Durable Pulmonary Vein Isolation Research Articles

Durability of thermal pulmonary vein isolation in persistent atrial fibrillation assessed by mandated repeat invasive study

BackgroundNo study has assessed the durability of pulmonary vein isolation (PVI) with radiofrequency (RF) and cryoballoon (CB) in patients with persistent atrial fibrillation. These data are especially lacking for those with significantly diseased left atria (LA). ObjectivesThe goals of this study were to assess PVI durability in patients with significant LA disease and to compare reconnection rates between RF and CB. MethodsForty-four patients (mean age 63 years; 34 (77%) male; median time since atrial fibrillation diagnosis 22.5 months; median indexed LA volume 36 mL/m2) were randomized 1:1 to RF or CB PVI. A redo procedure using ultra-high-density electroanatomic mapping was mandated at 2 months, where PV reconnections were identified and reisolated. ResultsThirty-eight patients underwent both procedures (CB n = 17; RF n = 21). Index RF procedures were longer (median 158 minutes vs 97 minutes; P < .001) but required less fluoroscopy (9.5 minutes vs 23 minutes; P < .001). At the index RF procedure, a median of 47% of LA myocardium had voltage < 0.5 mV, suggesting that half of the mapped LA comprised scar. PV reconnection was observed in 73 of 152 PVs (48.0%) and was more frequent with CB (58.8%) than with RF (39.3%) (P = .022). Reconnection of at least 1 PV was detected in >75% of patients. Significantly more ablation was required during the redo procedure to reisolate PVs in the CB arm (median 10.8 minutes vs 1.2 minutes; P < .001). ConclusionPVI durability may be poor in those with significant LA scarring and dilatation, even with modern thermal ablation technologies. RF resulted in significantly better PVI durability than did CB in this complex population.

First-in-human clinical series of a novel conformable large-lattice pulsed field ablation catheter for pulmonary vein isolation.

Pulsed field ablation (PFA) has significant advantages over conventional thermal ablation of atrial fibrillation (AF). This first-in-human, single-arm trial to treat paroxysmal AF (PAF) assessed the efficiency, safety, pulmonary vein isolation (PVI) durability and one-year clinical effectiveness of an 8 Fr, large-lattice, conformable single-shot PFA catheter together with a dedicated electroanatomical mapping system. After rendering the PV anatomy, the PFA catheter delivered monopolar, biphasic pulse trains (5-6 s per application; ∼4 applications per PV). Three waveforms were tested: PULSE1, PULSE2, and PULSE3. Follow-up included ECGs, Holters at 6 and 12 months, and symptomatic and scheduled transtelephonic monitoring. The primary and secondary efficacy endpoints were acute PVI and post-blanking atrial arrhythmia recurrence, respectively. Invasive remapping was conducted ∼75 days post-ablation. At three centres, PVI was performed by five operators in 85 patients using PULSE1 (n = 30), PULSE2 (n = 20), and PULSE3 (n = 35). Acute PVI was achieved in 100% of PVs using 3.9 ± 1.4 PFA applications per PV. Overall procedure, transpired ablation, PFA catheter dwell and fluoroscopy times were 56.5 ± 21.6, 10.0 ± 6.0, 19.1 ± 9.3, and 5.7 ± 3.9 min, respectively. No pre-defined primary safety events occurred. Upon remapping, PVI durability was 90% and 99% on a per-vein basis for the total and PULSE3 cohort, respectively. The Kaplan-Meier estimate of one-year freedom from atrial arrhythmias was 81.8% (95% CI 70.2-89.2%) for the total, and 100% (95% CI 80.6-100%) for the PULSE3 cohort. Pulmonary vein isolation (PVI) utilizing a conformable single-shot PFA catheter to treat PAF was efficient, safe, and effective, with durable lesions demonstrated upon remapping.

Adherence to the CLOSE Protocol and Low Baseline Generator Impedance Are Independent Predictors of Durable Pulmonary Vein Isolation.

Background: Atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) is predominantly attributed to pulmonary vein reconnection (PVR). Predictors of AF recurrence have been widely studied; however, data are scarce on procedural parameters that predict chronic PVR. We aimed to study PVR rates and predictors of PVR. Methods: We retrospectively included 100 patients who underwent repeated ablation due to AF recurrence after initial PVI with the CARTO system. PVR was determined during the repeated procedure by electrophysiological evaluation, and initial procedural characteristics predicting PVR were studied, including adherence to the CLOSE protocol, use of high power, first-pass isolation (FPI), and baseline generator impedance (BGI). Results: Thirty-eight patients underwent initial CLOSE-guided PVI, and sixty-two underwent initial non-CLOSE PVI. A repeat procedure was performed 23 ± 16 months after the initial procedure. In total, PVR was found in 192 of 373 PVs (51.5%), and all PVs were isolated in 17/100 (17%) patients. Factors associated with all PVs being isolated were adherence to the CLOSE protocol, a higher power setting, the presence of bilateral FPI, and lower BGI (88% vs. 28%, p < 0.0001; 37.5 W vs. 30 W, p = 0.0276; 88.2% vs. 40.4%, p = 0.0007; and 127.6 Ω vs. 136.6 Ω, p = 0.0027, respectively). In initial procedures with adherence to the CLOSE protocol, the FPI rate was significantly higher (73.7% vs. 25%, p < 0.0001), while there were no significant differences in terms of procedure time and left atrial dwell time (81 vs. 85 min, p = 0.83; and 60 vs. 58 min, p = 0.08, respectively). BGI ≥ 130 Ω (AUC = 0.7403, sensitivity: 77.1%, specificity: 68.8%, p = 0.0032) was associated with a significantly higher probability of PVR (OR = 6.757; p < 0.0001). In multivariable analysis, independent predictors for PVR were non-adherence to the CLOSE protocol and BGI ≥ 130 Ω. Conclusions: Our findings indicate that adherence to the CLOSE protocol and baseline generator impedance < 130 Ω during AF ablation are independent predictors of PVI durability.

Durability of Pulmonary Vein Isolation Using Pulsed-Field Ablation: Results From the Multicenter EU-PORIA Registry

BackgroundPulsed-field ablation (PFA) is a novel nonthermal ablation technology with high procedural safety and efficiency for pulmonary vein isolation (PVI). Premarket data showed high PVI durability during mandatory remapping studies. Data on lesion durability in real-world patients with clinically indicated redo procedures are scarce. ObjectivesThis study sought to report PVI durability rates in patients undergoing a clinically indicated redo procedure after an index PVI using PFA. MethodsPatients from 7 European centers undergoing an index PVI using PFA were included the EU-PORIA (European Real-world Outcomes With Pulsed Field Ablation in Patients With Symptomatic Atrial Fibrillation) registry. In patients with subsequent left atrial redo procedures due to arrhythmia recurrence, 3-dimensional electroanatomical maps were acquired. PVI durability was assessed on a per-vein and per-patient level, and sites of reconnections and predictors of lesion durability were identified. ResultsOf 1,184 patients (62% paroxysmal atrial fibrillation) undergoing an index PVI using PFA, 272 (23%) had an arrhythmia recurrence. Of these, 144 (53%) underwent a left atrial redo procedure a median of 7 (Q1-Q3: 5-10) months after the first ablation. Three-dimensional electroanatomical maps identified 404 of 567 pulmonary veins (71%) with durable isolation. In 54 patients (38%), all pulmonary veins were durably isolated. Prior operator experience with cryoballoon ablation was associated with a higher PVI durability compared to operators with only point-by-point radiofrequency experience (76% vs 60%; P < 0.001). Neither the operators’ cumulative experience in atrial fibrillation ablation (≤5 vs >5 years) nor the size of the PFA device used (31 mm vs 35 mm) had an impact on subsequent lesion durability (both P > 0.50). ConclusionsIn 144 patients with arrhythmia recurrence after PFA PVI, durable isolation was observed in 71% of the pulmonary veins during the redo procedure, and 38% of all patients showed durable isolation of all veins.

Adding Electroanatomical Mapping to Cryoballoon Pulmonary Vein Isolation Improves 1-Year Clinical Outcome and Durability of Pulmonary Vein Isolation: A Propensity Score-Matched Analysis.

Background: Adding electroanatomical left atrial (LA) voltage mapping to cryoballoon ablation (CBA) improves validation of acute pulmonary vein isolation (PVI). Aims: To determine whether the addition of mapping can improve outcome and PVI durability. Methods: One-year outcome and PV reconnection (PVR) rate at first repeat ablation were studied in 400 AF patients in a propensity-matched analysis (age, AF type, CHA2DS2-VASc score) between Achieve catheter-guided CBA with additional EnSite LA voltage maps performed pre- and post-CBA (mapping group; N = 200) and CT- and Achieve catheter-guided CBA (control group; N = 200). Clinical success was defined as freedom of documented AF or atrial tachycardia (AT) > 30 s. PV reconnection patterns were characterized in repeat ablations. Results: At 1 year, 77 (19.25%) patients had recurrence of AF/AT, significantly lower than in the mapping group: 21 (10.5%) vs. 56 (28%), p < 0.001. Procedure time was shorter (72.2 ± 25.4 vs. 78.2 ± 29.3 min, p = 0.034) and radiation exposure lower (4465.0 ± 3454.6 Gy.cm2 vs. 5940.5 ± 4290.5 Gy.cm2, p = 0.037). Use of mapping was protective towards AF/AT recurrence (HR = 0.348; 95% CI 0.210-0.579; p < 0.001), independent of persistent AF type (HR = 1.723; 95% CI 1.034-2.872; p = 0.037), and LA diameter (HR = 1.055; 95% CI 1.015-1.096; p = 0.006). At repeat ablation (N = 90), persistent complete PVI was seen in 14/20 (70.0%) versus 23/70 (32.9%) in the mapping and conventional group, respectively (p = 0.03). Reconnection rate of the right inferior PV was lower with mapping (10.0% vs. 34,3%, p = 0.035). Conclusions: Adding electroanatomical LA voltage mapping to CBA improves 1-year clinical outcome and lowers both procedure time and radiation exposure. At repeat, use of mapping increases complete persistent PVI mainly by improving PVI durability of the RIPV.

Meta-analysis of Pulsed Field Ablation Versus Thermal Ablation for Pulmonary Vein Isolation in AF: A Broad Overview Focusing on Efficacy, Safety and Outcomes.

The recently established non-thermal, single-shot pulsed field ablation (PFA) is a potential tool for achieving rapid pulmonary vein isolation (PVI) to cause cell death by electroporation, yet data regarding this state-of-the-art technology remain sparse. In this meta-analysis, we included 3,857 patients from 20 studies. There was no significant difference in AF recurrence between the PFA and control groups. Subgroup analysis showed that additional ablation beyond PVI has a similar rate of AF recurrence to PVI alone (10% versus 13%, respectively). PVI durability was achieved in 83% (mean), 95% CI [65-99%] of the PFA group and in 79% (mean), 95% CI [60-98%] of the control group, with no significant difference in the rate of PVI durability between the two groups. The PFA group had considerably reduced procedure duration, but not fluoroscopy time. No statistically significant differences in periprocedural complications were observed. PFA is associated with shorter procedural time than thermal ablation. Cardiac complications were uncommon and mainly reversible in both the PFA and control groups.

Posterior wall ablation by pulsed-field ablation: procedural safety, efficacy, and findings on redo procedures.

The left atrial posterior wall is a potential ablation target in patients with recurrent atrial fibrillation despite durable pulmonary vein isolation or in patients with roof-dependent atrial tachycardia (AT). Pulsed-field ablation (PFA) offers efficient and safe posterior wall ablation (PWA), but available data are scarce. Consecutive patients undergoing PWA using PFA were included. Posterior wall ablation was performed using a pentaspline PFA catheter and verified by 3D-electroanatomical mapping. Follow-up was performed using 7-day Holter ECGs 3, 6, and 12 months after ablation. Recurrence of any atrial arrhythmia lasting more than 30 s was defined as failure. Lesion durability was assessed during redo procedures. Posterior wall ablation was performed in 215 patients (70% males, median age 70 [IQR 61-75] years, 67% redo procedures) and was successful in all patients (100%) by applying a median of 36 (IQR 32-44) PFA lesions. Severe adverse events were cardiac tamponade and vascular access complication in one patient each (0.9%). Median follow-up was 7.3 (IQR 5.0-11.8) months. One-year arrhythmia-free outcome in Kaplan-Meier analysis was 53%. A redo procedure was performed in 26 patients (12%) after a median of 6.9 (IQR 2.4-11) months and showed durable PWA in 22 patients (85%) with only minor lesion regression. Among four patients with posterior wall reconnection, three (75%) presented with roof-dependent AT. Posterior wall ablation with this pentaspline PFA catheter can be safely and efficiently performed with a high durability observed during redo procedures. The added value of durable PWA for the treatment of atrial fibrillation remains to be evaluated.

Pulmonary vein isolation durability after very high-power short-duration ablation utilizing a very-close protocol – The FAST AND FURIOUS redo study

BackgroundVery high-power short-duration (vHP-SD) radiofrequency (RF) ablation of atrial fibrillation (AF) treatment by pulmonary vein isolation (PVI) aims for safer, more effective and faster procedures. Although acute efficacy and safety for PVI was recently shown data on chronic PVI durability is limited. Here chronic PVI durability was evaluated during repeat electrophysiological procedures in patients after initial vHP-SD and conventional RF based PVI. MethodsA total of 25 consecutive patients with repeat left atrial procedures after initial vHP-SD based PVI were included in this study. Twenty-five patients with previous conventional RF based PVI and repeat left atrial procedures served as control (control group). ResultsFor index procedures the median RF time was 328 (277, 392) seconds (vHP-SD) and 1470 (1310, 1742) seconds (control); p < 0.001, the median procedure time was 55 (53, 68) minutes (vHP-SD) and 110 (94, 119) (control); p < 0.001). First pass isolation rate was 84 % (vHP-SD) and 88 % (control, p = 0.888). No differences for severe adverse events (vHP-SD: 1/25, 4 % vs. control: 0/25, 0 %; p = 0.676 were detected.Chronic durability of all PVs was assessed in vHP-SD: 16/25 (64 %) and control: 8/25 (32 %) patients (p = 0.023) and vHP-SD: 81 % and control: 62 % of PVs were found to be isolated (p = 0.003). For right PVs vHP-SD: 84 % vs. control: 60 % of PVs (p < 0.001) and for left PVs vHP-SD: 78 % vs. control: 64 % (p = 0.123) were found to be isolated. ConclusionsPVI solely utilizing vHP-SD via a very close-protocol provides fast, safe and effective acute PVI. High rates of chronically isolated pulmonary veins have been detected.

Temperature to time Catch-Up: a novel procedural endpoint to predict durable pulmonary vein isolation after cryoballoon ablation of paroxysmal atrial fibrillation.

Cryoballoon ablation is a widely used single-shot technique for pulmonary vein isolation (PVI) in the treatment of paroxysmal atrial fibrillation (AF). Procedural endpoints ensuring maximal PVI durability are important. To assess the performance of cryoablation procedural markers to predict long-term PVI. In a single center, consecutive patients who underwent redo ablation with high-density mapping for symptomatic AF recurrence after cryoballoon ablation were included and cryoballoon procedural data were collected, including temperature values at 30 and 60s, time to isolation, nadir temperature and the velocity of temperature decline estimated with the temperature/time catch-up point (T2T-Catch-Up) defined as positive when the freeze temperature in minus degree equals the time in seconds after cryoablation initiation (e.g. -15°C in the first 15s of the ablation impulse). 47 patients (62% male; 58.3 ± 11.2years) were included. Overall, 38 (80.9%) patients had ≥ 1 reconnected PV. Among 186 PVs, 56 (30.1%; 1.2 per patient on average) were reconnected. Univariate analysis revealed T2T-Catch-Up in 103 (56%) and more frequent in durably isolated than in reconnected PVs (93 [72%] vs 10 [19%], p < 0.0001). Among binary endpoints, T2T-Catch-Up had the highest specificity (82%) and predictive value for durable PVI at redo ablation (90%). In multivariable analyses, absence of T2T-Catch-Up (Odds-ratio 0.12, 95% CI [0.05-0.31], p < 0.0001) and right superior PV (Odds-ratio 3.14, 95% CI [1.27-7.74], p = 0.01) were the only variables independently associated with PV reconnection. T2T-Catch-Up, a new and simple cryoballoon procedural endpoint demonstrated excellent predictive value and strong statistical association with durable PVI.

Repeat pulmonary vein isolation and anterior line ablation using a novel point-by-point pulsed-field ablation system

BackgroundPulsed-field ablation (PFA) is a nonthermal energy source for ablation of cardiac arrhythmias. This study investigated the prospective outcomes of a novel PFA generator in conjunction with a commercially available, contact force-sensing, focal ablation catheter. ObjectiveThe purpose of this study was to assess the feasibility, safety, and lesion characteristics of point-by-point PFA in consecutive patients undergoing repeat ablation of atrial fibrillation (AF). MethodsThe study involved reisolation of pulmonary veins (PVs) with electrical reconnection and the creation of an anterior line (AL) in patients with anterior substrate or durable pulmonary vein isolation (PVI). ResultsIn 24 patients (46% female; mean age 67 ± 10 years; 67% persistent AF), successful reisolation of 27 of 27 reconnected PVs (100%) was performed. In 19 patients, AL ablation was performed, with bidirectional block in 16 (84%), median ablation time 26 [21, 33] minutes, and first-pass bidirectional block in 13 patients (68%). Acute AL reconduction occurred in 8 of 19 patients (42%). Among these 8 patients, a subsequent sustained block of the AL was achieved in 5 (63%). Ultra-high-density electroanatomic mapping revealed homogeneous but relatively large low-voltage areas in the ablated regions. Median procedural, left atrial dwell, and fluoroscopy times were 100 [90, 109] minutes, 83 [75, 98] minutes, and 10 [8, 13] minutes, respectively. No major or minor complications occurred. ConclusionThis study demonstrated feasibility, acute efficacy, and safety of point-by-point PFA for repeat PVI and AL ablation. Further studies are warranted to assess the long-term durability and comparison with established ablation methods.

Comparison of myocardial injury and inflammation between ablation index-guided and conventional contact force-guided ablation in atrial fibrillation patients

Abstract Background Ablation index (AI)-guided ablation improves the incidence of arrhythmia recurrence as compared to conventional contact force (CF)-guided ablation. Purpose The aim of this study was to elucidate the differences in the biomarkers associated with myocardial injury and inflammation between conventional CF-guided and AI-guided ablation. Methods Atrial fibrillation (AF) patients who underwent pulmonary vein isolation (PVI) from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry were enrolled. We divided the patients into two groups: conventional CF-guided PVI (CF group) and AI-guided PVI (AI group). The differences in biomarkers associated with myocardial injury and inflammation, and long-term durability of PVI between the two groups were evaluated. Results This study population included a total of 794 patients (CF-guided, 241 patients; AI-guided, 553 patients). Total application time was significantly shorter, and total application number was significantly smaller in AI than CF group. High-sensitive troponin I (hs-TnI) post-ablation was significantly higher in AI than CF group (p&amp;lt;0.001), even after taking the total application number and total application time into consideration. No significant differences in inflammatory markers changes from pre- to post-ablation were observed between the two groups. Multiple regression analysis showed that age, AF type, AI-guided ablation and creatinine were significantly associated with the acute myocardial injury (hs-TnI value) after catheter ablation (standardized beta-coefficient=-0.096, p=0.013, standardized beta-coefficient=0.159, p&amp;lt;0.001, standardized beta-coefficient=0.078, p=0.031 and standardized beta-coefficient=0.118, p=0.003, respectively). AI-guided ablation was significantly associated with the hs-TnI post-ablation by multiple regression analysis. The PV reconnection ratio was significantly smaller in AI than CF group (p=0.037). Conclusion According to the results of the biomarkers during AF ablation, AI-guided ablation had the ability to create larger lesions than CF-guided ablation, but had an equivalent inflammatory status to CF-guided ablation. The differences in myocardial injury and inflammation could be the mechanism of the better durability of PVI for AI-guided ablation.

Pulmonary vein isolation durability after very high-power short-duration ablation utilizing a very-close protocol

Abstract Background Very high-power short-duration (vHP-SD) radiofrequency (RF) ablation of atrial fibrillation (AF) treatment by pulmonary vein isolation (PVI) aims for safer, more effective and faster procedures. The lesion formation of vHP-SD ablation creates wider but shallower lesions. Utilizing an individualized "very close-protocol" of 3-4mm inter-lesion distance (ILD) at the anterior and 5-6mm at the posterior aspect of the left atrium using vHP-SD only the close-protocol was adapted. Although acute efficacy for PVI was recently shown no data on chronic PVI durability has been assessed up to date. Here chronic PVI durability was evaluated during repeat electrophysiological procedures in patients after initial vHP-SD based PVI and recurrence of AF, atrial tachycardia or left atrial appendage closure. Methods and Results A total of 25 consecutive patients with repeat left atrial procedures after initial vHP-SD based PVI were included in this study. The median time to the repeat procedure was 5 (IQR 2, 10) months. The patients received a repeat procedure and verification of PVI due to recurrence of AF (n=8), atrial tachycardia (n=12), typical flutter (n=1) or left atrial appendage closure (n=4). During repeat procedures 3D electroanatomical mapping of the left atrium was conducted. Verified PVI durability of all PVs was found in 16/25 (64%) patients. In 1/25 (4%) patient PVI reconduction was found in 1 PV, in 6/25 (24%) patients PVI reconduction was found in 2 PVs and in 1/25 (4%) patient PVI reconduction was found in 3 PVs. A total of 81/100 PVs (81%) were found to be chronically isolated. For right sided PVs 42/50 PVs (84%) were isolated while for left sided PVs 39/50 PVs (78%) were isolated. All PVs were reisolated utilizing radiofrequency energy. Conclusions PVI solely utilizing vHP-SD via a very close-protocol provides high rates of chronically isolated pulmonary veins.

Abstract 12390: Differences in the Impact of Use of Contact Force Sensing Catheters on Subsequent Rates of Pulmonary Vein Reconnection Detected Between Men and Women During Repeat Ablation of Atrial Fibrillation

Background: Radiofrequency catheter ablation (CA) is an effective treatment for atrial fibrillation (AF). Contact force (CF) sensing catheters permit tissue contact monitoring that may lead to durable pulmonary vein (PV) isolation. Objective: To assess the impact of CF-sensing catheters on PV reconnection rates at repeat AF ablation and whether there are sex-based differences. Methods: We conducted a retrospective study of patients who underwent repeat AF ablation after index PV isolation between 2010 and 2022. Patients were divided into 2 groups: Group 1 (non-CF sensing catheters) and Group 2 (CF-sensing catheters). Results: One hundred sixty-one patients were included in the study (76 in Group 1 and 85 in Group 2, 32% female, 70 ± 10 years old). Initial use of CF-sensing catheters at index ablation was associated with a lower PV reconnection rate at repeat ablation (60% for Group 2 vs 87% for Group 1; P = 0.001). There were no significant differences in locations of PV reconnection between Group 1 and Group 2. When stratified by sex, there were significantly lower rates of PV reconnection in male patients with use of CF-sensing catheters (92% for Group 1 vs 67% for Group 2; p=0.001) but not for female patients (71% for Group 1 vs 50% for Group 2; p=0.23). On multivariable logistic regression analysis, use of CF-sensing catheters at index ablation (adjusted odds ratio [aOR]: 0.28, 95% CI: 0.12 to 0.65; p=0.003) and female sex (aOR: 0.38, 95% CI: 0.17 to 0.86; p=0.02) were associated with significantly lower rates of PV reconnection found at repeat ablation. Conclusion: Use of CF sensing catheters reduced PV reconnection rate found at repeat AF ablation. Females have lower rates of PV reconnection identified at repeat ablation which suggest that non-PV triggers may be a more common cause of recurrent AF, thereby blunting the impact of CF-sensing catheters on reducing recurrent AF in females.

Durability of pulmonary vein isolation for atrial fibrillation: a meta-analysis and systematic review.

Pulmonary vein isolation (PVI) plays a central role in the interventional treatment of atrial fibrillation (AF). Uncertainties remain about the durability of ablation lesions from different energy sources. We aimed to systematically review the durability of ablation lesions associated with various PVI-techniques using different energy sources for the treatment of AF. Structured systematic database search for articles published between January 2010 and January 2023 reporting PVI-lesion durability as evaluated in the overall cohort through repeat invasive remapping during follow-up. Studies evaluating only a proportion of the initial cohort in redo procedures were excluded. A total of 19 studies investigating 1050 patients (mean age 60 years, 31% women, time to remap 2-7 months) were included. In a pooled analysis, 99.7% of the PVs and 99.4% of patients were successfully ablated at baseline and 75.5% of the PVs remained isolated and 51% of the patients had all PVs persistently isolated at follow-up across all energy sources. In a pooled analysis of the percentages of PVs durably isolated during follow-up, the estimates of RFA were the lowest of all energy sources at 71% (95% CI 69-73, 11 studies), but comparable with cryoballoon (79%, 95%CI 74-83, 3 studies). Higher durability percentages were reported in PVs ablated with laser-balloon (84%, 95%CI 78-89, one study) and PFA (87%, 95%CI 84-90, 2 studies). We observed no significant difference in the durability of the ablation lesions of the four evaluated energies after adjusting for procedural and baseline populational characteristics.

Methods and techniques for increasing the safety and efficacy of pulmonary vein isolation in patients with atrial fibrillation.

The most common type of sustained arrhythmia is atrial fibrillation (AF). Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation, which has emerged as the primary therapeutic strategy for atrial fibrillation patients. Unfortunately, about one-third of patients experience recurrent atrial arrhythmias after the procedure.

Modification of the pulmonary vein antrum is associated with recurrence after durable pulmonary vein isolation for paroxysmal atrial fibrillation.

Although previous studies have shown the isolated areas after pulmonary vein isolation (PVI) using cryoballoons (CB) (CB-PVI), no studies have investigated the association between the isolated area and recurrence of atrial fibrillation (AF) and atrial tachycardia (AT). This single-center observational study investigated the association between the ablated area and recurrence rate after durable CB-PVI for paroxysmal AF. This study included 76 patients with paroxysmal AF who underwent CB-PVI and established durable PVI with a second procedure, regardless of AF/AT recurrence, 6months after the first procedure. To compare the ablated zones, we quantified the left- and right-sided PV antral isolation areas and non-ablated posterior wall (PW) area. We examined non-ablated areas of the PW and AF/AT recurrence in the chronic phase. In total, 16 of the 76 patients had AF/AT recurrence. The mean follow-up duration was 34months. The non-ablated PW area (14.0 ± 4.6 cm2 vs. 11.5 ± 3.7 cm2; p = 0.0213) and the ratio of the non-ablated PW area to the whole PW area (NAPW) (52.9 ± 9.1% vs. 44.8 ± 9.8%; p = 0.003) were significantly higher in the AF/AT recurrence group than in the AF/AT non-recurrence group. NAPW > 50% was an independent predictor of AF/AT recurrence. The NAPW after durable CB-PVI is associated with AF/AT recurrence. PW isolation or additional applications on the PV antrum with cryoballoon may be considered in addition to PVI in paroxysmal AF, especially in patients with dilated left atria.

Predictors of pulmonary vein non-reconnection in the second procedure after ablation index-guided pulmonary vein isolation for atrial fibrillation and its impact on the outcome.

Although first-pass isolation (FPI) of the pulmonary vein (PV) has been suggested as a marker for PV isolation (PVI) durability, it has not been confirmed. Non-PV atrial fibrillation (AF) triggers were the main target in patients without PV reconnection in the second ablation procedure, but the outcome was unclear. We aimed to validate FPI as a marker of PVI durability and evaluate the outcome after the second procedure in patients without PV reconnection by comparing it to those with reconnection. Among the 2087 patients undergoing the first ablation index-guided radiofrequency AF ablation, 309 with atrial tachyarrhythmias (ATs) recurrence and undergoing the second procedure were studied. Clinical characteristics and outcomes were compared between the patients without PV reconnection (PV non-reconnection group, n = 142) and with reconnection (PV reconnection group, n = 167). FPI in both PV sides in the first ablation procedure was significantly more frequent in thePV non-reconnection group (77.5%) than in thePV reconnection group (45.5%) (p < .001). Multivariate logistic regression analysis revealed that FPI (odds ratio, 3.71 [95% confidence interval, 2.23-6.19], p < .001) was the only predictor of PV non-reconnection. Radiofrequency applications for non-PV AF triggers were more frequently performed in thePV non-reconnection group (40.8% vs. 24.6%, respectively, p < .001). Kaplan-Meier analysis revealed that AT recurrence-free rate was significantly lower in thePV non-reconnection group (1-year recurrence-free rate, 62.7% vs. 75.4%, respectively; p = .01 by log-rank test). FPI was the only independent predictor of PV non-reconnection. Despite aggressive ablation for non-PV triggers, AT recurrence was more frequent in patients with PV non-reconnection.

Characterization of durability and reconnection patterns at time of repeat ablation after single-shot pulsed field pulmonary vein isolation

BackgroundPulsed field ablation (PFA) is a novel method of cardiac ablation where there is insufficient knowledge on the durability and reconnection patterns after pulmonary vein isolation (PVI). The aim of this study was to characterize the electrophysiological findings at time of repeat procedure in real-world atrial fibrillation (AF) patients.MethodsPatients who underwent a repeat procedure (n=26) for symptomatic recurrent arrhythmias after index first-time treatment with single-shot PFA PVI (n=266) from July 2021 to June 2023 were investigated with 3D high-density mapping and ad-hoc re-ablation by radiofrequency or focal PFA.ResultsIndex indication for PVI was persistent AF in 17 (65%) patients. The mean time to repeat procedure was 292 ± 119 days. Of the 26 patients (104 veins), complete durable PVI was observed in 11/26 (42%) with a durable vein isolation rate of 72/104 (69%). Two patients (8%) had all four veins reconnected. The posterior wall was durably isolated in 4/5 (80%) of the cases. The predominant arrhythmia mechanism was AF in 17/26 (65%) patients and regular atrial tachycardia (AT) in 9/26 (35%). Reconnection was observed 9/26 (35%) in right superior, 11/26 (42%) in right inferior, 7/26 (27%) in left superior, 5/26 (19%) in left inferior, p=0.31 between veins. The gaps were significantly clustered in the right-sided anterior carina compared to other regions (P=0.009).ConclusionsDurable PVI was observed in less than half of the patients at time of repeat procedure. No significant difference in PV reconnection pattern was observed, but the gap location was preferentially located at the anterior aspects of the right-sided PVs. Predominant recurrence was AF. More data is needed to establish lesion formation and durability and AT circuits after PFA.

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

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. This study aimed to investigate the efficacy and safety of LAPWI performed by non-thermal pulsed field ablation (PFA) in CA for persAF. 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. 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. 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.

Novel or established cryoballoon ablation system for pulmonary vein isolation: the prospective ICE-AGE-1 study.

Catheter ablation with a cryoballoon (CB) provides effective and durable pulmonary vein (PV) isolation (PVI) associated with encouraging clinical outcome data. The novel POLARx CB incorporates unique features, which may translate into improved safety, efficacy, and outcomes. The ICE-AGE-1 study aimed to assess the efficacy, safety, and 1-year clinical follow-up of the POLARx CB in comparison to the Arctic Front Advance Pro CB (AF-CB4). A total of 103 consecutive patients with paroxysmal or persistent atrial fibrillation (AF) who underwent POLARx-based PVI (POLARx group) were prospectively enrolled and were compared to 102 consecutive patients previously treated with the AF-CB4 (AF-CB4 group). The mean age was 68.7 ± 10.2 (POLARx) and 65.7 ± 12 (AF-CB4, P = 0.0551) years. A total of 412 (POLARx) and 404 (AF-CB4) PVs were identified. All PVs, except for one PV in the POLARx group, were successfully isolated. A significant difference regarding the mean minimal CB temperature reached using the POLARx CB (-56.1 ± 8.3°C) and AF-CB4 (-46.9 ± 10.1°C) was observed (P < 0.0001). Real-time PVI was visualized in 71% of PVs in the POLARx group and 46% of them in the AF-CB4 group (P < 0.001). The mean procedure time was comparable: 54.5 ± 17.1 min for POLARx and 59.4 ± 18.6 min for AF-CB4 (P = 0.0509). No differences were observed in terms of periprocedural complications. There were comparable rates in freedom of AF or atrial tachycardia recurrence after 12 months, beyond a 90-day long blanking period: 78.9% in the POLARx group vs. 77.2% in the AF-CB4 group (P = 0.804). The novel POLARx CB showed similar safety, efficacy, and 1-year recurrence-free survival rates compared to the AF-CB4. A higher rate of real-time electrical PV recordings and significantly lower balloon temperatures were observed using the POLARx as compared to AF-CB4.