16-22: Quantification of the ablation zone after wide area circumferential pulmonary vein isolation applying a new high-density mapping system
Francesco SantoroArdan M. SagunerChristine LemešChristian SohnsShibu MathewChristian‐Hendrik HeegerBruno ReißmannTilman MaurerJohannes RiedlThomas FinkKentaro HayashiFeifan OuyangKarl‐Heinz KückAndreas Metzner
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Introduction: Catheter-based pulmonary vein isolation (PVI) is an established treatment option for atrial fibrillation (AF). Aim of this study was to quantify the extent of the ablation zone after wide area circumferential (WAC) PVI applying a novel high density mapping system (Rhythmia – Boston scientific). Methods: 20 consecutive pts underwent WAC-PVI for AF using the Rhythmia System in conjunction with the Orion mini-basket catheter, which was utilized to create a detailed 3-dimensional electroanatomic map of the LA and PVs during sinus rhythm, before and after the ablation procedure. Results: Mean pts age was 60 ± 4 years. 60 % had paroxysmal and 40% persistent AF. LA diameter was 45 ± 10 mm and LV ejection fraction was 55 ± 10%. PV anatomy was normal in all patients. A total of 9772 ± 3108 mapping points were taken for the initial map and 7910 ± 2344 points for the remap. Mapping time for the initial map was 19 ± 4.2 min and 10.8 ± 3.2 min for the remap. When comparing the initial voltage map with the remap after WAC – PVI, PVs and all PV antra, during remapping were isolated and displayed scar (<0.2mV), while the LA roof had scar in 10 out of 20 patients (50%), although intentionally no roof line was placed (Figure 1 showing left atrium voltage map performed before (A) and after ablation (B)). Posterior wall (PW) area during the initial map was 19,7 ± 3,5 cm2 and the ablated area at the PW during remapping was 7,8 ± 3,34 cm2 ( 40 ± 17%), although no additional lesions were intentionally placed. When the posterior wall was divided into four segments, there were no significant statistical differences regarding the location and extent of ablation zones at the PW after WAC-PVI (Table).The management of atrial arrhythmia recurrence during repeat catheter ablation procedure is unclear despite persistent pulmonary vein isolation. It should be clarified whether an induced non-PV trigger-based (mechanistic) ablation approach more focusing on low-voltage zones is more effective compared to an empirical ablation of low-voltage zones via linear lesions during repeat ablation procedures. The operators should catch all triggers if possible rather than messing with the substrate.
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Abstract Point-by-point radiofrequency ablation (RF) and one-shot cryoballoon ablation (CRYO) electrically isolate pulmonary veins (PVs) in atrial fibrillation (AF) using different techniques and energies. This study aimed to examine differences in PVs reconnection pattern and ablation lesions required to re-isolate PVs after failed RF and failed CRYO. Methods Twenty-four patients who had their repeat ablation between January 2017-December 2020 were studied with six months of learning curve for CRYO. Fourteen patients had paroxysmal atrial fibrillation (PAF). Failed first ablations were defined by electrocardiogram (ECG) documented AF within twelve months following three months blanking period. Repeat ablations were performed using CARTO3® mapping system, which was utilized to locate ablation lesions and impedance drop details. Results 2,260 lesions were collected from 63 reconnected PVs (31 isolated after RF vs 32 isolated veins after CRYO). 849 lesions were targeted towards triggers. Repeat ablation procedure time was similar between both cohorts. However, repeat ablation after failed CRYO had longer fluoroscopy time (19.8±2 vs 12.4±2.1 minutes, P=0.019). The right lower pulmonary vein (RLPV) was reconnected after failed CRYO for AF in 92% of patients and 100% in PAF patients. Although PV reconnection pattern was similar between both cohorts, RLPV and left upper pulmonary vein (LUPV) required more ablation lesions after failed CRYO. Left lower pulmonary vein (LLPV) and right upper pulmonary vein (RUPV) required more ablation lesions after failed RF. Impedance drop was similar in both cohorts. Conclusion After failed CRYO for PAF, RLPV was reconnected in all patients. RUPV and LLPV required more ablation lesions after failed RF, while RLPV and LLPV required more ablation lesions after failed CRYO. Funding Acknowledgement Type of funding sources: None. PVs reconnection patternLesions number and percentage comparison
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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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The aim of this study was to compare the effectiveness and safety of very-high-power short-duration (VHPSD) ablation (70–90 W/4–7 s) with conventional ablation (30–40 W/>20 s, 50 W/7–11 s) for pulmonary vein isolation (PVI) in patients with AF. A total of 13 studies were included in this analysis (1,527 patients). AF recurrence occurred in 14% (95% CI [11–18%]) of the VHPSD group. VHPSD was associated with lower AF recurrence (OR 0.65; 95% CI [0.48–0.89]; p=0.006) compared with the conventional ablation group. Subgroup analysis showed that additional ablation beyond PVI had a similar rate of AF recurrence (16% versus 10%) compared with PVI alone. Procedure and ablation durations were significantly shorter in the VHPSD group with a mean differences of –14.4 minutes (p=0.017) and −14.1 minutes (p<0.001), respectively. Complications occurred in 6% (95% CI [3–9%]) of the VHPSD group, and the rate was similar between the two groups (OR 1.03; 95% CI [0.60–1.80]; p=0.498). VHPSD ablation resulted in less AF recurrence and a shorter procedure time. Additional ablation beyond PVI alone in VHPSD may not provide additional benefits.
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Atrial fibrillation (AF) is the most common sustained arrhythmia. Recent guidelines recommend pulmonary vein isolation (PVI) as the main procedural endpoint to control recurrent AF in symptomatic patients resistant to antiarrhythmic drugs. The efficacy of such procedure is higher in paroxysmal AF while is still unsatisfactory in persistent and long-standing persistent AF. This review will summarize the state-of-the-art of AF ablation techniques in patients with persistent AF, discussing the evidence underlying different approaches with a particular focus on adjunctive ablation strategies beyond PVI including linear ablation, ablation of complex fractionated atrial electrograms (CFAE), ablation of ganglionated plexi, dominant frequency, rotors and other anatomical sites frequently involved in AF triggers.
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Background: Pulmonary vein isolation (PVI) is an effective treatment option for patients with symptomatic atrial fibrillation (AF). However, the electrical recovery of pulmonary veins (PVs) is the main trigger for AF recurrences. This study investigates the characteristics of patients admitted for redo AF ablation, the PV reconnection rates depending on previous ablation modalities and the impact of different ablation strategies for redo procedures. Methods: Consecutive patients undergoing first redo AF ablation were included. Patients were grouped according to the electrical recovery of at least one PV. The impacts of the technique for first AF ablation on PV reconnection rates and patients with and without PV reconnection were compared. Different ablation strategies for redo procedures were compared and its recurrence rates after a mean follow-up of 25 ± 20 months were investigated. Results: A total of 389 patients (68 ± 10 years; 57% male; 39% paroxysmal AF) underwent a first redo. The median time between the first and redo procedure was 40 ± 39 months. Radiofrequency was used in 278 patients, cryoballoon was used in 85 patients and surgical AF ablation was performed on 26 patients. In total, 325 patients (84%) had at least one PV reconnected, and the mean number of reconnected PVs was 2.0 ± 1.3, with significant differences between ablation approaches (p for all = 0.002); this was mainly due to differences in the left inferior PV and right superior PV reconnections. The presence of PV reconnection during redo was not associated with better long-term success compared to completely isolated PVs (67% vs. 67%; log-rank p = 0.997). Overall, the different ablation strategies for redos were comparable regarding AF recurrences during follow-up (p = 0.079), with the ablation approach having no impact in the case of left atrial low voltage or without. Conclusions: PV reconnections after initial successful PVI are common among all techniques of AF ablation. Long-term rhythm control off antiarrhythmic drugs was possible in 2/3 of all patients after the redo procedure; however, different ablation strategies with extra-PV trigger ablation did not improve long-term success. Patients with recurrent AF after PVI constitute a challenging group of patients.
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Ablation of complex fractionated atrial electrograms (CFAEs) is a new approach for the treatment of atrial fibrillation (AF). The purpose of the study was to assess the efficacy of CFAE ablation as a stand-alone strategy in patients with persistent AF and to compare it with a combined approach of CFAE ablation and pulmonary vein isolation (PVI). The study included 77 consecutive patients with persistent AF who underwent radiofrequency (RF) ablation of CFAE as a sole ablation procedure (CFAE group, n = 23 patients) or a combined approach of CFAE ablation and PVI (CFAE plus PVI group, n = 54 patients). Procedures were guided by three-dimensional mapping systems. After the procedure, AF recurrences were evaluated with 7-day Holter recordings at 1, 3, and 6 months and every 6 months thereafter. Treatment failure was defined as ≥1 AF episode lasting >30 s on Holter recordings during follow-up. After a mean follow-up time of 13 ± 10 months, 2 of 23 patients (9%) with CFAE ablation and 22 of 54 patients (41%) with CFAE plus PVI were in sinus rhythm after a single ablation procedure without anti-arrhythmic medication ( P = 0.008). Ablation of CFAE as a stand-alone ablation strategy seems insufficient for the treatment of patients with persistent AF. Pulmonary vein isolation plus CFAE ablation significantly increases the mid-term success rate.
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