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New Ablation Techniques for Atrial Fibrillation

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (25 January 2024) | Viewed by 5974

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Dr. Melanie A. Gunawardene

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Guest Editor

Department of Cardiology and Internal Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
Interests: atrial fibrillation; catheter ablation; arrhythmias; pulsed field ablation; atrial tachycardia

Special Issue Information

Dear Colleagues,

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. The catheter ablation (CA) of AF is progressively becoming the therapy of choice to establish rhythm control. Due to advances in technology and new ablation strategies, the efficacy and safety of CA are constantly improving. Currently, different energy sources, catheter designs and mapping systems provide a broad spectrum of options for the electrophysiologist. Despite rapid progress in this emerging field and worldwide consensus updates, evidence gaps persist at all points. The aim of this Special Issue is to provide a comprehensive overview of the advances in new ablation techniques for atrial fibrillation, with particular interest in the use of innovative techniques and technologies in the CA of AF. Researchers in the field of clinical arrhythmology and electrophysiology are encouraged to submit their findings as original articles or reviews to this Special Issue.

Dr. Melanie A. Gunawardene
Guest Editor

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Keywords

cardiac arrhythmias
catheter ablation
atrial fibrillation
atrial tachycardia
three-dimensional mapping
radiofrequency current energy
cryoballoon
pulsed field ablation

Published Papers (5 papers)

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Research

12 pages, 789 KiB

Open AccessArticle

Dipole Density Guided Catheter Ablation versus Conventional Substrate Modification for Repeat Catheter Ablation of Persistent Atrial Fibrillation

by Jan-Hendrik Schipper, Daniel Steven, Jakob Lüker, Jonas Wörmann, Jan-Hendrik van den Bruck, Karlo Filipovic, Sebastian Dittrich, Cornelia Scheurlen, Susanne Erlhöfer, Friederike Pavel and Arian Sultan

J. Clin. Med. 2024, 13(1), 223; https://doi.org/10.3390/jcm13010223 - 30 Dec 2023

Viewed by 592

Abstract

Aims: The optimal ablation strategy for recurrent persistent atrial fibrillation (persAF) after initially successful catheter ablation (CA) remains debatable. Dipole density (DD) guided CA using the AcQMap system has been proven to be feasible and effective in patients with persAF. So far, long-term outcome data for DD-guided CA in patients with recurrence of persAF are sparse. This study sought to assess long-term outcome data in patients undergoing a DD-guided CA for recurrence of persAF after previous CA in comparison to conventional repeat CA. Methods and Results: Patients undergoing DD-guided CA for recurrence of persAF after previous ablation were compared to patients undergoing conventional substrate modification (CSM). A total of 64 patients (32 DD-guided and 32 CSM) were included in this analysis. Procedure duration (DD: 236 ± 61 min; CSM: 198 ± 59 min; p = 0.004) and fluoroscopy time (DD: 36 ± 15 min; CSM: 20 ± 11 min; p = 0.0001) were significantly longer in the DD group. After a long-term median follow-up (FU) of 27 months (interquartile range 12.8–34.3), DD-guided CA was inferior to CSM regarding overall arrhythmia-free survival (DD: 6 patients (19%), CSM: 11 patients (34%); HR 1.47; p = 0.04). Freedom from AF did not differ between both groups (DD: 16 patients (50%); CSM: 18 patients (56%), HR 0.99, p = 0.47). During FU, more patients underwent repeat CA after DD-guided ablation (DD: 16 patients (50%), CSM: 7 patients (22%), p = 0.04). No major complications occurred overall. Conclusions: Dipole density-guided CA is equally safe but associated with longer procedure duration compared to conventional substrate modification for treatment of recurrent persAF after previous CA. Of note, long-term arrhythmia-free survival is significantly worse after DD-guided ablation, and more patients undergo redo procedures. Full article

(This article belongs to the Special Issue New Ablation Techniques for Atrial Fibrillation)

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11 pages, 1509 KiB

Open AccessArticle

Biophysical Behavior of Very High-Power Short-Duration Radiofrequency Ablation in Pulmonary Vein Isolation: Fast but Gently—Implications for a Successful Procedure

by Eduardo Celentano, Ernesto Cristiano, Barbara Ignatiuk, Elena Bia, Lorenzo Girotto, Nicola Tarantino and Natasja M. S. De Groot

J. Clin. Med. 2023, 12(23), 7332; https://doi.org/10.3390/jcm12237332 - 26 Nov 2023

Cited by 1 | Viewed by 1009

Abstract

The very high-power short-duration (vHP-SD) ablation strategy is an alternative for pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF). However, the acute procedural biophysical behavior of successful lesion creation by means of this technique is still unexplored. We performed a retrospective case–control study aimed at evaluating the behavior of vHP-SD ablation parameters with the QDOT MICRO™ ablation catheter (Biosense Webster) compared with standard radiofrequency (RF) ablation with the THERMOCOOL SMARTTOUCH^® ablation catheter. Twenty consecutive cases of symptomatic PAF treated with the QDOT MICRO™ ablation catheter from December 2022 to March 2023 were compared with cases treated with the standard technique. The acute procedural success of PVI was obtained in all cases with 2192 RF applications, and no adverse events occurred. Compared with the controls, vHP-SD cases featured a significant reduction in procedural time (47 ± 10 vs. 56 ± 12 min, p = 0.023), total RF time (3.8 [CI 3.4–4.6] vs. 21.2 [CI 18.4–24.9] min, p < 0.001), ablation phase time (25 ± 5 vs. 39 ± 9 min, p < 0.001), and irrigation volume (165 [CI 139–185] vs. 404 [CI 336–472] ml, p < 0.001). In vHP-SD RF ablation, a contact force of 5 g minimum throughout the 4 s of RF application appeared to be statistically significant in terms of an impedance drop of at least 10 Ohm (OR 2.63 [CI 1.37; 5.07], p = 0.003). In contrast, in the control group, the impedance drop depended linearly on the contact force. This suggests a different biophysical behavior of vHP-SD ablation. A maximum temperature and minimum contact force of >5 g independently predicted an effective impedance drop in vHP-SD. Increasing the contact force over 5 g during 4 s of vHP RF application might not be necessary to achieve a successful lesion. Full article

(This article belongs to the Special Issue New Ablation Techniques for Atrial Fibrillation)

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18 pages, 3012 KiB

Open AccessEditor’s ChoiceArticle

Left Atrial Posterior Wall Isolation with Pulsed Field Ablation in Persistent Atrial Fibrillation

by Melanie A. Gunawardene, Gerrit Frommeyer, Christian Ellermann, Mario Jularic, Patrick Leitz, Jens Hartmann, Philipp Sebastian Lange, Omar Anwar, Benjamin Rath, Rahin Wahedi, Lars Eckardt and Stephan Willems

J. Clin. Med. 2023, 12(19), 6304; https://doi.org/10.3390/jcm12196304 - 29 Sep 2023

Cited by 7 | Viewed by 1693

Abstract

Background: Left atrial posterior wall isolation (LAPWI) may improve rhythm control in addition to pulmonary vein isolation (PVI) in persistent atrial fibrillation (persAF) patients undergoing catheter ablation (CA). However, LAPWI may be challenging when using thermal energy sources. Objective: This study aimed to investigate the efficacy and safety of LAPWI performed by non-thermal pulsed field ablation (PFA) in CA for persAF. Methods: Consecutive persAF patients from two German centers were prospectively enrolled. There were two study cohorts: (1) the LAPWI cohort, which included PFA-guided (re-)PVI with LAPWI for first-time and/or repeat ablation procedures; and (2) a comparative persAF cohort with a PFA PVI-only approach without LAPWI for first-time ablation within the same timeframe. Patients were followed up by routine Holter ECGs. Results: In total, 79 persistent AF patients were included in the study: 59/79 patients were enrolled in the LAPWI cohort, including 16/59 index (27%) and 43/59 repeat ablation procedures (73%). Sixteen patients (16/79; 21%) were in the PVI-only cohort without LAPWI. Of the patients treated with LAPWI, procedure time and fluoroscopy time was 91 ± 30 min and 15 ± 7 min, respectively. The acute PVI rate was 100% in all first-time ablation patients (32 patients (16 PVI only, 16 PVI plus LAPWI), 196/196 PVs). Of the 43 re-do patients in the LAPWI cohort, re-PVI was necessary in 33% (14/43) of patients (27 PVs; 1.9 PV per-patient); in 67% (29/43), all PVs were isolated, and antral ablation of the PV ostia was performed in 48% (14/29). LAPWI was performed successfully in all 59 (100%) patients of the LAPWI cohort. Two minor complications occurred. No esophageal lesion was detected in the LAPWI cohort (n = 33/59 (56%) patients underwent endoscopy). After 354 ± 197 days of follow-up, freedom from atrial arrhythmias was 79.3% (95-CI: 62–95%) in the complete LAPWI cohort (n = 14/59 (24%) on AAD: class Ic n = 9, class III n = 5). There was no difference regarding acute procedural and clinical outcome compared to the PVI-only cohort. Conclusion: LAPWI guided by PFA is feasible and safe in patients undergoing CA for persAF and shows favorable outcomes. In the context of durable PVI, PFA-guided LAPWI may be an effective adjunctive treatment option. Full article

(This article belongs to the Special Issue New Ablation Techniques for Atrial Fibrillation)

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Graphical abstract

12 pages, 1318 KiB

Open AccessArticle

Wide Antral Circumferential Re-Ablation for Recurrent Atrial Fibrillation after Prior Pulmonary Vein Isolation Guided by High-Density Mapping Increases Freedom from Atrial Arrhythmias

by Stefan Hartl, Hisaki Makimoto, Shqipe Gerguri, Lukas Clasen, Sophia Kluge, Christoph Brinkmeyer, Jan Schmidt, Obaida Rana, Malte Kelm and Alexandru Bejinariu

J. Clin. Med. 2023, 12(15), 4982; https://doi.org/10.3390/jcm12154982 - 28 Jul 2023

Viewed by 759

Abstract

Performing repeated pulmonary vein isolation (re-PVI) after recurrent atrial fibrillation (AF) following prior PVI is a standard procedure. However, no consensus exists regarding the most effective approach in redo procedures. We assessed the efficacy of re-PVI using wide antral circumferential re-ablation (WACA) supported by high-density electroanatomical mapping (HDM) as compared to conventional re-PVI. Consecutive patients with AF recurrences showing true PV reconnection (residual intra-PV and PV antral electrical potentials within the initial ablation line) or exclusive PV antral potentials (without intra-PV potentials) in the redo procedure were prospectively enrolled and received HDM-guided WACA (Re-WACA group). Conventional re-PVI patients treated using pure ostial gap ablation guided by a circular mapping catheter served as a historical control (Re-PVI group). Patients with durable PVI and no antral PV potentials were excluded. Arrhythmia recurrences ≥30 s were calculated as recurrences. In total, 114 patients were investigated (Re-WACA: n = 56, 68 ± 10 years, Re-PVI: n = 58, 65 ± 10 years). There were no significant differences in clinical characteristics including the AF type or the number of previous PVIs. In the Re-WACA group, 11% of patients showed electrical potentials only in the antrum but not inside any PV. At 402 ± 71 days of follow-up, the estimated freedom from arrhythmia was 89% in the Re-WACA group and 69% in the Re-PVI group (p = 0.01). Re-WACA independently predicted arrhythmia-free survival (HR = 0.39, 95% CI 0.16–0.93, p = 0.03), whereas two previous PVI procedures predicted recurrences (HR = 2.35, 95% CI 1.20–4.46, p = 0.01). The Re-WACA strategy guided by HDM significantly improved arrhythmia-free survival as compared to conventional ostial re-PVI. Residual PV antral potentials after prior PVI are frequent and can be easily visualized by HDM. Full article

(This article belongs to the Special Issue New Ablation Techniques for Atrial Fibrillation)

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11 pages, 1258 KiB

Open AccessArticle

Effect of Left Atrial Pulmonary Vein Angiography on Safety and Efficacy for High-Power, Short-Duration Pulmonary Vein Isolation in Patients with Atrial Fibrillation

by Sebastian Weyand, Viola Adam, Matthias Beuter, Simon Hanger, David Heinzmann, Willibald Schrezenmeier and Peter Seizer

J. Clin. Med. 2023, 12(3), 1094; https://doi.org/10.3390/jcm12031094 - 31 Jan 2023

Viewed by 1380

Abstract

Imaging of pulmonary vein (PV) anatomy by angiography before pulmonary vein isolation (PVI) for atrial fibrillation (AF) has long been standard practice in many centers. Nowadays, very accurate anatomical maps can be generated by the use of high-resolution mapping catheters, and very effective ablation lesions can be generated by the use of the high-power, short-duration (HPSD) technique. In our center, PV angiography was routinely performed before PVI. However, since there is no clear evidence for this, we refrained from performing PV angiography. This study aimed to investigate whether PV angiography is still necessary when using high-resolution mapping catheters after ablation in the high-power, short-duration (HPSD) technique. A total of 139 consecutive patients with atrial fibrillation (66.25 ± 11.68 years old, 62.39% male) undergoing radiofrequency PVI were included in the study. Ablation was performed with the HPSD technique using a fixed protocol for energy delivery of 50 watts (contact force 3–20 g). We observed no significant effect on the efficacy, efficiency and complications of the ablation procedure if pulmonary vein angiography was omitted before HPSD PVI. Thus, using our protocol, it may be useful that PV angiography is avoided, especially in young patients and those with chronic renal disease. Full article

(This article belongs to the Special Issue New Ablation Techniques for Atrial Fibrillation)

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