation. The remapping data prompted PFA waveform evolution: PULSE1 (n = 76), PULSE2 (n = 47), and the optimized PULSE3 (n = 55). RESULTS The study included 178 patients (paroxysmal/persistent AF = 70/108). Linear lesions, either PFA or RFA, included 78 mitral, 121 cavotricuspid isthmus, and 130 left atrial roof lines. All lesion sets (100%) were acutely successful. Invasive remapping of 122 patients revealed improvement of PVI durability with waveform evolution: PULSE1: 51%; PULSE2: 87%; and PULSE3: 97%. After 348 ± 652 days of follow-up, the 1-year Kaplan-Meier estimates for freedom from atrial arrhythmias were 78.3% ± 5.0% and 77.9% ± 4.1% for paroxysmal and persistent AF, respectively, and 84.8% ± 4.9% for the subset of persistent AF patients receiving the PULSE3 waveform. There was 1 primary adverse event-inflammatory pericardial effusion not requiring intervention. CONCLUSIONS AF ablation with a focal RF/PF catheter allows efficient procedures, chronic lesion durability, and good freedom from atrial arrhythmias-for both paroxysmal and persistent AF. (Safety and Performance Assessment of the Sphere-9 Catheter and the Affera Mapping and RF/PF Ablation System to Treat Atrial Fibrillation; NCT04141007 and NCT04194307).
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Affiliation(s)
- Vivek Y Reddy
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic; Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gediminas Rackauskas
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Jan Petru
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | | | - Kentaro Minami
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Pierre Jais
- University of Bordeaux, CHU Bordeaux, IHU LIRYC (L'Institut des maladies du rhythm cardiaque) ANR-10-IAHU-04, Bordeaux, France
| | - Germanas Marinskis
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Audrius Aidietis
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
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11
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Davong B, Adeliño R, Delasnerie H, Albenque JP, Combes N, Cardin C, Voglimacci-Stephanopoli Q, Combes S, Boveda S. Pulsed-Field Ablation on Mitral Isthmus in Persistent Atrial Fibrillation: Preliminary Data on Efficacy and Safety. JACC Clin Electrophysiol 2023:S2405-500X(23)00261-X. [PMID: 37354173 DOI: 10.1016/j.jacep.2023.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Pulsed-field ablation (PFA) is a new and promising modality of ablation that has been shown to specifically ablate cardiac tissue while sparing other anatomic structures, thus avoiding thermal ablation-related complications. Recent studies have certified safety and efficacy of PFA for pulmonary vein isolation (PVI) in the setting of paroxysmal atrial fibrillation (AF). However, there are very limited data assessing the feasibility and safety of PFA ablation of different substrates within the left atrium in the setting of persistent AF. OBJECTIVES The purpose of this study was to evaluate the feasibility and safety of mitral isthmus (MI) ablation in addition to PVI and posterior wall (PW) ablation with PFA in patients with persistent AF. METHODS We prospectively included all consecutive patients with persistent AF who underwent a first ablation procedure with PFA. We performed in all these patients a substrate ablation strategy comprising PVI, PW, and MI ablation with the use of PFA only. The primary feasibility endpoint was obtaining a persistent MI block at the end of the procedure. The safety endpoint was a composite of major safety events. RESULTS From November 2021 to September 2022, we included 45 patients. Complete MI block was achieved in all 45 (100%). Three patients presented with complications, among them 2 cases (4.4%) of reversible and nonfatal coronary spasm. During a mean follow-up time of 107.8 ± 59.5 days, a 20% recurrence rate was observed. CONCLUSIONS PFA is a feasible and safe ablation approach for mitral isthmus ablation in addition to PVI in patients with persistent AF.
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Affiliation(s)
- Baptiste Davong
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Raquel Adeliño
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Hubert Delasnerie
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | | | - Nicolas Combes
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Christelle Cardin
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | | | - Stéphane Combes
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France.
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12
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Hartl S, Reinsch N, Füting A, Neven K. Pearls and Pitfalls of Pulsed Field Ablation. Korean Circ J 2023; 53:273-293. [PMID: 37161743 PMCID: PMC10172271 DOI: 10.4070/kcj.2023.0023] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 05/11/2023] Open
Abstract
Pulsed field ablation (PFA) was recently rediscovered as an emerging treatment modality for the ablation of cardiac arrhythmias. Ultra-short high voltage pulses are leading to irreversible electroporation of cardiac cells subsequently resulting in cell death. Current literature of PFA for pulmonary vein isolation (PVI) consistently reported excellent acute and long-term efficacy along with a very low adverse event rate. The undeniable benefit of the novel ablation technique is that cardiac cells are more susceptible to electrical fields whereas surrounding structures such as the pulmonary veins, the phrenic nerve or the esophagus are not, or if at all, minimally affected, which results in a favorable safety profile that is expected to be superior to the current standard of care without compromising efficacy. Nevertheless, the exact mechanisms of electroporation are not yet entirely understood on a cellular basis and pulsed electrical field protocols of different manufactures are not comparable among one another and require their own validation for each indication. Importantly, randomized controlled trials and comparative data to current standard of care modalities, such as radiofrequency- or cryoballoon ablation, are still missing. This review focuses on the "pearls" and "pitfalls" of PFA, a technology that has the potential to become the future leading energy source for PVI and beyond.
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Affiliation(s)
- Stefan Hartl
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany.
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13
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Schaack D, Schmidt B, Tohoku S, Bordignon S, Urbanek L, Ebrahimi R, Hirokami J, Efe TH, Chen S, Chun KRJ. Pulsed Field Ablation for Atrial Fibrillation. Arrhythm Electrophysiol Rev 2023; 12:e11. [PMID: 37427302 PMCID: PMC10326665 DOI: 10.15420/aer.2022.45] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 01/31/2023] [Indexed: 07/11/2023] Open
Abstract
Catheter ablation is a widely used, effective and safe treatment for AF. Pulsed field ablation (PFA), as a novel energy source for cardiac ablation, has been shown to be tissue selective and is expected to decrease damage to non-cardiac tissue while providing high efficacy in pulmonary vein isolation. The FARAPULSE ablation system (Boston Scientific) follows the idea of single-shot ablation and is the first device approved for clinical use in Europe. Since its approval, multiple high-volume centres have performed increasing numbers of PFA procedures in patients with AF and have published their experiences. This review summarises the current clinical experience regarding the use of PFA for AF using the FARAPULSE system. It provides an overview of its efficacy and safety.
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Affiliation(s)
- David Schaack
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
- Universitätsklinikum Frankfurt, Medizinische Klinik 3 – Klinik für Kardiologie, Frankfurt, Germany
| | - Shota Tohoku
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | | | - Lukas Urbanek
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Ramin Ebrahimi
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Jun Hirokami
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Tolga Han Efe
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
- Die Sektion Medizin, Universität zu Lübeck, Lübeck, Germany
| | - KR Julian Chun
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
- Die Sektion Medizin, Universität zu Lübeck, Lübeck, Germany
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14
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PV Isolation Using a Spherical Array PFA Catheter: Application Repetition and Lesion Durability (PULSE-EU Study). JACC Clin Electrophysiol 2023; 9:638-648. [PMID: 36828771 DOI: 10.1016/j.jacep.2023.01.009] [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: 12/21/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Preclinical studies have revealed that pulsed field ablation (PFA) lesion dimensions increase with repetitive applications at a similar electric field. OBJECTIVES This study investigated whether pulmonary vein isolation (PVI) durability varies with single vs repetitive pulsed field (PF) applications. METHODS Atrial fibrillation patients underwent PVI using a spherical multielectrode array PFA catheter delivered with a 19-F deflectable sheath under intracardiac echocardiographic guidance. Esophagogastroduodenoscopy and brain magnetic resonance imaging were performed within 1 to 3 days, and invasive remapping at ∼2 to 3 months. RESULTS The patient cohort (n = 21; age 63 ± 11 years; 67% women) underwent PVI in either of 2 groups: group 1 (n = 11)-single PF application/PV; and group 2 (n = 10)-3 PF applications/PV. In both groups, PVI was acutely successful in all (100%) patients. Despite significantly longer pulse delivery times (75.2 ± 7.4 s/patient vs 24.5 ± 5.5 s/patient) the procedure times (73.2 ± 13.7 minutes vs 93.7 ± 18.5 minutes) were shorter with group 2 vs group 1. There was no stroke/transient ischemic attack, pericardial effusion, phrenic nerve injury, or esophageal complications. Esophagogastroduodenoscopy was normal in both groups of patients (n = 9). Screening brain magnetic resonance imaging revealed asymptomatic cerebral lesions (diffusion weighted imaging+/ fluid attenuated inversion recovery-) in 3 of 16 (18.7%) patients. PV remapping revealed durable PVI in 62.5% PVs in group 1 (n = 10), compared with all 100% PVs in group 2 (n = 9); this translates to all PVs being durably isolated in 30% vs 100% (P < 0.05) of patients in groups 1 and 2, respectively. CONCLUSIONS In his first-in-human trial, the "single-shot" spherical array PFA catheter was shown to safely isolate PVs. Repetitive PF application is key for lesion consolidation to maximize PVI durability.
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15
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Reddy VY, Petru J, Funasako M, Kopriva K, Hala P, Chovanec M, Janotka M, Kralovec S, Neuzil P. Coronary Arterial Spasm During Pulsed Field Ablation to Treat Atrial Fibrillation. Circulation 2022; 146:1808-1819. [PMID: 36134574 DOI: 10.1161/circulationaha.122.061497] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pulsed field ablation (PFA) has a unique safety profile when used to treat atrial fibrillation, largely related to its preferentiality for myocardial tissue ablation, in particular, esophageal sparing. A pentaspline catheter was the first such PFA system studied clinically for atrial fibrillation ablation; in these initial regulatory trials, the catheter was used for pulmonary vein isolation and left atrial posterior wall ablation. Since its regulatory approval in Europe, in clinical practice, physicians have ablated beyond pulmonary vein isolation and left atrial posterior wall ablation to expanded lesion sets in closer proximity to coronary arteries. This is an unstudied important issue because preclinical and clinical data have raised the potential for coronary arterial spasm. Herein, we studied the vasospastic potential of PFA lesion sets, both remote from and adjacent to coronary arteries. METHODS During routine atrial fibrillation ablation using the pentaspline PFA catheter, coronary angiography was performed before, during, and after pulsed field applications. The lesion sets studied included: (1) those remote from the coronary arteries such as pulmonary vein isolation (n=25 patients) and left atrial posterior wall ablation (n=5), and (2) ablation of the cavotricuspid isthmus (n=20) that is situated adjacent to the right coronary artery. RESULTS During pulmonary vein isolation and left atrial posterior wall ablation, coronary spasm did not occur, but cavotricuspid isthmus ablation provoked severe subtotal vasospasm in 5 of 5 (100%) consecutive patients, and this was relieved by intracoronary nitroglycerin in 5.5±3.5 minutes. ST-segment elevation was not observed. However, no patient (0%, P=0.004) had severe spasm if first administered parenteral nitroglycerin, either intracoronary (n=5) or intravenous (n=10), before treatment. CONCLUSIONS Coronary vasospasm was not provoked during PFA at locations remote from coronary arteries, but when the energy is delivered adjacent to a coronary artery, PFA routinely provokes subclinical vasospasm. This phenomenon is attenuated by nitroglycerin, administered either post hoc to treat spasm or as prophylaxis.
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Affiliation(s)
- Vivek Y Reddy
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.).,Icahn School of Medicine at Mount Sinai, New York (V.Y.R.)
| | - Jan Petru
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Moritoshi Funasako
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Karel Kopriva
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Pavel Hala
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Milan Chovanec
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Marek Janotka
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Stepan Kralovec
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
| | - Petr Neuzil
- Homolka Hospital, Prague, Czech Republic (V.Y.R., J.P., M.F., K.K., P.H., M.C., M.J., S.K., P.N.)
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16
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Nakagawa H, Ikeda A, Yokoyama K, An Y, Hussein AA, Saliba WI, Wazni OM, Castellvi Q. Improvement in Lesion Formation with Radiofrequency Energy and Utilization of Alternate Energy Sources (Cryoablation and Pulsed Field Ablation) for Ventricular Arrhythmia Ablation. Card Electrophysiol Clin 2022; 14:757-767. [PMID: 36396191 DOI: 10.1016/j.ccep.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Current ablation systems rely on thermal energy to produce ablation lesions (heating: RF, laser and ultrasound, and cooling: cryo-thermia). While thermal ablation has been proven to be effective, there are several limitations: 1) relatively long procedural times; 2) high recurrence rate of ventricular arrhythmias; and 3) excessive heating potentially leading to serious complications, including steam pop (perforation), coronary arterial injury and thrombo-embolism. Pulsed field ablation (PFA)/irreversible electroporation (IRE) offers a unique non-thermal ablation strategy which has the potential to overcome these limitations. Recent pre-clinical studies suggest that PFA/IRE might be effective and safe for the treatment of cardiac arrhythmias.
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Affiliation(s)
- Hiroshi Nakagawa
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA.
| | - Atsushi Ikeda
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Katsuaki Yokoyama
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshimori An
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ayman A Hussein
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Walid I Saliba
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Oussama M Wazni
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Quim Castellvi
- Department of Information and Communications Technologies, Pompeu Fabra University, Barcelona, Spain
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17
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Reinsch N, Füting A, Höwel D, Bell J, Lin Y, Neven K. Cerebral safety after pulsed field ablation for paroxysmal atrial fibrillation. Heart Rhythm 2022; 19:1813-1818. [PMID: 35718318 DOI: 10.1016/j.hrthm.2022.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a novel, nonthermal ablation modality that can ablate myocardial tissue with minimal effects on surrounding tissue. Preclinical data show an absence of cerebral emboli after extensive PFA. However, clinical data on silent cerebral lesions (SCLs) and/or silent cerebral events (SCEs) after PFA are lacking. OBJECTIVES The purpose of this study was to investigate the occurrence of neurological deficits and SCL and/or SCE after PFA in paroxysmal atrial fibrillation (AF) using National Institutes of Health Stroke Scale (NIHSS) scores and magnetic resonance imaging (MRI). METHODS In patients with symptomatic paroxysmal AF, pulmonary vein isolation (PVI) using PFA was performed. NIHSS scores were assessed before and 2 days and 30 days after PVI. One day after PVI, patients underwent cerebral 1.5-T MRI scanning using diffusion-weighted imaging and fluid-attenuated inversion recovery sequences to document the occurrence of SCL/SCE. RESULTS PFA was performed in 30 patients (age 63 ± 10 years). No patient showed neurological deficits. All NIHSS scores showed the minimum value of 0. Cerebral MRI scans were normal in 29 of 30 patients (97%). In 1 patient (3%), a single 7-mm cerebellar lesion was observed. Forty days after the procedure, follow-up cerebral MRI scan showed complete regression of the lesion. CONCLUSION In patients treated with PFA for symptomatic paroxysmal AF, the incidence of MRI-detected asymptomatic thromboembolic cerebral events or lesions was as low as 3%. No neurological deficits occurred in any of the patients.
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Affiliation(s)
- Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany.
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Dennis Höwel
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - John Bell
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Yali Lin
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
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18
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Blockhaus C, Guelker JE, Feyen L, Bufe A, Seyfarth M, Shin DI. Pulsed field ablation for pulmonary vein isolation: real-world experience and characterization of the antral lesion size compared with cryoballoon ablation. J Interv Card Electrophysiol 2022; 66:567-575. [PMID: 36038739 DOI: 10.1007/s10840-022-01359-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/22/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a new, non-thermal technology in the treatment of atrial fibrillation (AF). Early investigations have shown a promising safety profile with durable pulmonary vein isolation (PVI) and large antral lesions. However, clinical data remains scarce. METHODS We investigated a cohort of 43 patients. Twenty-three patients underwent PVI with PFA in our hospital and we analyzed them with regard to procedural characteristics and with regard to the size of acute antral lesion which was estimated by using an electroanatomical map of the left atrium (LA). We compared these data with data of 20 patients who had undergone cryoballon (CB) PVI in our hospital. RESULTS We could show acute isolation of all veins in all patients (100% PFA, 100% CB). Post-ablation high-density mapping revealed no early reconnection (0%). The acute antral lesion size of PFA was significantly higher compared to the CB (67.03 ± 12.69% vs. 57.39 ± 10.91%, p = 0.01). In the PFA group, we found no acute phrenic nerve injury, no major or minor bleeding, and no tamponade but one (4.34%) patient suffered from a stroke. Transient hypotension was observed frequently as well as transient bradycardia or asystole episodes requiring right ventricular pacing. In the CB group, no complications occurred. Furthermore, we discuss practical issues on PFA procedures. CONCLUSIONS PFA is a promising technology with high acute PV isolation rate and large antral lesions compared to CB. However, larger trials with more patients and data on long-term freedom of AF but also complications are needed.
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Affiliation(s)
- Christian Blockhaus
- Department of Cardiology, Heart Centre Niederrhein, Helios Clinic Krefeld, Lutherplatz 40, 47805, Krefeld, Germany. .,Faculty of Health, School of Medicine, University Witten/Herdecke, 58448, Witten, Germany.
| | - Jan-Erik Guelker
- Faculty of Health, School of Medicine, University Witten/Herdecke, 58448, Witten, Germany.,Department of Cardiology, Petrus Hospital, 42283, Wuppertal, Germany
| | - Ludger Feyen
- Faculty of Health, School of Medicine, University Witten/Herdecke, 58448, Witten, Germany.,Department of Diagnostic and Interventional Radiology, Helios Clinic Krefeld, 47805, Krefeld, Germany.,Department of Diagnostic and Interventional Radiology, Helios University Hospital, 42283, Wuppertal, Germany
| | - Alexander Bufe
- Department of Cardiology, Heart Centre Niederrhein, Helios Clinic Krefeld, Lutherplatz 40, 47805, Krefeld, Germany.,Faculty of Health, School of Medicine, University Witten/Herdecke, 58448, Witten, Germany
| | - Melchior Seyfarth
- Faculty of Health, School of Medicine, University Witten/Herdecke, 58448, Witten, Germany.,Department of Cardiology, Helios University Hospital, 42283, Wuppertal, Germany
| | - Dong-In Shin
- Department of Cardiology, Heart Centre Niederrhein, Helios Clinic Krefeld, Lutherplatz 40, 47805, Krefeld, Germany.,Faculty of Health, School of Medicine, University Witten/Herdecke, 58448, Witten, Germany
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19
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Qiu J, Lan L, Wang Y. Pulsed Electrical Field in Arrhythmia Treatment: Current Status and Future Directions. Pacing Clin Electrophysiol 2022; 45:1255-1262. [PMID: 36029174 DOI: 10.1111/pace.14586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
Pulsed electrical field (PEF) ablation is a promising novel ablation modality for the treatment of arrhythmia, especially for atrial fibrillation(AF). It relies on electroporation inducing cellular permeabilization by the formation of pores in cell membranes, potentially resulting in cell death. Due to its' non-thermal nature and remarkable tissue selectivity, PEF ablation has be expected largely to replace conventional energy sources, such as radiofrequency (RF) and cryothermy. Up to now, the results in almost all clinical studies of PFA for AF ablation are optimistic, both in terms of effectiveness and safety. The possibility of clinical application of this technology to ventricular tachycardia(VT) has also been supported by several animal models. In this review, we aim to give an overview of the mechanism and technical progress of PFA in cardiac arrhythmia treatment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jie Qiu
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lan Lan
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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20
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Groen MHA, van Driel VJHM, Neven K, van Wessel H, de Bakker JMT, Doevendans PAF, Wittkampf FHM, Loh P, van Es R. Multielectrode Contact Measurement Can Improve Long-Term Outcome of Pulmonary Vein Isolation Using Circular Single-Pulse Electroporation Ablation. Circ Arrhythm Electrophysiol 2022; 15:e010835. [PMID: 35917465 PMCID: PMC9384826 DOI: 10.1161/circep.121.010835] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) ablation is generally performed with multielectrode catheters. Electrode-tissue contact is an important predictor for the success of pulmonary vein (PV) isolation; however, contact force is difficult to measure with multielectrode ablation catheters. In a preclinical study, we assessed the feasibility of a multielectrode impedance system (MEIS) as a predictor of long-term success of PV isolation. In addition, we present the first-in-human clinical experience with MEIS. METHODS In 10 pigs, one PV was ablated based on impedance (MEIS group), and the other PV was solely based on local electrogram information (electrophysiological group). IRE ablations were performed at 200 J. After 3 months, recurrence of conduction was assessed. Subsequently, in 30 patients undergoing PV isolation with IRE, MEIS was evaluated and MEIS contact values were compared to local electrograms. RESULTS In the porcine study, 43 IRE applications were delivered in 19 PVs. Acutely, no reconnections were observed in either group. After 3 months, 0 versus 3 (P=0.21) PVs showed conduction recurrence in the MEIS and electrophysiological groups, respectively. Results from the clinical study showed a significant linear relation was found between mean MEIS value and bipolar dV/dt (r2=0.49, P<0.001), with a slope of 20.6 mV/s per Ohm. CONCLUSIONS Data from the animal study suggest that MEIS values predict effective IRE applications. For the long-term success of electrical PV isolation with circular IRE applications, no significant difference in efficacy was found between ablation based on the measurement of electrode interface impedance and ablation using the classical electrophysiological approach for determining electrode-tissue contact. Experiences of the first clinical use of MEIS were promising and serve as an important basis for future research.
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Affiliation(s)
- Marijn H A Groen
- Division Heart and Lungs, Department of Cardiology, University Medical Center (M.H.A.G., V.J.H.M.v.D., K.N., H.v.W., P.A.F.D., F.H.M.W., P.L., R.v.E.).,Netherlands Heart Institute, Utrecht (M.H.A.G., P.A.F.D.)
| | - Vincent J H M van Driel
- Division Heart and Lungs, Department of Cardiology, University Medical Center (M.H.A.G., V.J.H.M.v.D., K.N., H.v.W., P.A.F.D., F.H.M.W., P.L., R.v.E.).,Department of Cardiology, Haga Teaching Hospital, The Hague, the Netherlands (V.J.H.M.v.D.)
| | - Kars Neven
- Division Heart and Lungs, Department of Cardiology, University Medical Center (M.H.A.G., V.J.H.M.v.D., K.N., H.v.W., P.A.F.D., F.H.M.W., P.L., R.v.E.).,Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen (K.N.).,Department of Medicine, Witten/Herdecke University, Witten, Germany (K.N.)
| | - Harry van Wessel
- Division Heart and Lungs, Department of Cardiology, University Medical Center (M.H.A.G., V.J.H.M.v.D., K.N., H.v.W., P.A.F.D., F.H.M.W., P.L., R.v.E.).,Abbott Medical Nederland B.V., Veenendaal (H.v.W.)
| | - J M T de Bakker
- Heart Center, Department of Experimental Cardiology, Academic Medical Center Amsterdam, the Netherlands (J.M.T.d.B.)
| | - Pieter A F Doevendans
- Division Heart and Lungs, Department of Cardiology, University Medical Center (M.H.A.G., V.J.H.M.v.D., K.N., H.v.W., P.A.F.D., F.H.M.W., P.L., R.v.E.).,Netherlands Heart Institute, Utrecht (M.H.A.G., P.A.F.D.)
| | - Fred H M Wittkampf
- Division Heart and Lungs, Department of Cardiology, University Medical Center (M.H.A.G., V.J.H.M.v.D., K.N., H.v.W., P.A.F.D., F.H.M.W., P.L., R.v.E.)
| | - Peter Loh
- Division Heart and Lungs, Department of Cardiology, University Medical Center (M.H.A.G., V.J.H.M.v.D., K.N., H.v.W., P.A.F.D., F.H.M.W., P.L., R.v.E.)
| | - René van Es
- Division Heart and Lungs, Department of Cardiology, University Medical Center (M.H.A.G., V.J.H.M.v.D., K.N., H.v.W., P.A.F.D., F.H.M.W., P.L., R.v.E.)
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21
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Tan NY, Ladas TP, Christopoulos G, Sugrue AM, van Zyl M, Ladejobi AO, Lodhi FK, Hu TY, Ezzeddine FM, Agboola K, Uecker D, Maor E, Tri JA, Jiang Z, Yasin OZ, DeSimone CV, Killu AM, Asirvatham SJ, Del-Carpio Munoz F. Ventricular nanosecond pulsed electric field delivery using active fixation leads: a proof-of-concept preclinical study. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01268-z. [PMID: 35771400 DOI: 10.1007/s10840-022-01268-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/02/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Mid-myocardial ventricular arrhythmias are challenging to treat. Cardiac electroporation via pulsed electric fields (PEFs) offers significant promise. We therefore tested PEF delivery using screw-in pacemaker leads as proof-of-concept. METHODS In 5 canine models, we applied nanosecond PEF (pulse width 300 ns) across the right ventricular (RV) septum using a single lead bipolar configuration (n = 2) and between two leads (n = 3). We recorded electrograms (EGMs) prior to, immediately post, and 5 min after PEF. Cardiac magnetic resonance imaging (cMRI) and histopathology were performed at 2 weeks and 1 month. RESULTS Nanosecond PEF induced minimal extracardiac stimulation and frequent ventricular ectopy that terminated post-treatment; no canines died with PEF delivery. With 1 lead, energy delivery ranged from 0.64 to 7.28 J. Transient ST elevations were seen post-PEF. No myocardial delayed enhancement (MDE) was seen on cMRI. No lesions were noted on the RV septum at autopsy. With 2 leads, energy delivery ranged from 56.3 to 144.9 J. Persistent ST elevations and marked EGM amplitude decreases developed post-PEF. MDE was seen along the septum 2 weeks and 1 month post-PEF. There were discrete fibrotic lesions along the septum; pathology revealed dense connective tissue with < 5% residual cardiomyocytes. CONCLUSIONS Ventricular electroporation is feasible and safe with an active fixation device. Reversible changes were seen with lower energy PEF delivery, whereas durable lesions were created at higher energies. Central illustration: pulsed electric field delivery into ventricular myocardium with active fixation leads.
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Affiliation(s)
- Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Thomas P Ladas
- Department of Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Georgios Christopoulos
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Alan M Sugrue
- Department of Cardiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin van Zyl
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Adetola O Ladejobi
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Fahad K Lodhi
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Tiffany Y Hu
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Kolade Agboola
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | | | - Elad Maor
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Jason A Tri
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Zhi Jiang
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Omar Z Yasin
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Freddy Del-Carpio Munoz
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA.
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22
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Grimaldi M, Di Monaco A, Gomez T, Berman D, Datta K, Sharma T, Govari A, Altman A, Di Biase L. Time Course of Irreversible Electroporation Lesion Development Through Short- and Long-Term Follow-Up in Pulsed-Field Ablation-Treated Hearts. Circ Arrhythm Electrophysiol 2022; 15:e010661. [PMID: 35763432 DOI: 10.1161/circep.121.010661] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulsed-field ablation (PFA) is a tissue-selective, nonthermal cardiac ablation modality. A novel PFA ablation system consisted of a multichannel irreversible electroporation generator system and a multielectrode circular irreversible electroporation catheter has been developed for catheter ablation. To understand the progression and immediate impacts of PFA, this study evaluated the subchronic (7±3 day) and chronic (30±3 day) safety and performance of the novel PFA system when simulating pulmonary vein and superior vena cava isolation in a porcine beating heart model. METHODS Ten swine models were divided into subchronic (n=6) and chronic cohorts (n=4). Lesions were performed within the right and left atrium to conduct right pulmonary veins and superior vena cava isolations, in addition to creating stacked lesions in the left atrium roof and right atrium posterior wall. RESULTS Acute pulmonary vein and superior vena cava isolation were achieved in 10 out of 10 swine and demonstrated 100% lesion durability in both cohorts, including sustained elimination of electrical activity at the left atrium roof and right atrium posterior wall. Histology demonstrated that all the cardiac sites ablated showed discrete zones of loss of myocardial fibers or smooth muscle cells with preservation of the tissue architecture with resultant fibrocellular replacement, neovascularization, and neocollagen deposition. Mineralization findings were present in association with residual necrotic muscle fibers. Only in 7 days group, areas of mineralization were frequently associated with inflammation. There were no treatment-related changes in other tissues, including complete sparing of the phrenic nerve. CONCLUSIONS Pulsed-field ablation for pulmonary vein and superior vena cava isolation with the novel PFA system was feasible, safe with myocardial-specific ablative effect. Durable lesions were observed at the target areas. with inflammation phenomena mainly documented at 7 days.
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Affiliation(s)
- Massimo Grimaldi
- Ospedale Generale Regionale "F. Miulli," Dipartimento di Cardiologia, Acquaviva delle Fonti, Bari, Italy (M.G., A.D.M.)
| | - Antonio Di Monaco
- Ospedale Generale Regionale "F. Miulli," Dipartimento di Cardiologia, Acquaviva delle Fonti, Bari, Italy (M.G., A.D.M.)
| | - Tara Gomez
- Biosense Webster, Inc, Irvine, CA (T.G., D.B., K.D., T.S., A.G., A.A.)
| | - Dror Berman
- Biosense Webster, Inc, Irvine, CA (T.G., D.B., K.D., T.S., A.G., A.A.)
| | - Keshava Datta
- Biosense Webster, Inc, Irvine, CA (T.G., D.B., K.D., T.S., A.G., A.A.)
| | - Tushar Sharma
- Biosense Webster, Inc, Irvine, CA (T.G., D.B., K.D., T.S., A.G., A.A.)
| | - Assaf Govari
- Biosense Webster, Inc, Irvine, CA (T.G., D.B., K.D., T.S., A.G., A.A.)
| | - Andres Altman
- Biosense Webster, Inc, Irvine, CA (T.G., D.B., K.D., T.S., A.G., A.A.)
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (L.D.B.).,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (L.D.B.)
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23
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Darby AE. Pulsed Field Ablation: a Novel Therapeutic Tool for Catheter-Based Treatment of Atrial Fibrillation. Curr Cardiol Rep 2022; 24:793-799. [PMID: 35608722 DOI: 10.1007/s11886-022-01697-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW With catheter ablation of atrial fibrillation becoming increasingly common, the field of electrophysiology is searching for tools to improve procedural efficacy and safety. This review focuses on a novel ablation tool, pulsed field ablation, which promises to push the needle forward. Pulsed field ablation uses high-frequency electrical pulses to ablate cardiac tissue. RECENT FINDINGS A number of pre-clinical and clinical studies have shown pulsed field ablation offers an efficient means of ablating cardiac tissue with minimal risk of collateral injury. Pulsed field ablation provides a non-thermal means of cardiac tissue ablation with minimal risk of injury to adjacent structures. Future studies will define the optimal current delivery, number of lesions needed to achieve the desired tissue effect, and how best to integrate pulsed field ablation catheters into 3-dimensional mapping systems.
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Affiliation(s)
- Andrew E Darby
- Department of Medicine, Cardiology Division, University of Virginia Health System: UVA Health, Charlottesville, VA, USA.
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24
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Füting A, Reinsch N, Höwel D, Brokkaar L, Rahe G, Neven K. First experience with pulsed field ablation as routine treatment for paroxysmal atrial fibrillation. Europace 2022; 24:1084-1092. [PMID: 35513354 DOI: 10.1093/europace/euac041] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Catheter ablation for atrial fibrillation (AF) using thermal energy can cause collateral damage. Pulsed field ablation (PFA) is a novel non-thermal energy source. Few small clinical studies have been published. We report on the first 'real-world' experience with pulmonary vein isolation (PVI) using PFA for paroxysmal AF (PAF). METHODS AND RESULTS Pre- and post-ablation, phrenic nerve function was assessed. After high-density left atrial (LA) bipolar voltage mapping, all PVs were individually isolated using a 13 Fr steerable sheath and a pentaspline PFA over-the-wire catheter. After ablation, bipolar voltage mapping was repeated to assess lesion formation. In 30 PAF patients (mean 63 years; 53% female), uncomplicated PFA was performed, with all PVs acutely isolated. The median procedure time was 116 min. The median PFA catheter LA dwell time was 29 min. The median fluoroscopy time was 26 min. In one patient with roof-dependent flutter, a roof line was intentionally created. In two patients, unintentional bidirectional mitral isthmus block was created. There was no phrenic nerve or oesophageal damage. In one patient, pericardial drainage after cardiac tamponade was performed. In-hospital stay and 30-day follow-up were uneventful. After 90 days, 97% of patients were in sinus rhythm. CONCLUSION PVI using PFA for PAF in a 'real-world' setting appears to be safe and feasible in this small patient cohort. Procedure times are homogeneous, and LA dwell time is short. Atrial ablation lines can easily be created. Unintentional ablation of atrial tissue can occur, accurate catheter alignment to the PV ostium and axis should be ensured.
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Affiliation(s)
- Anna Füting
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany.,Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany.,Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Dennis Höwel
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany.,Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Lenny Brokkaar
- Department of Medicine, Witten/Herdecke University, Witten, Germany.,Department of Pulmonology, Alfried Krupp Hospital, Essen, Germany
| | - Gilbert Rahe
- Department of Medicine, Witten/Herdecke University, Witten, Germany.,Department of Gastroenterology, Alfried Krupp Hospital, Alfried-Krupp-Str. 21, 45131 Essen, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany.,Department of Medicine, Witten/Herdecke University, Witten, Germany
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25
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Hsu JC, Gibson D, Banker R, Doshi SK, Gidney B, Gomez T, Berman D, Datta K, Govari A, Natale A. In-vivo porcine characterization of atrial lesion safety and efficacy utilizing a circular pulsed-field ablation catheter including assessment of collateral damage to adjacent tissue in supratherapeutic ablation applications. J Cardiovasc Electrophysiol 2022; 33:1480-1488. [PMID: 35510408 PMCID: PMC9545022 DOI: 10.1111/jce.15522] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Pulsed field ablation (PFA), an ablative method that causes cell death by irreversible electroporation, has potential safety advantages over radiofrequency ablation and cryoablation. Pulmonary vein (PV) isolation was performed in a porcine model to characterize safety and performance of a novel, fully-integrated biphasic PFA system comprising a multi-channel generator, variable loop circular catheter, and integrated PFA mapping software module. METHODS Eight healthy porcine subjects were included. To evaluate safety, multiple ablations were performed, including sites not generally targeted for therapeutic ablation, such as the right inferior PV lumen, right superior PV ostium, and adjacent to the esophagus and phrenic nerve. To evaluate efficacy, animals were recovered, followed for 30(±3) days, then re-mapped. Gross pathological and histopathological examinations assessed procedural injuries, chronic thrombosis, tissue ablation, penetration depth, healing, and inflammatory response. RESULTS All 8 animals survived follow-up. PV narrowing was not observed acutely nor at follow-up, even when ablation was performed deep to the PV ostium. No injury was seen grossly or histologically in adjacent structures. All PVs were durably isolated, confirmed by bidirectional block at re-map procedure. Histological examination showed complete, transmural necrosis around the circumference of the ablated section of right PVs. CONCLUSION This pre-clinical evaluation of a fully-integrated PFA system demonstrated effective and durable ablation of cardiac tissue and PV isolation without collateral damage to adjacent structures, even when ablation was performed in more extreme settings than those used therapeutically. Histological staining confirmed complete transmural cell necrosis around the circumference of the PV ostium at 30 days. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine University of California, San Diego, 9452 Medical Center Dr., MC7411, La Jolla, CA, 92037
| | - Douglas Gibson
- Interventional Electrophysiology, Scripps Clinic and Prebys Cardiovascular Institute, 9898 Genesee Ave, La Jolla, CA, 92037
| | - Rajesh Banker
- Premier Cardiology, 520 Superior Avenue Suite 330, Newport Beach, CA, 92663
| | - Shephal K Doshi
- Pacific Heart Institute, 2001 Santa Monica Blvd., Suite 280 W, Santa Monica, CA, 90494
| | - Brett Gidney
- Heart Rhythm Center, 504 W Pueblo Street Suite 101, Santa Barbara, CA, 93105
| | - Tara Gomez
- Biosense Webster Inc., 15715 Arrow Hwy, Irwindale, CA, 91706
| | - Dror Berman
- Biosense Webster Inc., 15715 Arrow Hwy, Irwindale, CA, 91706
| | - Keshava Datta
- Biosense Webster Inc., 15715 Arrow Hwy, Irwindale, CA, 91706
| | - Assaf Govari
- Biosense Webster Inc., 15715 Arrow Hwy, Irwindale, CA, 91706
| | - Andrea Natale
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine University of California, San Diego, 9452 Medical Center Dr., MC7411, La Jolla, CA, 92037.,Texas Cardiac Arrhythmia Research, 3000 N. IH-35, Suite 705, Austin, TX, 78705.,MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 Metrohealth Dr., Cleveland, OH, 44109
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26
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Bi S, Jia F, Lv C, He Q, Xu X, Xue Z, Su S. Preclinical Study of Biphasic Asymmetric Pulsed Field Ablation. Front Cardiovasc Med 2022; 9:859480. [PMID: 35402543 PMCID: PMC8987372 DOI: 10.3389/fcvm.2022.859480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/28/2022] [Indexed: 11/25/2022] Open
Abstract
Pulsed field ablation (PFA) is a novel method of pulmonary venous isolation in atrial fibrillation ablation and is featured by tissue-selective ablation. Isolation is achieved via the application of high-voltage microsecond pulses that create irreversible perforations in cell membranes (i.e., electroporation). We proposed a new biphasic asymmetric pulse mode and verified the lesion persistence and safety of this mode for pulmonary vein ostia ablation in preclinical studies. We found that biphasic asymmetric pulses can effectively reduce muscle contractions and drop ablation threshold. In the electroanatomic mapping, the ablation site showed a continuous low potential area, and the atrium was not captured after 30 days of pacing. Pathological staining showed that cardiomyocytes in the ablation area were replaced by fibroblasts and there was no damage outside the ablation zone. Our results show that pulmonary venous isolation using the biphasic asymmetric discharge mode is safe, durable, effective, and causes no damage to other tissues.
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Affiliation(s)
- Shengyu Bi
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
| | - Fenglin Jia
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
| | - Chang Lv
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
| | - Qiang He
- Department of Cardiology, Tianjin First Central Hospital, Tianjin, China
| | - Xinyu Xu
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
- *Correspondence: Xinyu Xu
| | - Zhixiao Xue
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
- Zhixiao Xue
| | - Siying Su
- Tianjin Intelligent Health Medical Co., Ltd., Tianjin, China
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27
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Maan A, Koruth J. Pulsed Field Ablation: a New Paradigm for Catheter Ablation of Arrhythmias. Curr Cardiol Rep 2022; 24:103-108. [PMID: 35235146 DOI: 10.1007/s11886-021-01630-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Current ablation approach for arrhythmias relies upon the use of radiofrequency (RF) and cryoablation catheters. Although there have been significant advances both in catheter design and in energy delivery approaches, limitations such as suboptimal efficacy and safety remain. Pulsed field ablation (PFA) has emerged as a novel approach to ablation that is distinct from RF and cryoablation by virtue of selective ablation of myocardial tissue. Preclinical and clinical reports have demonstrated lesion durability with an excellent safety profile. These findings need to be confirmed in prospective randomized trials that are currently ongoing. In this review, we describe efficacy and safety outcomes from both pre-clinical and clinical studies that have been performed so far and briefly discuss ongoing clinical trials and future investigations. RECENT FINDINGS Data from pre-clinical and clinical research have shown PFA as a promising tool for ablation of cardiac arrhythmias. In addition to safety regarding mitigating the risk to surrounding structures such as the phrenic nerve, esophagus, PFA also offers an effective method for ablation. In this review, we summarize the currently published pre-clinical and clinical data evaluating the safety and efficacy of PFA for cardiac arrhythmias.
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Affiliation(s)
- Abhishek Maan
- Cardiac Arrhythmia Service, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Jacob Koruth
- Division of Cardiac Electrophysiology, Mount Sinai School of Medicine, New York, NY, USA
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Baykaner T, Fazal M, Verma A. Taking the "pulse" of pulsed-field ablation: Real-world experience. J Cardiovasc Electrophysiol 2022; 33:357-359. [PMID: 34978359 PMCID: PMC9022476 DOI: 10.1111/jce.15348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/04/2021] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, CA
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29
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Reinsch N, Füting A, Höwel D, Neven K. [Pulsed field ablation : The ablation technique of the future?]. Herzschrittmacherther Elektrophysiol 2022; 33:12-18. [PMID: 34997292 DOI: 10.1007/s00399-021-00833-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 11/25/2022]
Abstract
The ablation of cardiac arrhythmias is now standard therapy in invasive electrophysiology with a focus on atrial fibrillation due to its high prevalence. Thermal energy sources such as radiofrequency or cryoablation are the most commonly used techniques to date. Due to limitations in terms of effectiveness and safety because of possible indiscriminate tissue destruction, ablation using pulsed field ablation (PFA) can be a safe and effective alternative to thermal ablation techniques. This is a nonthermal form of energy that creates effective myocardial lesions by means of irreversible electroporation by generating short, high-energy electrical impulses. Preliminary data show high effectiveness with a low complication rate. Myocardial tissue shows a high specificity while sparing surrounding structures such as the esophagus, the phrenic nerve and surrounding vascular structures. Therefore, irreversible electroporation is a very promising technique and has the potential to become the perfect form of energy for many catheter ablations and especially for pulmonary vein isolation. In this article we provide an overview of the current status of PFA as well as an outlook on future fields of treatment.
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Affiliation(s)
- Nico Reinsch
- Abteilung für Elektrophysiologie, Alfried Krupp Krankenhaus, Alfried-Krupp-Str. 21, 45131, Essen, Deutschland.
- Universität Witten/Herdecke, Witten, Deutschland.
| | - Anna Füting
- Abteilung für Elektrophysiologie, Alfried Krupp Krankenhaus, Alfried-Krupp-Str. 21, 45131, Essen, Deutschland
- Universität Witten/Herdecke, Witten, Deutschland
| | - Dennis Höwel
- Abteilung für Elektrophysiologie, Alfried Krupp Krankenhaus, Alfried-Krupp-Str. 21, 45131, Essen, Deutschland
| | - Kars Neven
- Abteilung für Elektrophysiologie, Alfried Krupp Krankenhaus, Alfried-Krupp-Str. 21, 45131, Essen, Deutschland
- Universität Witten/Herdecke, Witten, Deutschland
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Verma A, Boersma L, Haines DE, Natale A, Marchlinski FE, Sanders P, Calkins H, Packer DL, Hummel J, Onal B, Rosen S, Kuck KH, Hindricks G, Wilsmore B. First-in-Human Experience and Acute Procedural Outcomes Using a Novel Pulsed Field Ablation System: The PULSED AF Pilot Trial. Circ Arrhythm Electrophysiol 2021; 15:e010168. [PMID: 34964367 PMCID: PMC8772438 DOI: 10.1161/circep.121.010168] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Pulsed field ablation (PFA) is a novel form of ablation using electrical fields to ablate cardiac tissue. There are only limited data assessing the feasibility and safety of this type of ablation in humans. Methods: PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; https://www.clinicaltrials.gov; unique identifier: NCT04198701) is a nonrandomized, prospective, multicenter, global, premarket clinical study. The first-in-human pilot phase evaluated the feasibility and efficacy of pulmonary vein isolation using a novel PFA system delivering bipolar, biphasic electrical fields through a circular multielectrode array catheter (PulseSelect; Medtronic, Inc). Thirty-eight patients with paroxysmal or persistent atrial fibrillation were treated in 6 centers in Australia, Canada, the United States, and the Netherlands. The primary outcomes were ability to achieve acute pulmonary vein isolation intraprocedurally and safety at 30 days. Results: Acute electrical isolation was achieved in 100% of pulmonary veins (n=152) in the 38 patients. Skin-to-skin procedure time was 160±91 minutes, left atrial dwell time was 82±35 minutes, and fluoroscopy time was 28±9 minutes. No serious adverse events related to the PFA system occurred in the 30-day follow-up including phrenic nerve injury, esophageal injury, stroke, or death. Conclusions: In this first-in-human clinical study, 100% pulmonary vein isolation was achieved using only PFA with no PFA system–related serious adverse events. Graphic Abstract: A graphic abstract is available for this article.
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Affiliation(s)
- Atul Verma
- Southlake Regional Health Centre, Newmarket, Canada (A.V.)
| | - Lucas Boersma
- St. Antonius Hospital, Amsterdam, the Netherlands (L.B.)
| | | | | | | | | | | | | | - John Hummel
- OSU Wexner Medical Center, Columbus, OH (J.H.)
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Avazzadeh S, O’Brien B, Coffey K, O’Halloran M, Keane D, Quinlan LR. Establishing Irreversible Electroporation Electric Field Potential Threshold in A Suspension In Vitro Model for Cardiac and Neuronal Cells. J Clin Med 2021; 10:jcm10225443. [PMID: 34830725 PMCID: PMC8622402 DOI: 10.3390/jcm10225443] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/15/2021] [Accepted: 11/20/2021] [Indexed: 11/17/2022] Open
Abstract
Aims: Irreversible electroporation is an ablation technique being adapted for the treatment of atrial fibrillation. Currently, there are many differences reported in the in vitro and pre-clinical literature for the effective voltage threshold for ablation. The aim of this study is a direct comparison of different cell types within the cardiovascular system and identification of optimal voltage thresholds for selective cell ablation. Methods: Monophasic voltage pulses were delivered in a cuvette suspension model. Cell viability and live–dead measurements of three different neuronal lines, cardiomyocytes, and cardiac fibroblasts were assessed under different voltage conditions. The immediate effects of voltage and the evolution of cell death was measured at three different time points post ablation. Results: All neuronal and atrial cardiomyocyte lines showed cell viability of less than 20% at an electric field of 1000 V/cm when at least 30 pulses were applied with no significant difference amongst them. In contrast, cardiac fibroblasts showed an optimal threshold at 1250 V/cm with a minimum of 50 pulses. Cell death overtime showed an immediate or delayed cell death with a proportion of cell membranes re-sealing after three hours but no significant difference was observed between treatments after 24 h. Conclusions: The present data suggest that understanding the optimal threshold of irreversible electroporation is vital for achieving a safe ablation modality without any side-effect in nearby cells. Moreover, the evolution of cell death post electroporation is key to obtaining a full understanding of the effects of IRE and selection of an optimal ablation threshold.
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Affiliation(s)
- Sahar Avazzadeh
- Physiology and Cellular Physiology Research Laboratory, School of Medicine, Human Biology Building, National University of Ireland, H91 TK33 Galway, Ireland;
| | - Barry O’Brien
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 TK33 Galway, Ireland; (B.O.); (K.C.)
| | - Ken Coffey
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 TK33 Galway, Ireland; (B.O.); (K.C.)
| | - Martin O’Halloran
- Translational Medical Devise Lab, Lambe Institute of Translational Research, University College Hospital Galway, H91 TK33 Galway, Ireland;
- Electrical & Electronic Engineering, School of Engineering, National University of Ireland Galway, H91 TK33 Galway, Ireland
| | - David Keane
- Cardiac Arrhythmia Service, St Vincent’s University Hospital, D04 T6F4 Dublin, Ireland;
| | - Leo R. Quinlan
- Physiology and Cellular Physiology Research Laboratory, School of Medicine, Human Biology Building, National University of Ireland, H91 TK33 Galway, Ireland;
- CÚRAM SFI Centre for Research in Medical Devices, National University of Ireland, H91 TK33 Galway, Ireland
- Correspondence: ; Tel.: +353-91493710
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32
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O’Neill L, Wielandts JY, Gillis K, Hilfiker G, Le Polain De Waroux JB, Tavernier R, Duytschaever M, Knecht S. Catheter Ablation in Persistent AF, the Evolution towards a More Pragmatic Strategy. J Clin Med 2021; 10:jcm10184060. [PMID: 34575173 PMCID: PMC8467025 DOI: 10.3390/jcm10184060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 08/27/2021] [Accepted: 09/04/2021] [Indexed: 11/16/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and represents a heterogeneous disorder with a complex pathological basis. While significant technological advances have taken place over the last decade in the field of catheter ablation of AF, response to ablation varies and long-term success rates in those with persistent AF remain modest. Mechanistic studies have highlighted potentially different sustaining factors for AF in the persistent AF population with substrate-driven focal and re-entrant sources in the body of the atria identified on invasive and non-invasive mapping studies. Translation to clinical practice, however, remains challenging and the application of such mapping techniques to clinical ablation has yet to demonstrate a significant benefit beyond pulmonary vein isolation (PVI) alone in the persistent AF cohort. Recent advances in catheter and ablation technology have centered on improving the durability of ablation lesions at index procedure and although encouraging results have been demonstrated with early studies, large-scale trials are awaited. Further meaningful improvement in clinical outcomes in the persistent AF population requires ongoing advancement in the understanding of AF mechanisms, coupled with continuing progress in catheter technology capable of delivering durable transmural lesions.
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33
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Di Biase L, Diaz JC, Zhang XD, Romero J. Pulsed field catheter ablation in atrial fibrillation. Trends Cardiovasc Med 2021; 32:378-387. [PMID: 34329732 DOI: 10.1016/j.tcm.2021.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/06/2021] [Accepted: 07/23/2021] [Indexed: 12/21/2022]
Abstract
Catheter ablation (CA) has become the mainstay therapy for the maintenance of sinus rhythm in patients with atrial fibrillation (AF), with pulmonary vein isolation (PVI) the most frequently used treatment strategy. Although several energy sources have been tested (including radiofrequency, cryothermal and laser), these are not devoid of safety issues and in many instances effectiveness is dependent on operator experience. Pulsed field ablation (PFA) is a novel energy source by which high-voltage electric pulses are used to create pores in the cellular membrane (i.e., electroporation), leading to cellular death. The amount of energy required to produce irreversible electroporation is highly tissue dependent. In consequence, a tailored protocol in which specific targeting of the atrial myocardium is achieved while sparing adjacent tissues is theoretically feasible, increasing the safety of the procedure. While large scale clinical trials are lacking, current clinical evidence has demonstrated significant efficacy in achieving durable PVI without ablation related adverse events.
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Affiliation(s)
- Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx 10467, NY, United States.
| | - Juan Carlos Diaz
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx 10467, NY, United States
| | - Xiao-Dong Zhang
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx 10467, NY, United States
| | - Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx 10467, NY, United States
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Groen MHA, van Es R, van Klarenbosch BR, Stehouwer M, Loh P, Doevendans PA, Wittkampf FH, Neven K. In vivo analysis of the origin and characteristics of gaseous microemboli during catheter-mediated irreversible electroporation. Europace 2021; 23:139-146. [PMID: 33111141 PMCID: PMC7842095 DOI: 10.1093/europace/euaa243] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/27/2020] [Indexed: 01/21/2023] Open
Abstract
Aims Irreversible electroporation (IRE) ablation is a non-thermal ablation method based on the application of direct current between a multi-electrode catheter and skin electrode. The delivery of current through blood leads to electrolysis. Some studies suggest that gaseous (micro)emboli might be associated with myocardial damage and/or (a)symptomatic cerebral ischaemic events. The aim of this study was to compare the amount of gas generated during IRE ablation and during radiofrequency (RF) ablation. Methods and results In six 60–75 kg pigs, an extracorporeal femoral shunt was outfitted with a bubble-counter to detect the size and total volume of gas bubbles. Anodal and cathodal 200 J IRE applications were delivered in the left atrium (LA) using a 14-electrode circular catheter. The 30 and 60 s 40 W RF point-by-point ablations were performed. Using transoesophageal echocardiography (TOE), gas formation was visualized. Average gas volumes were 0.6 ± 0.6 and 56.9 ± 19.1 μL (P < 0.01) for each anodal and cathodal IRE application, respectively. Also, qualitative TOE imaging showed significantly less LA bubble contrast with anodal than with cathodal applications. Radiofrequency ablations produced 1.7 ± 2.9 and 6.7 ± 7.4 μL of gas, for 30 and 60 s ablation time, respectively. Conclusion Anodal IRE applications result in significantly less gas formation than both cathodal IRE applications and RF applications. This finding is supported by TOE observations.
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Affiliation(s)
- Marijn H A Groen
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - René van Es
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Bas R van Klarenbosch
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marco Stehouwer
- Department of Extracorporeal Circulation, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter Loh
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Fred H Wittkampf
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Kars Neven
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany.,Faculty of Health, Witten/Herdecke University, Witten, Germany
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Kowlgi GN, Kapa S. Advances in Atrial Fibrillation Ablation: Energy Sources Here to Stay. Card Electrophysiol Clin 2021; 12:167-174. [PMID: 32451101 DOI: 10.1016/j.ccep.2020.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Energy sources used for catheter ablation of atrial fibrillation (AF) ablation have undergone an exceptional journey over the past 50 years. Traditional energy sources, such as radiofrequency and cryoablation, have been the mainstay of AF ablation. Novel investigations have led to inclusion of other techniques, such as laser, high-frequency ultrasound, and microwave energy, in the armamentarium of electrophysiologists. Despite these modalities, AF has remained one of the most challenging arrhythmias. Advances in the understanding of electroporation promise to overcome the shortcomings of conventional energy sources. A thorough understanding of the biophysics and practical implications of the existing energy sources is paramount.
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Affiliation(s)
- Gurukripa N Kowlgi
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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36
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McBride S, Avazzadeh S, Wheatley AM, O’Brien B, Coffey K, Elahi A, O’Halloran M, Quinlan LR. Ablation Modalities for Therapeutic Intervention in Arrhythmia-Related Cardiovascular Disease: Focus on Electroporation. J Clin Med 2021; 10:jcm10122657. [PMID: 34208708 PMCID: PMC8235263 DOI: 10.3390/jcm10122657] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023] Open
Abstract
Targeted cellular ablation is being increasingly used in the treatment of arrhythmias and structural heart disease. Catheter-based ablation for atrial fibrillation (AF) is considered a safe and effective approach for patients who are medication refractory. Electroporation (EPo) employs electrical energy to disrupt cell membranes which has a minimally thermal effect. The nanopores that arise from EPo can be temporary or permanent. Reversible electroporation is transitory in nature and cell viability is maintained, whereas irreversible electroporation causes permanent pore formation, leading to loss of cellular homeostasis and cell death. Several studies report that EPo displays a degree of specificity in terms of the lethal threshold required to induce cell death in different tissues. However, significantly more research is required to scope the profile of EPo thresholds for specific cell types within complex tissues. Irreversible electroporation (IRE) as an ablative approach appears to overcome the significant negative effects associated with thermal based techniques, particularly collateral damage to surrounding structures. With further fine-tuning of parameters and longer and larger clinical trials, EPo may lead the way of adapting a safer and efficient ablation modality for the treatment of persistent AF.
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Affiliation(s)
- Shauna McBride
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Sahar Avazzadeh
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Antony M. Wheatley
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Barry O’Brien
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 R6W6 Galway, Ireland; (B.O.); (K.C.)
| | - Ken Coffey
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 R6W6 Galway, Ireland; (B.O.); (K.C.)
| | - Adnan Elahi
- Translational Medical Device Lab (TMDL), Lamb Translational Research Facility, University College Hospital Galway, H91 V4AY Galway, Ireland; (A.E.); (M.O.)
- Electrical & Electronic Engineering, School of Engineering, National University of Ireland Galway, H91 HX31 Galway, Ireland
| | - Martin O’Halloran
- Translational Medical Device Lab (TMDL), Lamb Translational Research Facility, University College Hospital Galway, H91 V4AY Galway, Ireland; (A.E.); (M.O.)
| | - Leo R. Quinlan
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
- CÚRAM, SFI Research Centre for Medical Devices, National University of Ireland Galway, H92 W2TY Galway, Ireland
- Correspondence:
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Reddy VY, Dukkipati SR, Neuzil P, Anic A, Petru J, Funasako M, Cochet H, Minami K, Breskovic T, Sikiric I, Sediva L, Chovanec M, Koruth J, Jais P. Pulsed Field Ablation of Paroxysmal Atrial Fibrillation: 1-Year Outcomes of IMPULSE, PEFCAT, and PEFCAT II. JACC Clin Electrophysiol 2021; 7:614-627. [PMID: 33933412 DOI: 10.1016/j.jacep.2021.02.014] [Citation(s) in RCA: 178] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This study sought to determine whether durable pulmonary vein isolation (PVI) using pulsed field ablation (PFA) translates to freedom from atrial fibrillation recurrence without an increase in adverse events. BACKGROUND PFA is a nonthermal ablative modality that, in preclinical studies, is able to preferentially ablate myocardial tissue with minimal effect on surrounding tissues. Herein, we present 1-year clinical outcomes of PFA. METHODS In 3 multicenter studies (IMPULSE [A Safety and Feasibility Study of the IOWA Approach Endocardial Ablation System to Treat Atrial Fibrillation], PEFCAT [A Safety and Feasibility Study of the FARAPULSE Endocardial Ablation System to Treat Paroxysmal Atrial Fibrillation], and PEFCAT II [Expanded Safety and Feasibility Study of the FARAPULSE Endocardial Multi Ablation System to Treat Paroxysmal Atrial Fibrillation]), paroxysmal atrial fibrillation patients underwent PVI using a basket or flower PFA catheter. Invasive remapping was performed at ∼2 to 3 months, and reconnected PVs were reisolated with PFA or radiofrequency ablation. After a 90-day blanking period, arrhythmia recurrence was assessed over 1-year follow-up. RESULTS In 121 patients, acute PVI was achieved in 100% of PVs with PFA alone. PV remapping, performed in 110 patients at 93.0 ± 30.1 days, demonstrated durable PVI in 84.8% of PVs (64.5% of patients), and 96.0% of PVs (84.1% of patients) treated with the optimized biphasic energy PFA waveform. Primary adverse events occurred in 2.5% of patients (2 pericardial effusions or tamponade, 1 hematoma); in addition, there was 1 transient ischemic attack. The 1-year Kaplan-Meier estimates for freedom from any atrial arrhythmia for the entire cohort and for the optimized biphasic energy PFA waveform cohort were 78.5 ± 3.8% and 84.5 ± 5.4%, respectively. CONCLUSIONS PVI with a "single-shot" PFA catheter results in excellent PVI durability and acceptable safety with a low 1-year rate of atrial arrhythmia recurrence. These data mitigate concern that the nonthermal ablative mechanism of PFA might mask undiscovered compromises to clinical success. (IMPULSE: A Safety and Feasibility Study of the IOWA Approach Endocardial Ablation System to Treat Atrial Fibrillation, NCT03700385; A Safety and Feasibility Study of the FARAPULSE Endocardial Ablation System to Treat Paroxysmal Atrial Fibrillation, NCT03714178; PEFCAT II Expanded Safety and Feasibility Study of the FARAPULSE Endocardial Multi Ablation System to Treat Paroxysmal Atrial Fibrillation [PEFCAT II], NCT04170608).
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Affiliation(s)
- Vivek Y Reddy
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic; Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Ante Anic
- Department of Cardiology, University Clinical Hospital Split, Split, Croatia
| | - Jan Petru
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | | | - Hubert Cochet
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kentaro Minami
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Toni Breskovic
- Department of Cardiology, University Clinical Hospital Split, Split, Croatia
| | - Ivan Sikiric
- Department of Cardiology, University Clinical Hospital Split, Split, Croatia
| | - Lucie Sediva
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Milan Chovanec
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Jacob Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pierre Jais
- IHU LIRYC ANR-10-IAHU-04, Centre Hospitalier Universitaire Bordeaux, Bordeaux University, Bordeaux, France
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Abstract
PURPOSE OF REVIEW Pulsed field ablation is a nonthermal ablative modality that uses short living, strong electrical field created around catheter to create microscopic pores in cell membranes (electroporation). When adequately dosed/configured it shows a preference for myocardial tissue necrosis. Thus, it holds a promise to become a 'perfect' energy source for cardiac ablation to treat arrhythmias. Herein, we present update on platforms in clinical development. RECENT FINDINGS First in human series using pulsed field ablation for atrial fibrillation ablation have been completed and data published for several platforms. Acute safety outcomes are similar across the platforms with exceptionally low rate of those complications that are typically reported for thermal ablation methods (esophageal injury, pulmonary vein stenosis, phrenic nerve palsy). Promising acute data on pulmonary vein isolation had been corroborated with satisfactory 1-year clinical follow-up for a single platform, whereas reports are pending for the rest. Research efforts are being expanded to a development of focal catheters, and therefore, pulsed field ablation application for ventricular arrhythmias. SUMMARY As the reports confirming its safety and efficacy build up, there seems to be no way that the promise of pulsed field ablation could end in a blind alley.
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Hunter DW, Kostecki G, Fish JM, Jensen JA, Tandri H. In Vitro Cell Selectivity of Reversible and Irreversible: Electroporation in Cardiac Tissue. Circ Arrhythm Electrophysiol 2021; 14:e008817. [PMID: 33729827 DOI: 10.1161/circep.120.008817] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- David W Hunter
- Department of Medicine (D.W.H., H.T.), The Johns Hopkins University, Baltimore, MD
| | - Geran Kostecki
- Department of Biomedical Engineering (G.K.), The Johns Hopkins University, Baltimore, MD
| | | | | | - Harikrishna Tandri
- Department of Medicine (D.W.H., H.T.), The Johns Hopkins University, Baltimore, MD
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40
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Stewart MT, Haines DE, Miklavčič D, Kos B, Kirchhof N, Barka N, Mattison L, Martien M, Onal B, Howard B, Verma A. Safety and chronic lesion characterization of pulsed field ablation in a Porcine model. J Cardiovasc Electrophysiol 2021; 32:958-969. [PMID: 33650743 PMCID: PMC8048690 DOI: 10.1111/jce.14980] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/06/2021] [Accepted: 01/23/2021] [Indexed: 12/11/2022]
Abstract
Background Pulsed field ablation (PFA) has been identified as an alternative to thermal‐based ablation systems for treatment of atrial fibrillation patients. The objective of this Good Laboratory Practice (GLP) study was to characterize the chronic effects and safety of overlapping lesions created by a PFA system at intracardiac locations in a porcine model. Methods A circular catheter with nine gold electrodes was used for overlapping low‐ or high‐dose PFA deliveries in the superior vena cava (SVC), right atrial appendage (RAA), and right superior pulmonary vein (RSPV) in six pigs. Electrical isolation was evaluated acutely and chronic lesions were assessed via necropsy and histopathology after 4‐week survival. Acute and chronic safety data were recorded peri‐ and post‐procedurally. Results No animal experienced ventricular arrhythmia during PFA delivery, and there was no evidence of periprocedural PFA‐related adverse events. Lesions created in all anatomies resulted in electrical isolation postprocedure. Lesions were circumferential, contiguous, and transmural, with all converting into consistent lines of chronic replacement fibrosis, regardless of trabeculated or smooth endocardial surface structure. Ablations were non‐thermally generated with only minimal post‐delivery temperature rises recorded at the electrodes. There was no evidence of extracardiac damage, stenosis, aneurysms, endocardial disruption, or thrombus. Conclusion PFA deliveries to the SVC, RAA, and RSPV resulted in complete circumferential replacement fibrosis at 4‐week postablation with an excellent chronic myocardial and collateral tissue safety profile. This GLP study evaluated the safety and efficacy of a dosage range in preparation for a clinical trial and characterized the non‐thermal nature of PFA.
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Affiliation(s)
- Mark T Stewart
- Cardiac Rhythm Management, Medtronic, Inc., Minneapolis, Minnesota, USA
| | - David E Haines
- Beaumont Health System, Div of Cardiology, EP Services, Oakland University William Beaumont School of Medicine, Royal Oaks, Michigan, USA
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Bor Kos
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Nicole Kirchhof
- Cardiac Rhythm Management, Medtronic, Inc., Minneapolis, Minnesota, USA
| | - Noah Barka
- Cardiac Rhythm Management, Medtronic, Inc., Minneapolis, Minnesota, USA
| | - Lars Mattison
- Cardiac Rhythm Management, Medtronic, Inc., Minneapolis, Minnesota, USA
| | - Matt Martien
- Cardiac Rhythm Management, Medtronic, Inc., Minneapolis, Minnesota, USA
| | - Birce Onal
- Cardiac Rhythm Management, Medtronic, Inc., Minneapolis, Minnesota, USA
| | - Brian Howard
- Cardiac Rhythm Management, Medtronic, Inc., Minneapolis, Minnesota, USA
| | - Atul Verma
- Southlake Regional Health Centre, Arrhythmia Services, University of Toronto, Newmarket, Ontario, Canada
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Absence of (sub-)acute cerebral events or lesions after electroporation ablation in the left-sided canine heart. Heart Rhythm 2021; 18:1004-1011. [PMID: 33617997 DOI: 10.1016/j.hrthm.2021.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/03/2021] [Accepted: 02/12/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Irreversible electroporation (IRE) is a nonthermal ablation modality. A 200-J application can create deep myocardial lesions, but gas bubbles are created at the ablation electrode. Cerebral effects of these bubbles are unknown. OBJECTIVE The purpose of this study was to investigate gas microemboli-induced brain lesions after IRE and radiofrequency (RF) ablation to the left side of the canine heart, using magnetic resonance imaging (MRI) and histopathology. METHODS In 11 canines, baseline cerebral MRI scans were performed. In 9 animals, after retrograde femoral artery access, 12 ± 4 200-J IRE applications were administered in the ascending aorta. In 2 animals, 30 minutes of irrigated 30-W RF ablation using 10-30g of contact force was applied in the left ventricle. At days 1 and 5 after ablation, MRI was repeated. The brain tissue then was histopathologically examined. RESULTS All ablations and follow-up were uneventful. Intracardiac echography confirmed gas bubble formation after each IRE application. Neurologic examination was normal. MRI scans were normal in all animals at day 1 and were normal in 10 of 11 animals at day 5. In 1 animal, a single <2-mm-diameter lesion in the right temporal region could not be excluded as a small infarct or early hemorrhagic site. Histopathologic analysis of the same region showed no pathologic changes. In all other animals, gross and microscopic pathology were normal. CONCLUSION MRI images alone or in combination with histologic follow-up did not reveal treatment-related embolic events. Gross and microscopic pathology did not reveal evidence of treatment-related embolic events. IRE seems to be a safe ablation modality for the brain.
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Caluori G, Odehnalova E, Jadczyk T, Pesl M, Pavlova I, Valikova L, Holzinger S, Novotna V, Rotrekl V, Hampl A, Crha M, Cervinka D, Starek Z. AC Pulsed Field Ablation Is Feasible and Safe in Atrial and Ventricular Settings: A Proof-of-Concept Chronic Animal Study. Front Bioeng Biotechnol 2020; 8:552357. [PMID: 33344428 PMCID: PMC7744788 DOI: 10.3389/fbioe.2020.552357] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 11/09/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction Pulsed field ablation (PFA) exploits the delivery of short high-voltage shocks to induce cells death via irreversible electroporation. The therapy offers a potential paradigm shift for catheter ablation of cardiac arrhythmia. We designed an AC-burst generator and therapeutic strategy, based on the existing knowledge between efficacy and safety among different pulses. We performed a proof-of-concept chronic animal trial to test the feasibility and safety of our method and technology. Methods We employed 6 female swine - weight 53.75 ± 4.77 kg - in this study. With fluoroscopic and electroanatomical mapping assistance, we performed ECG-gated AC-PFA in the following settings: in the left atrium with a decapolar loop catheter with electrodes connected in bipolar fashion; across the interventricular septum applying energy between the distal electrodes of two tip catheters. After procedure and 4-week follow-up, the animals were euthanized, and the hearts were inspected for tissue changes and characterized. We perform finite element method simulation of our AC-PFA scenarios to corroborate our method and better interpret our findings. Results We applied square, 50% duty cycle, AC bursts of 100 μs duration, 100 kHz internal frequency, 900 V for 60 pulses in the atrium and 1500 V for 120 pulses in the septum. The inter-burst interval was determined by the native heart rhythm - 69 ± 9 bpm. Acute changes in the atrial and ventricular electrograms were immediately visible at the sites of AC-PFA - signals were elongated and reduced in amplitude (p < 0.0001) and tissue impedance dropped (p = 0.011). No adverse event (e.g., esophageal temperature rises or gas bubble streams) was observed - while twitching was avoided by addition of electrosurgical return electrodes. The implemented numerical simulations confirmed the non-thermal nature of our AC-PFA and provided specific information on the estimated treated area and need of pulse trains. The postmortem chest inspection showed no peripheral damage, but epicardial and endocardial discolorations at sites of ablation. T1-weighted scans revealed specific tissue changes in atria and ventricles, confirmed to be fibrotic scars via trichrome staining. We found isolated, transmural and continuous scars. A surviving cardiomyocyte core was visible in basal ventricular lesions. Conclusion We proved that our method and technology of AC-PFA is feasible and safe for atrial and ventricular myocardial ablation, supporting their systematic investigation into effectiveness evaluation for the treatment of cardiac arrhythmia. Further optimization, with energy titration or longer follow-up, is required for a robust atrial and ventricular AC-PFA.
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Affiliation(s)
- Guido Caluori
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,IHU LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,Univ. Bordeaux, INSERM, UMR 1045, Cardiothoracic Research Center of Bordeaux, Pessac, France
| | - Eva Odehnalova
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Tomasz Jadczyk
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Martin Pesl
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czechia.,First Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, Masaryk University, Brno, Czechia
| | - Iveta Pavlova
- Institute of Scientific Instruments of the Czech Academy of Sciences, Brno, Czechia
| | - Lucia Valikova
- Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences, Brno, Czechia
| | | | - Veronika Novotna
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Power Electrical and Electronic Engineering, Faculty of Electrical Engineering and Communication, Brno University of Technology, Brno, Czechia
| | - Vladimir Rotrekl
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Ales Hampl
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Michal Crha
- Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences, Brno, Czechia
| | - Dalibor Cervinka
- Department of Power Electrical and Electronic Engineering, Faculty of Electrical Engineering and Communication, Brno University of Technology, Brno, Czechia
| | - Zdenek Starek
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,First Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, Masaryk University, Brno, Czechia
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Loh P, van Es R, Groen MH, Neven K, Kassenberg W, Wittkampf FH, Doevendans PA. Pulmonary Vein Isolation With Single Pulse Irreversible Electroporation. Circ Arrhythm Electrophysiol 2020; 13:e008192. [DOI: 10.1161/circep.119.008192] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background:
Irreversible electroporation (IRE) is a promising new nonthermal ablation technology for pulmonary vein (PV) isolation in patients with atrial fibrillation. Experimental data suggest that IRE ablation produces large enough lesions without the risk of PV stenosis, artery, nerve, or esophageal damage. This study aimed to investigate the feasibility and safety of single pulse IRE PV isolation in patients with atrial fibrillation.
Methods:
Ten patients with symptomatic paroxysmal or persistent atrial fibrillation underwent single pulse IRE PV isolation under general anesthesia. Three-dimensional reconstruction and electroanatomical voltage mapping (EnSite Precision, Abbott) of left atrium and PVs were performed using a conventional circular mapping catheter. PV isolation was performed by delivering nonarcing, nonbarotraumatic 6 ms, 200 J direct current IRE applications via a custom nondeflectable 14-polar circular IRE ablation catheter with a variable hoop diameter (16–27 mm). A deflectable sheath (Agilis, Abbott) was used to maneuver the ablation catheter. A minimum of 2 IRE applications with slightly different catheter positions were delivered per vein to achieve circular tissue contact, even if PV potentials were abolished after the first application. Bidirectional PV isolation was confirmed with the circular mapping catheter and a post ablation voltage map. After a 30-minute waiting period, adenosine testing (30 mg) was used to reveal dormant PV conduction.
Results:
All 40 PVs could be successfully isolated with a mean of 2.4±0.4 IRE applications per PV. Mean delivered peak voltage and peak current were 2154±59 V and 33.9±1.6 A, respectively. No PV reconnections occurred during the waiting period and adenosine testing. No periprocedural complications were observed.
Conclusions:
In the 10 patients of this first-in-human study, acute bidirectional electrical PV isolation could be achieved safely by single pulse IRE ablation.
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Affiliation(s)
- Peter Loh
- Department of Cardiology, University Medical Centre Utrecht, the Netherlands (P.L., R.v.E., M.H.A.G., W.K., F.H.M.W., P.A.D.)
| | - René van Es
- Department of Cardiology, University Medical Centre Utrecht, the Netherlands (P.L., R.v.E., M.H.A.G., W.K., F.H.M.W., P.A.D.)
| | - Marijn H.A. Groen
- Department of Cardiology, University Medical Centre Utrecht, the Netherlands (P.L., R.v.E., M.H.A.G., W.K., F.H.M.W., P.A.D.)
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen (K.N.)
- Witten/Herdecke University, Germany (K.N.)
| | - Wil Kassenberg
- Department of Cardiology, University Medical Centre Utrecht, the Netherlands (P.L., R.v.E., M.H.A.G., W.K., F.H.M.W., P.A.D.)
| | - Fred H.M. Wittkampf
- Department of Cardiology, University Medical Centre Utrecht, the Netherlands (P.L., R.v.E., M.H.A.G., W.K., F.H.M.W., P.A.D.)
| | - Pieter A. Doevendans
- Department of Cardiology, University Medical Centre Utrecht, the Netherlands (P.L., R.v.E., M.H.A.G., W.K., F.H.M.W., P.A.D.)
- Netherlands Heart Institute, Utrecht (P.A.D.)
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Reddy VY, Anic A, Koruth J, Petru J, Funasako M, Minami K, Breskovic T, Sikiric I, Dukkipati SR, Kawamura I, Neuzil P. Pulsed Field Ablation in Patients With Persistent Atrial Fibrillation. J Am Coll Cardiol 2020; 76:1068-1080. [DOI: 10.1016/j.jacc.2020.07.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
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Howard B, Haines DE, Verma A, Packer D, Kirchhof N, Barka N, Onal B, Fraasch S, Miklavčič D, Stewart MT. Reduction in Pulmonary Vein Stenosis and Collateral Damage With Pulsed Field Ablation Compared With Radiofrequency Ablation in a Canine Model. Circ Arrhythm Electrophysiol 2020; 13:e008337. [PMID: 32877256 PMCID: PMC7495982 DOI: 10.1161/circep.120.008337] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary vein (PV) stenosis is a highly morbid condition that can result after catheter ablation for PV isolation. We hypothesized that pulsed field ablation (PFA) would reduce PV stenosis risk and collateral injury compared with irrigated radiofrequency ablation (IRF). METHODS IRF and PFA deliveries were randomized in 8 dogs with 2 superior PVs ablated using one technology and 2 inferior PVs ablated using the other technology. IRF energy (25-30 W) or PFA was delivered (16 pulse trains) at each PV in a proximal and in a distal site. Contrast computed tomography scans were collected at 0, 2, 4, 8, and 12-week (termination) time points to monitor PV cross-sectional area at each PV ablation site. RESULTS Maximum average change in normalized cross-sectional area at 4-weeks was -46.1±45.1% post-IRF compared with -5.5±20.5% for PFA (P≤0.001). PFA-treated targets showed significantly fewer vessel restrictions compared with IRF (P≤0.023). Necropsy showed expansive PFA lesions without stenosis in the proximal PV sites, compared with more confined and often incomplete lesions after IRF. At the distal PV sites, only IRF ablations were grossly identified based on focal fibrosis. Mild chronic parenchymal hemorrhage was noted in 3 left superior PV lobes after IRF. Damage to vagus nerves as well as evidence of esophagus dilation occurred at sites associated with IRF. In contrast, no lung, vagal nerve, or esophageal injury was observed at PFA sites. CONCLUSIONS PFA significantly reduced risk of PV stenosis compared with IRF postprocedure in a canine model. IRF also caused vagus nerve, esophageal, and lung injury while PFA did not.
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Affiliation(s)
- Brian Howard
- Medtronic, Inc, Minneapolis, MN (B.H., N.K., N.B., B.O., S.F., M.T.S.)
| | - David E Haines
- Oakland University William Beaumont School of Medicine, Royal Oak, MI (D.E.H.)
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada (A.V.)
| | | | - Nicole Kirchhof
- Medtronic, Inc, Minneapolis, MN (B.H., N.K., N.B., B.O., S.F., M.T.S.)
| | - Noah Barka
- Medtronic, Inc, Minneapolis, MN (B.H., N.K., N.B., B.O., S.F., M.T.S.)
| | - Birce Onal
- Medtronic, Inc, Minneapolis, MN (B.H., N.K., N.B., B.O., S.F., M.T.S.)
| | - Steve Fraasch
- Medtronic, Inc, Minneapolis, MN (B.H., N.K., N.B., B.O., S.F., M.T.S.)
| | | | - Mark T Stewart
- Medtronic, Inc, Minneapolis, MN (B.H., N.K., N.B., B.O., S.F., M.T.S.)
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Polajžer T, Miklavčič D. Development of adaptive resistance to electric pulsed field treatment in CHO cell line in vitro. Sci Rep 2020; 10:9988. [PMID: 32561789 PMCID: PMC7305184 DOI: 10.1038/s41598-020-66879-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/26/2020] [Indexed: 12/02/2022] Open
Abstract
Pulsed electric field treatment has increased over the last few decades with successful translation from in vitro studies into different medical treatments like electrochemotherapy, irreversible electroporation for tumor and cardiac tissue ablation and gene electrotransfer for gene therapy and DNA vaccination. Pulsed electric field treatments are efficient but localized often requiring repeated applications to obtain results due to partial response and recurrence of disease. While these treatment times are several orders of magnitude lower than conventional biochemical treatment, it has been recently suggested that cells may become resistant to electroporation in repetitive treatments. In our study, we evaluate this possibility of developing adaptive resistance in cells exposed to pulsed electric field treatment over successive lifetimes. Mammalian cells were exposed to electroporation pulses for 30 generations. Every 5th generation was analyzed by determining permeabilization and survival curve. No statistical difference between cells in control and cells exposed to pulsed electric field treatment was observed. We offer evidence that electroporation does not affect cells in a way that they would become less susceptible to pulsed electric field treatment. Our findings indicate pulsed electric field treatment can be used in repeated treatments with each treatment having equal efficiency to the initial treatment.
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Affiliation(s)
- Tamara Polajžer
- University of Ljubljana, Faculty of Electrical Engineering, Tržaška 25, 1000, Ljubljana, Slovenia
| | - Damijan Miklavčič
- University of Ljubljana, Faculty of Electrical Engineering, Tržaška 25, 1000, Ljubljana, Slovenia.
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Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with considerable morbidity and mortality. Electrically isolating the pulmonary veins from the left atrium by catheter ablation is superior to antiarrhythmic drug therapy for maintaining sinus rhythm, but its success varies depending on multiple factors, including arrhythmic burden. Although procedural outcomes have improved over the years, further gains are limited by a seemingly zero-sum relationship between effectiveness and safety, which is largely a product of the available technologies. Current energies used to create contiguous, transmural, and durable atrial lesions can result in serious complications if they reach the esophagus or phrenic nerve, for instance—structures that can be adjacent to the atrial myocardium, often within millimeters of the energy source. Consequently, high rates of pulmonary vein-left atrium reconnections are consistently seen in clinical studies and in clinical practice as operators appropriately forgo ablation effectiveness to protect patients from harm. However, as ablative technologies evolve to circumvent this stalemate, safer, and more effective pulmonary vein isolation seems increasingly realistic. Furthermore, the innovative nature of these technologies raises the prospect of markedly improved procedural efficiency, which could increase patient comfort, reduce operator occupational injuries, and enhance the use of health resources—all of which are increasingly important considerations particularly as the demand for catheter ablation for atrial fibrillation continues to rise. We herein review 3 promising candidate ablation technologies with the potential to revolutionize the management of patients with atrial fibrillation: electroporation (pulsed-field ablation), expandable lattice-tip radiofrequency ablation/electroporation, and ultra-low temperature cryoablation.
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Affiliation(s)
- F. Daniel Ramirez
- From the University of Bordeaux, CHU Bordeaux, Bordeaux-Pessac, France (F.D.R., M.H., P.J.)
- IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030 (F.D.R., M.H., P.J.)
| | - Vivek Y. Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (V.Y.R.)
- Homolka Hospital, Prague, Czech Republic (V.Y.R.)
| | | | - Mélèze Hocini
- From the University of Bordeaux, CHU Bordeaux, Bordeaux-Pessac, France (F.D.R., M.H., P.J.)
- IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030 (F.D.R., M.H., P.J.)
| | - Pierre Jaïs
- From the University of Bordeaux, CHU Bordeaux, Bordeaux-Pessac, France (F.D.R., M.H., P.J.)
- IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030 (F.D.R., M.H., P.J.)
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Reddy VY, Anter E, Rackauskas G, Peichl P, Koruth JS, Petru J, Funasako M, Minami K, Natale A, Jais P, Nakagawa H, Marinskis G, Aidietis A, Kautzner J, Neuzil P. Lattice-Tip Focal Ablation Catheter That Toggles Between Radiofrequency and Pulsed Field Energy to Treat Atrial Fibrillation. Circ Arrhythm Electrophysiol 2020; 13:e008718. [DOI: 10.1161/circep.120.008718] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The tissue selectivity of pulsed field ablation (PFA) provides safety advantages over radiofrequency ablation in treating atrial fibrillation. One-shot PFA catheters have been shown capable of performing pulmonary vein isolation, but not flexible lesion sets such as linear lesions. A novel lattice-tip ablation catheter with a compressible 9-mm nitinol tip is able to deliver either focal radiofrequency ablation or PFA lesions, each in 2 to 5 s.
Methods:
In a 3-center, single-arm, first-in-human trial, the 7.5F lattice catheter was used with a custom mapping system to treat paroxysmal or persistent atrial fibrillation. Toggling between energy sources, point-by-point pulmonary vein encirclement was performed using biphasic PFA posteriorly and either temperature-controlled irrigated radiofrequency ablation or PFA anteriorly (RF/PF or PF/PF, respectively). Linear lesions were created using either PFA or radiofrequency ablation.
Results:
The 76-patient cohort included 55 paroxysmal and 21 persistent atrial fibrillation patients undergoing either RF/PF (40 patients) or PF/PF (36 patients) ablation. The pulmonary vein isolation therapy duration time (transpiring from first to last lesion) was 22.6±8.3 min/patient, with a mean of 50.1 RF/PF lesions/patient. Linear lesions included 14 mitral (4 RF/2 RF+PF/8 PF), 34 left atrium roof (12 RF/22 PF), and 44 cavotricuspid isthmus (36 RF/8 PF) lines, with therapy duration times of 5.1±3.5, 1.8±2.3, and 2.4±2.1 min/patient, respectively. All lesion sets were acutely successful, using 4.7±3.5 minutes of fluoroscopy. There were no device-related complications, including no strokes. Postprocedure esophagogastroduodenoscopy revealed minor mucosal thermal injury in 2 of 36 RF/PF and 0 of 24 PF/PF patients. Postprocedure brain magnetic resonance imaging revealed diffusion-weighted imaging+/fluid-attenuated inversion recovery- and diffusion-weighted imaging+/fluid-attenuated inversion recovery+ asymptomatic lesions in 5 and 3 of 51 patients, respectively.
Conclusions:
A novel lattice-tip catheter could safely and rapidly ablate atrial fibrillation using either a combined RF/PF approach (capitalizing on the safety of PFA and the years of experience with radiofrequency energy) or an entirely PF approach.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifiers: NCT04141007 and NCT04194307.
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Affiliation(s)
- Vivek Y. Reddy
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic (V.Y.R., M.F., K.M., P.N.)
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (V.Y.R., J.S.K.)
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (E.A., H.N.)
| | - Gediminas Rackauskas
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Lithuania (G.R., G.M., A.A.)
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (P.P., J.K.)
| | - Jacob S. Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (V.Y.R., J.S.K.)
| | | | - Moritoshi Funasako
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic (V.Y.R., M.F., K.M., P.N.)
| | - Kentaro Minami
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic (V.Y.R., M.F., K.M., P.N.)
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin (A.N.)
| | - Pierre Jais
- University of Bordeaux, CHU Bordeaux, IHU LIRYC ANR-10-IAHU-04, France (P.J.)
| | - Hiroshi Nakagawa
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (E.A., H.N.)
| | - Germanas Marinskis
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Lithuania (G.R., G.M., A.A.)
| | - Audrius Aidietis
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Lithuania (G.R., G.M., A.A.)
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (P.P., J.K.)
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic (V.Y.R., M.F., K.M., P.N.)
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Bradley CJ, Haines DE. Pulsed field ablation for pulmonary vein isolation in the treatment of atrial fibrillation. J Cardiovasc Electrophysiol 2020; 31:2136-2147. [DOI: 10.1111/jce.14414] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/02/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Christopher J. Bradley
- Department of Cardiovascular Medicine, Beaumont HospitalOakland University William Beaumont School of Medicine Royal Oak Michigan
| | - David E. Haines
- Department of Cardiovascular Medicine, Beaumont HospitalOakland University William Beaumont School of Medicine Royal Oak Michigan
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Koruth JS, Kuroki K, Kawamura I, Stoffregen WC, Dukkipati SR, Neuzil P, Reddy VY. Focal Pulsed Field Ablation for Pulmonary Vein Isolation and Linear Atrial Lesions: A Preclinical Assessment of Safety and Durability. Circ Arrhythm Electrophysiol 2020; 13:e008716. [PMID: 32370542 DOI: 10.1161/circep.120.008716] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A novel ablation and mapping system can toggle between delivering biphasic pulsed field (PF) and radiofrequency energy from a 9-mm lattice-tip catheter. We assessed the preclinical feasibility and safety of (1) focal PF-based thoracic vein isolation and linear ablation, (2) combined PF and radiofrequency focal ablation, and (3) PF delivered directly atop the esophagus. METHODS Two cohorts of 6 swine were treated with pulsed fields at low dose (PFLD) and high dose (PFHD) and followed for 4 and 2 weeks, respectively, to isolate 25 thoracic veins and create 5 right atrial (PFLD), 6 mitral (PFHD), and 6 roof lines (radiofrequency+PFHD). Baseline and follow-up voltage mapping, venous potentials, ostial diameters, and phrenic nerve viability were assessed. PFHD and radiofrequency lesions were delivered in 4 and 1 swine from the inferior vena cava onto a forcefully deviated esophagus. All tissues were submitted for histopathology. RESULTS Hundred percent of thoracic veins (25 of 25) were successfully isolated with 12.4±3.6 applications/vein with mean PF times of <90 seconds/vein. Durable isolation improved from 61.5% PFLD to 100% with PFHD (P=0.04), and all linear lesions were successfully completed without incurring venous stenoses or phrenic injury. PFHD sections had higher transmurality rates than PFLD (98.3% versus 88.1%; P=0.03) despite greater mean thickness (2.5 versus 1.3 mm; P<0.001). PF lesions demonstrated homogenous fibrosis without epicardial fat, nerve, or vessel involvement. In comparison, radiofrequency+PFHD sections revealed similar transmurality but expectedly more necrosis, inflammation, and epicardial fat, nerve, and vessel involvement. Significant ablation-related esophageal necrosis, inflammation, and fibrosis were seen in all radiofrequency sections, as compared with no PF sections. CONCLUSIONS The lattice-tip catheter can deliver focal PF to durably isolate veins and create linear lesions with excellent transmurality and without complications. The PF lesions did not damage the phrenic nerve, vessels, and the esophagus.
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Affiliation(s)
- Jacob S Koruth
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
| | - Kenji Kuroki
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
| | - Iwanari Kawamura
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
| | | | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
| | - Petr Neuzil
- Homolka Hospital, Prague, Czech Republic (P.N., V.Y.R.)
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.).,Homolka Hospital, Prague, Czech Republic (P.N., V.Y.R.)
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