Effective Lesion Formation Research Articles

664Local catheter impedance drop during pulmonary vein isolation predicts conduction block in patients with paroxysmal atrial fibrillation: initial results of the LOCALIZE clinical trial

Abstract Funding Acknowledgements Boston Scientific Background Radiofrequency (RF) catheter ablation for pulmonary vein isolation (PVI) requires resistively heating cardiac tissue to create conduction block. Creation of an RF lesion results in an impedance drop and the magnitude of this drop depends on the temperature and amount of myocardium being heated. Pre-clinical and clinical evaluation of an advanced local impedance (LI) metric found that greater LI drops were indicative of more effective lesion formation. Purpose To evaluate whether LI drop is associated with conduction block after first pass encirclement of the PVs in patients with paroxysmal AF. Methods LOCALIZE is an ongoing, single-arm, multi-center clinical trial (clinicaltrials.gov NCT03232645). LOCALIZE consists of an index PVI procedure (results presented here) and a 3-month follow-up mapping procedure. In the index procedure, electroanatomical maps of the left atrium were created and ipsilateral PVs were divided into 8 anatomical segments (n = 16 per patient). PVI was performed using point-by-point ablation with blinding of operators to LI. Following initial encirclement and a 20-minute wait period, coronary sinus-paced electroanatomical maps were created to identify gaps within anatomical segments. Gaps were annotated on the map and subsequently ablated. Mean LI drop within each segment was calculated offline as an estimate of regional RF energy delivery (Figure - Left). The diagnostic accuracy of LI drop for predicting segment block was assessed using receiver operating characteristic (ROC) analysis in segments with inter-lesion spacing ≤6mm. Results Forty-seven patients with paroxysmal AF underwent PVI at 5 centers (age 62 ± 11 years, male 55.3%). All patients left the index procedure with all PVs isolated. When blinded to LI (n = 3,064 ablations), median baseline LI was 106 (IQR: 97-115) Ω and median LI drop was 18.4 (12.7-24.9) Ω. After first pass encirclement, blocked segments had a significantly larger LI drop (20.2 [14.6-26.0] Ω) than segments with gaps (10.6 [6.9-15.1] Ω, p < 0.01, Figure - Right). The association between LI drop and block was further evaluated along anatomical anterior/posterior wall thickness differences. Anterior block segments were found to have significantly larger LI drops (21.0 [15.9-27.2] Ω) than posterior block segments (16.6 [12.7-23.7] Ω, p < 0.01). ROC analysis of segments with inter-lesion spacing ≤6mm identified optimal LI cut-off values of 16Ω in anterior segments and 11Ω posteriorly, which had positive predictive values for conduction block of 95.6% and 96.7%, respectively. Conclusions The magnitude of LI drop is predictive of acute PVI segment conduction block in patients with paroxysmal AF. The thinner posterior wall required smaller LI drops for block compared to the thicker anterior wall. With inter-lesion spacing of ≤6mm, reaching a LI drop of ≥16Ω anteriorly and ≥11Ω posteriorly was highly predictive of acute segment block in de novo PVI. Abstract Figure. Local impedance drop in de novo PVI

P1447Use of novel local impedance-based catheter in typical right atrial flutter ablation: preliminary data from a multicenter Italian study

Abstract Funding Acknowledgements NO FUNDING Background Many studies demonstrated the importance of an optimal tissue contact to obtain safe and effective lesions and to improve the clinical outcome in ablation of cavotricuspid isthmus (CTI) for typical right atrial flutter (AFL). Data about a novel technology able to measure local tissue impedance (LI) providing a measure of tissue characteristics and lesion formation is still lacking in right atrium or CTI working. Purpose This analysis explores the relationship between LI measures and ablation spot lesion locations during ablation of CTI in common AFL patients (pts). Methods Consecutive pts undergoing AFL ablation from the CHARISMA registry were included. A novel RF ablation catheter with dedicated algorithm (DirectSense - DS -) was used to measure LI at the distal electrode of this catheter. Each targeted spot was characterized in terms of LI parameters during RF delivery at the lateral, intermediate and posterior portions of the CTI. Successful single RF ablation was defined according with a reduction of voltage (RedV) by at least 50% or split in two separate potentials (SPL). Ablation endpoint was the creation of bidirectional conduction block across the isthmus. Results A total of 135 ablation spot lesions were delivered in 20 pts (median 5 [3-11] lesions per pt): 7 (5%) at lateral, 88 (65%) at intermediate and 40 (30%) at posterior portions of the CTI. Acute success was obtained in all cases and no complications were observed. The median ablation time was 26 [17 – 36] seconds per lesion. 100 (74%) and 51 (38%) ablation spots were effective according with RedV or SPL, respectively. The mean LI was 106 ± 15Ω prior to ablation and 93 ± 13Ω after ablation (p < 0.0001, mean absolute LI drop 14 ± 7Ω, mean percentage LI drop 13%±6). Effective ablation spots showed a higher absolute impedance drop (15 ± 7Ω at effective RedV vs 9.6 ± 8Ω at ineffective RedV, p = 0.0001; 15.6 ± 7Ω at effective SPL vs 12.5 ± 7Ω at ineffective SPL, p = 0.0173) or % impedance drop (14%±6 at effective RedV vs 9%±7 at ineffective RedV, p < 0.0001; 14.5%±6 at effective SPL vs 11.6%±6 at ineffective SPL, p = 0.0103) compared with ineffective sites. No significant differences were found in terms of starting LI, ending LI or LI drop among CTI areas. The percentage of LI drop was associated both with RedV (odd ratio 1.17 (95%CI: 1.08 to 1.26, p = 0.0001)) and with SPL (odd ratio 1.08 (1.02 to 1.14, p = 0.0132)). Conclusion In our preliminary experience, measured LI before and after RF delivery and LI drop appear to be consistent and homogeneous across different CTI ablation locations. The magnitude of the LI drop was associated with effective lesion formation and conduction block.

Contact Stability Analysis of Magnetically-Actuated Robotic Catheter Under Surface Motion.

Contact force quality is one of the most critical factors for safe and effective lesion formation during cardiac ablation. The contact force and contact stability plays important roles in determining the lesion size and creating a gap-free lesion. In this paper, the contact stability of a novel magnetic resonance imaging (MRI)-actuated robotic catheter under tissue surface motion is studied. The robotic catheter is modeled using a pseudo-rigid-body model, and the contact model under surface constraint is provided. Two contact force control schemes to improve the contact stability of the catheter under heart surface motions are proposed and their performance are evaluated in simulation.

Optimal lesion size index to prevent conduction gap during pulmonary vein isolation.

A novel real-time lesion size index (LSI) that incorporates contact force (CF), time, and power has been developed for safe and effective catheter ablation. Theoptimal LSI was evaluated to eliminate gap formation during pulmonary vein isolation (PVI). Consecutive patients wereenrolled,who underwent their first PVI using a fiber-optic CF-sensing catheter for atrial fibrillation between December 2016 and October 2017. The CF parameters, force-time integral (FTI), and LSI for 3095 ablation points in 34 patients were evaluated. The FTI and LSI in the lesions with gaps or dormant conduction (gaps/DC) were significantly lower than those in the lesion without gaps/DC (FTI: 140.5 ± 54.5 and 232.4 ± 121.4 g s, P < 0.0001; LSI: 4.0 ± 0.6 and 4.7 ± 0.9, P < 0.0001, respectively). On receiver operating characteristic curve analysis, the optimal LSI threshold was 4.05 (sensitivity, 63.4%; specificity, 76.3%). The LSI of <5.25 predicted a gap or DC with a high sensitivity (sensitivity, 97.6%; specificity, 25.7%). In the posterior wall, which was 37% thinner than the nonposterior wall, a lower LSI of <3.95 showed a relatively high sensitivity (92.3%) and specificity (65.6%). The LSI can be used to predict gaps/DC during the PVI procedure. An LSI of 5.2 may be a suitable target for effective lesion formation. An LSI of 4.0 may be acceptable in the posterior wall, especially in areas adjacent to the esophagus.

Role of contact force in ischemic scar-related ventricular tachycardia ablation; optimal force required and impact of left ventricular access route.

Contact force-sensing technology has become a widely used addition to catheter ablation procedures. Neither the optimal contact force required to achieve adequate lesion formation in the ventricle, nor the impact of left ventricular access route on contact force has been fully clarified. Consecutive patients (n = 24) with ischemic cardiomyopathy who underwent ablation for scar-related ventricular tachycardia were included in the study. All ablations (n = 25) were performed using irrigated contact force-sensing catheters (Smart Touch, Biosense Webster). Effective lesion formation was defined as electrical unexcitability post ablation at sites which were electrically excitable prior to ablation (unipolar pacing at 10mA, 2ms pulse width). We explored the contact force which achieved effective lesion formation and the impact of left ventricular access route (retrograde aortic or transseptal) on the contact force achieved in various segments of the left ventricle. Scar zone was defined as bipolar signal amplitude < 0.5mV. Among 427 ablation points, effective lesion formation was achieved at 201 points (47.1%). Contact force did not predict effective lesion formation in the overall group. However, within the scar zone, mean contact force ≥ 10g was significantly associated with effective lesion formation [OR 3.21 (1.43, 7.19) P = 0.005]. In the 12-segment model of the left ventricle, the retrograde approach was associated with higher median contact force in the apical anterior segment (31 vs 19g; P = 0.045) while transseptal approach had higher median force in the basal inferior segment (25 vs 15g; P = 0.021). In the 4-segment model, the retrograde approach had higher force in the anterior wall (28 vs 16g; P = 0.004) while the transseptal approach had higher force in the lateral wall (21 vs 18g; P = 0.032). There was a trend towards higher force in the inferior wall with the transseptal approach, but this was not statistically significant (20 vs 15g; P = 0.063). In patients with ischemic cardiomyopathy, a mean contact force of 10g or more within the scar zone had the best correlation with electrical unexcitability post ablation in our study. The retrograde aortic approach was associated with better contact force over the anterior wall while use of a transseptal approach had better contact force over the lateral wall.

First clinical use of novel ablation catheter incorporating local impedance data.

Successful catheter ablation is limited by both poor spatial resolution of abnormal local signals and inability to deliver an effective lesion due to poor tissue contact. We report first worldwide use of the Intellanav MiFi OI catheter (Boston Scientific), providing ultra-high density mapping and incorporating a "DirectSense" algorithm to measure local tissue impedance (LI). 31 patients (65±6 years, 20 male) underwent ablation. LI from the catheter, generator impedance (GI) and maximum electrogram amplitude were recorded in the blood pool, and in regions from healthy to dense scar before, during and after ablation. The catheter demonstrated clear nearfield signal where standard bipolar recordings included farfield signal. LI was lower in dense scar than either healthy tissue or blood pool, and demonstrated an exponential relationship with maximum electrogram amplitude. Maximum LI drop on ablation linearly correlated with initial LI. The median LI drop for successful lesions, resulting in lack of local tissue capture, was 16.0Ω (12.1-19.8 Ω) for LV and 14.6 Ω (10.0-18.3 Ω) for LA, which was larger than for unsuccessful lesions (LV: 9.4 Ω [5.4-15.6 Ω] P=0.001; LA: 6.8 Ω [4.7-13.0 Ω], P=0.049). LI percentage drop was also significantly larger for successful than unsuccessful lesions (LV: 17.1 Ω [14.0-19.6 Ω] vs. 10.6 Ω (7.1-16.5 Ω) P=0.002; LA: 14.2 Ω [10.8-19.5 Ω] vs. 7.5Ω [5.1-11.0 Ω], P=0.005). This novel catheter gives reproducible recordings of local impedance, which are dependent on scar level. Absolute LI drop, and also percentage drop, on ablation may give an indication of tissue contact and subsequent effective lesion formation.

Role of Contact Force Sensing in Catheter Ablation of Cardiac Arrhythmias: Evolution or History Repeating Itself?

Adequate catheter-tissue contact facilitates efficient heat energy transfer to target tissue. Tissue contact is thus critical to achieving lesion transmurality and success of radiofrequency (RF) ablation procedures, a fact recognized more than 2 decades ago. The availability of real-time contact force (CF)-sensing catheters has reinvigorated the field of ablation biophysics and optimized lesion formation. The ability to measure and display CF came with the promise of dramatic improvement in safety and efficacy; however, CF quality was noted to have just as important an influence on lesion formation as absolute CF quantity. Multiple other factors have emerged as key elements influencing effective lesion formation, including catheter stability, lesion contiguity and continuity, lesion density, contact homogeneity across a line of ablation, spatiotemporal dynamics of contact governed by cardiac and respiratory motion, contact directionality, and anatomic wall thickness, in addition to traditional ablation indices of power and RF duration. There is greater appreciation of surrogate markers as a guide to lesion formation, such as impedance fall, loss of pace capture, and change in unipolar electrogram morphology. In contrast, other surrogates such as tactile feedback, catheter motion, and electrogram amplitude are notably poor predictors of actual contact and lesion formation. This review aims to contextualize the role of CF sensing in lesion formation with respect of the fundamental principles of biophysics of RF ablation and summarize the state-of-the-art evidence behind the role of CF in optimizing lesion formation.

Determination of cryothermal injury thresholds in tissues impacted by cardiac cryoablation

Despite widespread clinical use of cryoablation, there remain questions regarding dosing and treatment times which may affect efficacy and collateral injury. Dosing and treatment times are directly related to the degree of cooling necessary for effective lesion formation. Human and swine atrial, ventricular, and lung tissues were ablated using two cryoablation systems with concurrent infrared thermography. Post freeze-thaw samples were cultured and stained to differentiate viable and non-viable tissue. Matlab code correlated viability staining to applied freeze-thaw thermal cycles, to determine injury thresholds. Tissue regions were classified as live, injured, or dead based upon staining intensity at the lesion margin. Injury begins at rates of ∼10 °C/min to 0 °C, with non-viable tissue requiring cooling rates close to 100 °C/min to ∼ −22 °C for swine and significantly greater cooling to −26 °C for human tissue (p = 0.041). At similar rates, lung tissue injury began at 0 °C, with human tissue requiring significantly less cooling, to ∼ −15 °C for complete necrosis and −26 °C for swine (p = 0.024). Data suggest that there are no significant differences between swine and human myocardial response, but there may be differences between swine and human lung cryothermal tolerance.

IMPACT OF CONTACT FORCE TECHNOLOGY ON ATRIAL FIBRILLATION ABLATION: A META-ANALYSIS

Catheter-tissue contact is essential for effective lesion formation hence there is a growing usage of contact force (CF) technology in atrial fibrillation (AF) ablation. Data regarding the efficacy and safety of CF for catheter ablation of AF are limited. We conducted a meta-analysis to assess the impact of CF on clinical outcomes and procedural parameters in comparison to conventional catheter (CC) for AF ablation. An electronic search was performed using Cochrane central database, PubMed, Embase, and Web of Knowledge. References were searched manually. Outcomes of interest were: recurrence rate, major complications (including major bleeding, ischemic stroke, embolism or transient ischemic attack), total procedure, and fluoroscopic times. Continuous variables were reported as standardized difference in means (SDM); odds ratios (OR) were reported for dichotomous variables. Eleven studies (2 randomized controlled studies and 9 cohorts) involving 1428 adult patients (855 patients (60%) with paroxysmal AF) were identified. CF was deployed in 552 patients. The range of CF used was between 2 and 60 grams-force (Mean CF 17±5 g). Follow up period ranged between 10- 53 weeks. In comparison between CF and CC groups, a lower recurrence rate was noted with CF (35% vs. 46%, OR 0.62 (95% confidence interval [CI] 0.45; 0.86), P=0.004). No significant heterogeneity was noted for the comparison (I2=23%, P=0.23). Shorter procedure and fluoroscopic times were achieved with CF (156 vs. 173 mins, SDM -0.85 (95% CI -1.48; -0.21), P=0.009; 28 vs. 36 mins, SDM -0.94 (95% CI.66; -0.21), P=0.01, respectively). Major complication rate was higher numerically in the CC group but this did not reach statistical significance (1.33% vs. 1.94%, OR 0.71 (95% CI 0.29; 1.73), P= 0.45). The use of CF technology results in a significant reduction of AF recurrence rate after AF ablation in comparison to CC group. CF technology is able to significantly reduce procedure and fluoroscopic times without compromising complication rate.

Impact of Contact Force Technology on Atrial Fibrillation Ablation: A Meta-Analysis.

BackgroundCatheter–tissue contact is essential for effective lesion formation, thus there is growing usage of contact force (CF) technology in atrial fibrillation ablation. We conducted a meta-analysis to assess the impact of CF on clinical outcomes and procedural parameters in comparison to conventional catheter for atrial fibrillation ablation.Methods and ResultsAn electronic search was performed using major databases. Outcomes of interest were recurrence rate, major complications, total procedure, and fluoroscopic times. Continuous variables were reported as standardized mean difference; odds ratios were reported for dichotomous variables. Eleven studies (2 randomized controlled studies and 9 cohorts) involving 1428 adult patients were identified. CF was deployed in 552 patients. The range of CF used was between 2 to 60 gram-force. The follow-up period ranged between 10 and 53 weeks. In comparing CF and conventional catheter groups, the recurrence rate was lower with CF (35.1% versus 45.5%, odds ratio 0.62 [95% CI 0.45–0.86], P=0.004). Shorter procedure and fluoroscopic times were achieved with CF (procedure time: 156 versus 173 minutes, standardized mean difference −0.85 [95% CI −1.48 to −0.21], P=0.009; fluoroscopic time: 28 versus 36 minutes, standardized mean difference −0.94 [95% CI −1.66; −0.21], P=0.01). Major complication rate was lower numerically in the CF group but not statistically significant (1.3% versus 1.9%, odds ratio 0.71 [95% CI 0.29–1.73], P=0.45).ConclusionsThe use of CF technology results in significant reduction of the atrial fibrillation recurrence rate after atrial fibrillation ablation in comparison to the conventional catheter group. CF technology is able to significantly reduce procedure and fluoroscopic times without compromising complication rate.

Real-time contact force measurement: a key parameter for controlling lesion creation with radiofrequency energy.

Radiofrequency (RF) energy, the dominant energy source for the treatment of various arrhythmias by catheter ablation, has replaced most other treatments for the effective suppression of supraventricular and ventricular arrhythmias.1 With expanding indications, it has become increasingly clear that the success and sustainable effect of RF ablation depends on a critical understanding of the biophysics of lesion creation and its control. RF current at the electrode tissue (ET) interface is the key to RF lesion creation by virtue of its tissue heating capability2 but cannot be measured directly, and therefore, delivered RF power and duration are typically manipulated to control lesion creation.3 Despite such manipulation, there is significant variability in lesion size, which is thought to be responsible for both inefficacy and complications. Contact between electrode and tissue may be the key parameter to control lesion size because it is essential for the passage of current into the target tissue, but has until recently remained intangible and unmeasurable. RF energy delivery creates tissue coagulation and necrosis by producing targeted tissue hyperthermia. This hyperthermia is the consequence of resistive heating of a thin rim of tissue in direct contact with the RF energy delivering electrode, with surrounding tissue being heated by conduction. Direct resistive heating is produced by a high density of alternating current, the magnitude of which declines with the inverse of the square of the distance; therefore, target tissue contact is essential for effective lesion formation.3 The key to effective and safe treatment with RF catheter ablation is controlling lesion size, that is, increasing or decreasing lesion size as desired. Precise control of lesion size is particularly important for treatment strategies requiring multiple coalescent ablations, for example, linear lesions making strategies, such as for atrial flutter, atrial fibrillation (AF), and reentrant ventricular tachycardia.4 The …

Catheter‐Tissue Contact Force Determines Atrial Electrogram Characteristics Before and Lesion Efficacy After Antral Pulmonary Vein Isolation in Humans

Electrogram (EGM) characteristics are used to infer catheter-tissue contact. We examined if (a) atrial EGM characteristics predicted CF and (b) compared the value of CF versus other surrogates for predicting lesion efficacy. Twelve paroxysmal AF patients underwent pulmonary vein isolation using radiofrequency (RF) ablation facilitated by a novel CF-sensing catheter. Operators were blinded to CF. EGM amplitude, width, and morphology were measured pre- and post-RF. At each RF site, average CF, force-time integral (FTI), impedance fall, time to impedance plateau, maximum power, catheter tip temperature, and total energy delivered were recorded. An effective lesion was defined based on previously validated EGM criteria for transmural lesions. There was a moderate correlation between CF and EGM amplitude (r = 0.19) and EGM width (r = -0.22). Pre-RF, EGM amplitude, and width had modest to poor discriminative capacity for identifying preablation CF (e.g., EGM amplitude identified CF>20 g with sensitivity and specificity of 67% and 60%, respectively). Preablation CF, FTI, and total energy delivered during RF were the only independent predictors of effective lesion formation. Neither pre-RF EGM amplitude/width nor power, temperature, and impedance changes during RF predicted effective lesion formation. An average CF >16 g or FTI >404 g*s had excellent sensitivity and specificity (>80%) for identifying an effective lesion. EGM characteristics do not reliably predict either CF before the onset of RF, nor do they predict the likelihood of an effective lesion. CF parameters were superior to power, temperature, and impedance changes during RF in predicting lesion efficacy.

Gold tip ablation facilitates acute pulmonary vein isolation. A prospective randomized pilot study

Background: Pulmonary vein isolation (PVI) is the standard treatment for drug-refractory paroxysmal atrial fibrillation (PAF). Effective lesion formation is determined by ablation power, ablation time and contact force enabling a better energy transfer into tissue. Moreover, animal experiments suggest that gold tip catheters may provide larger lesion volume by enabling larger energy deployment avoiding tip electrode overheating. Objective: To compare the acute procedural performance of an irrigated gold tip catheter (Alcath Flux G Extra, Biotronik; Au) with an irrigated Pt/Ir catheter (Alcath Flux, Biotronik; Pt). Methods: Twenty patients (11male, mean age 62±11 yrs) with a history of PAF were enrolled and underwent PVI in a prospective randomized fashion in two groups. After double transseptal access and 3D mapping (EnSite) circumferential PVI was performed using the Au or Pt catheter at a maximum power of 40W and a flush rate of 17-25ml/min. Maximal tip temperature was set at 43°C. Acute procedural endpoint was complete electrical PVI proven by a circular mapping catheter. Results: Acute electrical PVI was achieved in all patients. The total procedure time was 81±13 and 120±35 min in the Au and Pt group, respectively (p=0.01). Total ablation time was significantly shorter in the Au group 963±276 s versus 2085±1137 (p=0.01). Ablation energy and mean catheter tip temperature were significantly lower in the Au group 28682±8129 Ws versus 47974±23966 Ws (p=0.01) and 47±2°C versus 41±2 °C. The mean ablation power delivered was 30±2 with Au and 23±4 with Pt, respectively (p=0.0002). Conclusion: Gold tip ablation demonstrated superior acute efficacy expressed by shorter procedure times due to more efficient ablation power delivery with less catheter tip heating. Long-term results will be presented.

Real-time lesion assessment using a novel combined ultrasound and radiofrequency ablation catheter

Assessment of lesion size and transmurality is currently via indirect measures. Real-time image assessment may allow ablation parameters to be titrated to achieve transmurality and reduce recurrences due to incomplete lesions. The purpose of this study was to visualize lesion formation in real time using a novel combined ultrasound and externally irrigated ablation catheter. In an in vivo open-chest sheep model, 144 lesions were delivered in 11 sheep to both the atria and the ventricles, while lesion development was monitored in real time. Energy was delivered for a minimum of 15 seconds and a maximum of 60 seconds, with a range of powers, to achieve different lesion depths. Twenty-two lesions were also delivered endocardially. The ultrasound appearance was assessed and compared with the pathological appearance by four independent blinded observers. For the ventricular lesions (n = 126), the mean power delivered was 6.1 ± 2.0 W, with a mean impedance of 394.7 ± 152.4 Ω and with an impedance drop of 136.4 ± 100.1 Ω. Lesion depths varied from 0 to 10 mm, with a median depth of 3.5 mm. At tissue depths up to 5 mm, changes in ultrasound contrast correlated well (r = 0.79, R(2) = 0.62) with tissue necrosis. The depth of ultrasound contrast correlated poorly with the depth of the zone of hemorrhage (r = 0.33, R(2) = 0.11), and impedance change correlated poorly with lesion depth (r = 0.29, R(2) = 0.08). Real-time lesion assessment using high-frequency ultrasound integrated into an ablation catheter is feasible and allows differentiation between true necrosis and hemorrhage. This may lead to safer and more efficient power delivery, allowing more effective lesion formation.

The creation of linear contiguous lesions in the atria with an expandable loop catheter

OBJECTIVESThis article describes a catheter system designed to create linear atrial lesions and identifies electrophysiologic markers that are associated with the creation of linear lesions.BACKGROUNDAtrial fibrillation (Afib) is the most common arrhythmia in humans and causes a significant morbidity. The success of surgical interventions has provided the impetus for the development of a catheter-based approach for the ablation of Afib.METHODSWe tested a catheter system with 24 4-mm ring electrodes that can create loops in the atria. The electrodes can be used to record electrical activity and deliver radiofrequency power for ablation. In 33 dogs, 82 linear lesions were generated using three power titration protocols: fixed levels, manual titration guided by local electrogram activity and temperature control. Bipolar activity was recorded from the 24 electrodes before, during and after lesion generation. Data were gathered regarding lesion contiguity, transmurality and dimensions; the changes in local electrical activity amplitude; the incidence rate of rapid impedance rises and desiccation or char formation; and rhythm outcomes.RESULTSCatheter deployment usually requires <60 s. Linear lesions (12 to 16 cm in length and 6 ± 2 mm wide) can be generated in 24 to 48 min without moving the catheter. Effective lesion formation can be predicted by a decrease of greater than 50% in the amplitude of bipolar recordings. Splitting or fragmentation of the electrogram and increasing pacing threshold (3.1 ± 3.3 mV to 7.1 ± 3.8 mV, p < 0.01) are indicative of effective lesion formation. Impedance rises and char formation occurred at 91 ± 12°C. Linear lesion creation does not result in the initiation of Afib. However, atrial flutter was recorded after the completion of the final lesion in 3/12 hearts. When using temperature control, no char was noted in the left atrium, whereas 8% of the right atrium burns had char.CONCLUSIONSThis adjustable loop catheter forces the atrial tissue to conform around the catheter and is capable of producing linear, contiguous lesions up to 16 cm long with minimal effort and radiation exposure. Pacing thresholds and electrogram amplitude and character are markers of effective lesion formation. Although Afib could not be induced after lesion set completion, sustained atrial flutter could be induced in 25% of the hearts.