Feasibility of selective cardiac ventricular electroporation

Contemporary Trends in Pulsed Field Ablation for Cardiac Arrhythmias

Pulsed field ablation (PFA) is a catheter-based procedure that utilizes short high voltage and short-duration electrical field pulses to induce tissue injury. The last decade has yielded significant scientific progress and quickened interest in PFA as an energy modality leading to the emergence of the clinical use of PFA technologies for the treatment of atrial fibrillation. It is generally agreed that more research is needed to improve our biophysical understanding of PFA for clinical cardiac applications as well as its potential as a potential alternative energy source to thermal ablation modalities for the treatment of other arrhythmias. In this review, we discuss the available preclinical and clinical evidence for PFA for atrial fibrillation, developments for ventricular arrhythmia (VA) ablation, and future perspectives.

Focal Pulsed Field Ablation for Premature Ventricular Contractions: A Multicenter Experience

BACKGROUND

Pulsed field ablation (PFA) is a novel technology for catheter-based atrial arrhythmia treatment. Evidence of its application for ventricular arrhythmia ablation is still limited. In this study, we describe the feasibility and efficacy of focal PFA for premature ventricular contraction (PVC) ablation.

METHODS

A prospective cohort of 20 patients referred for PVC ablation at 2 centers was enrolled, regardless of the presence of structural heart disease, PVC morphology, or previous ablation attempts. All procedures were performed using the CENTAURI System in combination with contact force sensing catheters and 3-dimensional electroanatomical mapping systems. Energy output and the number of applications were left to the operator's discretion.

RESULTS

Eleven (55%) procedures were conducted under general anesthesia, 6 (30%) under deep sedation, and 3 (15%) under light sedation. Muscular contraction was observed in one case (5%). Median procedural and fluoroscopy times were 95.5 and 6.55 minutes, respectively. The median number of PFA applications was 8 with a median contact force of 10g. A statistically significant (76%) reduction was observed in mean peak-to-peak bipolar electrogram voltage before and after ablation (0.707 versus 0.098 mV; P=0.008). Ventricular irritative firing was observed in 11 (55%) patients after PFA. The median follow-up was 120 days. Acute procedural success was achieved in 17 of 20 (85% [95% CI, 0.70-1]) patients. Two of the patients with procedural failure had late success with >80% clinical PVC burden suppression during follow-up, and 2 of 17 patients with acute success had late PVC recurrence, which accounts for a total of 17 of 20 (85% [95% CI, 0.70-1]) patients with chronic success. Transient ST-segment depression occurred in 1 patient, and the right bundle branch block was induced in 2 others (permanently only in one case).

CONCLUSIONS

PVC ablation using a focal PFA is feasible, effective, and safe, with promising acute and long-term results in several ventricular locations. Irritative firing is frequently observed. Coronary evaluation should be considered when targeting the outflow tract.

A New Hope for the Treatment of Atrial Fibrillation: Application of Pulsed-Field Ablation Technology

In recent years, the prevalence of and mortality associated with cardiovascular diseases have been rising in most countries and regions. AF is the most common arrhythmic condition, and there are several treatment options for AF. Pulmonary vein isolation is an effective treatment for AF and is the cornerstone of current ablation techniques, which have one major limitation: even when diagnosed and treated at a facility that specializes in ablation, patients have a greater chance of recurrence. Therefore, there is a need to develop better ablation techniques for the treatment of AF. This article first compares the current cryoablation (CBA) and radiofrequency ablation (RFA) techniques for the treatment of AF and discusses the utility and advantages of the development of pulsed-field ablation (PFA) technology. The current research on PFA is summarized from three perspectives, namely, simulation experiments, animal experiments, and clinical studies. The results of different stages of experiments are summarized, especially during animal studies, where pulmonary vein isolation was carried out effectively without causing injury to the phrenic nerve, esophagus, and pulmonary veins, with higher safety and shorter incision times. This paper focuses on a review of various a priori and clinical studies of this new technique for the treatment of AF.

The Safety and Feasibility of Pulsed-Field Ablation in Atrioventricular Nodal Re-Entrant Tachycardia: First-in-Human Pilot Trial

BACKGROUND

The incidence of atrioventricular conduction system damage during the catheter ablation procedure has long been a safety concern in patients with atrioventricular nodal re-entrant tachycardia (AVNRT). Pulsed-field ablation (PFA) with high tissue selectivity is a promising technique to address this problem in patients with AVNRT.

OBJECTIVES

This study aimed to evaluate the safety and feasibility of PFA in patients with AVNRT.

METHODS

This was an investigator-initiated, single-center, single-arm, prospective study performed in West China Hospital, Sichuan University. Patients diagnosed with AVNRT by electrophysiological examination were included and treated using PFA. The primary outcome was the ability to achieve acute ablation success. The secondary outcomes were ablation success after 6 months and safety incidents reported.

RESULTS

A total of 30 patients with AVNRT with a mean age of 47.9 ± 13.9 years were included and underwent PFA. Acute ablation success was achieved in all patients. The skin-to-skin procedure time was 109.1 ± 32.1 minutes, and fluoroscopy time was 4.1 ± 0.9 minutes. A median of 8 (range: 6.5 to 11.0) PFA applications were delivered. The average distance of the closest ablation site to the His bundle was 6.5 ± 2.5 mm, with a minimum distance of 2.0 mm. All patients maintained sinus rhythm after 6 months. No adverse events occurred in any patient during the ablation or the 6-month follow-up.

CONCLUSIONS

PFA showed favorable feasibility and safety in patients with AVNRT in this pilot study. Further study with larger population and longer follow-up time is warranted to verify the results.

Potential Application of Pulsed Field Ablation in Ventricular Arrhythmias

Pulsed field ablation (PFA) is a new ablative method for the therapy of arrhythmia. Recent preclinical and clinical studies have already demonstrated the feasibility and safety of PFA for the treatment of atrial fibrillation (AF). However, the application of PFA may not be limited to the above fields. There are some data on the application of PFA on ventricular arrhythmias (VAs), such as ventricular fibrillation (VF) and ventricular tachycardia (VT). Further, a case report about PFA has been published recently, in which PFA was successfully applied to the ablation of premature ventricular contractions (PVCs) from the right ventricular outflow tract. Thus, we aimed to review recent research findings of PFA in ventricular ablation and evaluate the possibility of its application in VAs.

Catheter Ablation of Ventricular Fibrillation

Ventricular fibrillation (VF) is a common cause of sudden cardiac death (SCD) and is unfortunately without a cure. Current therapies focus on prevention of SCD, such as implantable cardioverter-defibrillator (ICD) implantation and anti-arrhythmic agents. Significant progress has been made in improving our understanding and ability to target the triggers of VF, via advanced mapping and ablation techniques, as well as with autonomic modulation. However, the critical substrate for VF maintenance remains incompletely defined. In this review, we discuss the evidence behind the basic mechanisms of VF and review the current role of catheter ablation in patients with VF.

A computational comparison of radiofrequency and pulsed field ablation in terms of lesion morphology in the cardiac chamber

Pulsed Field Ablation (PFA) has been developed over the last years as a novel electrical ablation technique for treating cardiac arrhythmias. It is based on irreversible electroporation which is a non-thermal phenomenon innocuous to the extracellular matrix and, because of that, PFA is considered to be safer than the reference technique, Radiofrequency Ablation (RFA). However, possible differences in lesion morphology between both techniques have been poorly studied. Simulations including electric, thermal and fluid physics were performed in a simplified model of the cardiac chamber which, in essence, consisted of a slab of myocardium with blood in motion on the top. Monopolar and bipolar catheter configurations were studied. Different blood velocities and catheter orientations were assayed. RFA was simulated assuming a conventional temperature-controlled approach. The PFA treatment was assumed to consist in a sequence of 20 biphasic bursts (100 µs duration). Simulations indicate that, for equivalent lesion depths, PFA lesions are wider, larger and more symmetrical than RFA lesions for both catheter configurations. RFA lesions display a great dependence on blood velocity while PFA lesions dependence is negligible on it. For the monopolar configuration, catheter angle with respect to the cardiac surface impacted both ablation techniques but in opposite sense. The orientation of the catheter with respect to blood flow direction only affected RFA lesions. In this study, substantial morphological differences between RFA and PFA lesions were predicted numerically. Negligible dependence of PFA on blood flow velocity and direction is a potential important advantage of this technique over RFA.

Study of necrotic apoptosis by pulsed electric field ablation in rabbit left ventricular myocardium

Objective

We investigate the characteristics of histological damage to myocardial cells in the ablation region and surrounding areas of the left ventricular epicardium in rabbits using our self-developed cardiac pulsed electric field (PEF) ablation instrument and ablation catheter.

Methods

Forty eight New Zealand rabbits underwent ablation on the left ventricular myocardium after open-heart exposure with a cardiac arrhythmia PEF ablation device and ablation catheter developed by the Medical Translation Laboratory of Pulsed Electric Field Technology in Zhejiang Province. The ablation parameters were set as biphasic electrical pulses; voltage, ±800 V; pulse width, 10 μs; interphase delay, 500 us. Six rabbits were included in the sham group and 42 other rabbits were randomly divided into immediately, 6-h, 1-, 3-day, 1-, 2-, and 4-week post-ablation groups, with six rabbits in each group. Creatine kinase- (CK)-MB isoenzyme (CK-MB), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) levels were measured before and at different time points after PEF ablation to analyze their dynamic evolution. Masson staining of tissue block sections of left ventricular myocardial ablation and adjacent tissue heart specimens was performed, and the occurrence of TUNEL apoptosis in myocardium tissue was analyzed.

Results

All rabbits completed the PEF ablation procedure and the follow-up process. After PEF ablation, the levels of cardiac enzymes, including CK-MB, CK, and AST, increased significantly, peaking 1–3 days after the procedure. In particular, those of CK and CK-MB increased by 15–20 times but returned to the preoperative level after 2 weeks. Based on general observation, it was found that the myocardium in the ablation area was swollen immediately after PEF ablation. Masson staining analysis revealed that cardiomyocytes were broken and infiltrated by erythrocytes after 6 h. After 1 day, the cells started to experience atrophy and necrosis; after 3 days, fibrotic replacement of the necrotic area became obvious. Then, by 4 weeks, the myocardial cells were completely replaced by hyperplasia. Apoptosis occurred significantly at 6 h and peaked at 24 h post-ablation, demonstrating a 37.7-fold increase; apoptotic cell counts decreased significantly at 3 days post-ablation, and no significant apoptotic cardiomyocytes were seen after 1 week.

Conclusion

After PEF ablation, cardiomyocytes showed apoptotic process and dyed, at least partially, through a secondary necrosis, the ablation boundary was clear, the ablation area was replaced by structurally intact fibroblasts, no island myocardium tissue were seen, and the ablation area vessels and nerves were not affected.

Pulsed Electrical Field in Arrhythmia Treatment: Current Status and Future Directions

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.

Ventricular nanosecond pulsed electric field delivery using active fixation leads: a proof-of-concept preclinical study

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.

Pulsed Field Ablation of Left Ventricular Myocardium in a Swine Infarct Model

BACKGROUND

Pulsed field ablation (PFA) leads to cell death by irreversible electroporation. There are limited data about PFA lesion characteristics in the ventricle, particularly in the presence of myocardial scar.

OBJECTIVES

This study sought to evaluate the lesion characteristics of PFA and radiofrequency energy (RFA) in healthy and infarcted left ventricular (LV) myocardium in swine.

METHODS

Swine (n = 10) underwent either: 1) 120-minute left anterior descending coronary artery balloon occlusion myocardial infarction and survived for 6 to 8 weeks (n = 8); or 2) served as healthy control subjects (n = 2). PFA or RFA was delivered to the LV endocardium in regions of healthy myocardium or scar identified with electroanatomical mapping. Bipolar, biphasic PFA was delivered for 2.5 seconds × 4 applications/site using 2 different catheters: linear quadripolar (FOCAL) or multispline 8-pole catheter (BASKET). Gross and histologic measurements of lesion size were performed.

RESULTS

In the PFA group, 21 lesions were delivered to healthy LV and 20 to areas of scar. Overall, there was no significant difference in lesion depth between catheter groups (FOCAL linear vs BASKET; P = 0.740), whereas lesion width was greater for BASKET (10.6 ± 2.4 mm vs 13.3 ± 3.3 mm; P = 0.007). In myocardial scar, lesion depth was not significantly different between PFA catheters (P = 0.235). However, lesion depth for PFA was greater than for RFA (PFA vs RFA; 6.1 ± 1.7 mm vs 3.8 ± 1.7 mm; P = 0.005).

CONCLUSIONS

PFA allows rapid, safe, and effective ablation of surviving islands of myocardium within and around infarcted LV substrate. This technology holds promise for treating infarct-related ventricular tachycardia in humans.

Pulsed Field Ablation to Treat Atrial Fibrillation: A Review of the Literature

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and catheter ablation, which can be used in symptomatic patients refractory to antiarrhythmic therapy. Pulmonary vein isolation (PVI) remains the cornerstone of any ablation procedure. A major limitation of current catheter ablation procedures is important to recognize because even when the PVI is performed in highly experienced centers, PVI reconnection was documented in about 20% of patients. Therefore, better technology is needed to improve ablation lesions. One of the novelties in recent years is pulsed filed ablation (PFA), a non-thermal energy that uses trains of high-voltage, very-short-duration pulses to kill the cells. The mechanism of action of this energy consists of creating pores in the myocardiocyte cell membrane in a highly selective and tissue-specific way; this leads to death of the target cells reducing the risk of damage to surrounding non-cardiac tissues. In particular during the animal studies, PVI and atrial lines were performed effectively without PV stenosis. Using PFA directly on coronary arteries, there was no luminal narrowing, there has been no evidence of incidental phrenic nerve injury, and finally, PFA has been shown not to injure esophageal tissue when directly applied to the esophagus or indirectly through ablation in the left atrium. The aim of this review is to report all published animal and clinical studies regarding this new technology to treat paroxysmal and persistent AF.

Regional and Temporal Variation of Ventricular and Conduction Tissue Activity During Ventricular Fibrillation in Canines

[Figure: see text].

Comparing High-Frequency With Monophasic Electroporation Protocols in an In Vivo Beating Heart Model

This study compared monophasic 100-μs pulses with high-frequency electroporation (HF-EP) bursts using an in vivo animal model. Myocardial damage was evaluated by histologic analysis. Compared with 10 monophasic pulses, 20 bursts of HF-EP at 100 and 150 kHz were associated with less damage. However, when the number of HF-EP bursts was increased to 60, myocardial damage was comparable to that of the monophasic group. HF-EP protocols were associated with attenuated collateral muscle contractions. This study shows that HF-EP is feasible and effective and that pulse frequency has a significant effect on extent of ablation.

Ablation Modalities for Therapeutic Intervention in Arrhythmia-Related Cardiovascular Disease: Focus on Electroporation

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.

Non-viral Gene Delivery Methods for Bone and Joints

Viral carrier transport efficiency of gene delivery is high, depending on the type of vector. However, viral delivery poses significant safety concerns such as inefficient/unpredictable reprogramming outcomes, genomic integration, as well as unwarranted immune responses and toxicity. Thus, non-viral gene delivery methods are more feasible for translation as these allow safer delivery of genes and can modulate gene expression transiently both in vivo, ex vivo, and in vitro. Based on current studies, the efficiency of these technologies appears to be more limited, but they are appealing for clinical translation. This review presents a summary of recent advancements in orthopedics, where primarily bone and joints from the musculoskeletal apparatus were targeted. In connective tissues, which are known to have a poor healing capacity, and have a relatively low cell-density, i.e., articular cartilage, bone, and the intervertebral disk (IVD) several approaches have recently been undertaken. We provide a brief overview of the existing technologies, using nano-spheres/engineered vesicles, lipofection, and in vivo electroporation. Here, delivery for microRNA (miRNA), and silencing RNA (siRNA) and DNA plasmids will be discussed. Recent studies will be summarized that aimed to improve regeneration of these tissues, involving the delivery of bone morphogenic proteins (BMPs), such as BMP2 for improvement of bone healing. For articular cartilage/osteochondral junction, non-viral methods concentrate on targeted delivery to chondrocytes or MSCs for tissue engineering-based approaches. For the IVD, growth factors such as GDF5 or GDF6 or developmental transcription factors such as Brachyury or FOXF1 seem to be of high clinical interest. However, the most efficient method of gene transfer is still elusive, as several preclinical studies have reported many different non-viral methods and clinical translation of these techniques still needs to be validated. Here we discuss the non-viral methods applied for bone and joint and propose methods that can be promising in clinical use.

Future Perspectives and New "Frontiers" in Cardiac Rhythmology

In the last three decades the Cardiac Rhythmology field has experienced tremendous change and evolution. Our understanding of the underlying mechanism of arrhythmic diseases has dramatically improved, starting from the genetic and molecular mechanisms. Innovative pharmacological and non-pharmacological treatment options have been introduced, and arrhythmias previously considered “untreatable” are now successfully managed in most referral centers. The increasing awareness of the detrimental effects of arrhythmias on any underlying cardiac substrate, targeted as a potentially modifiable cause, has therefore led to an increasingly stronger effort in developing novel methods and approaches to treat arrhythmia and improve patients' health and quality of life. Of all potentially significant developments in the field, we have decided to focus on the approaches generally applicable to multiple arrhythmic cardiac disorders and related to the advancement of technology. More specifically, we will deal with electroanatomical mapping and lesion creation during interventional procedures.