Initial Radiofrequency Ablation Research Articles

Relationship between sodium-glucose cotransporter 2 inhibitors and atrial fibrillation recurrence after pulmonary vein isolation in patients with type 2 diabetes and persistent atrial fibrillation.

The impact of sodium-glucose cotransporter 2 (SGLT2) inhibitors on the postoperative recurrence of atrial fibrillation (AF) in patients with persistent AF undergoing an initial radiofrequency ablation is not yet established. The objective of this study is to assess the impact of SGLT2 inhibitors on the recurrence of AF after radiofrequency ablation in patients with type 2 diabetes complicated persistent AF. A total of 182 patients with type 2 diabetes and persistent AF, who underwent their first radiofrequency ablation for AF at our center, were enrolled and divided into two groups: the SGLT2 inhibitor group and the non-SGLT2 inhibitor group. The main outcome of the follow-up was the postoperative recurrence of AF. A total of 49 participants experienced AF recurrence. The use of SGLT2 inhibitors in patients with type 2 diabetes who underwent AF ablation was associated with a significantly lower risk of AF recurrence (adjusted hazard ratio: 0.65; 95% confidence interval: 0.28-0.83; p < .01). The use of SGLT2 inhibitors is associated with a decreased risk of arrhythmia recurrence after AF ablation in patients with type 2 diabetes complicated with persistent AF.

P.076 Long-term outcomes of radiofrequency ablation for temporal lobe epilepsy

Background: Radiofrequency ablation (RFA) is a minimally-invasive procedure that has been used to treat temporal lobe epilepsy (TLE), however its long-term efficacy is unknown. We aim to characterize the long-term outcomes of patients from the original series by Parrent and Blume (1999). Methods: Consecutive patients who underwent stereotactic RFA for TLE were retrospectively reviewed. Demographics, procedural details, and seizure outcomes until last follow-up were abstracted. Seizure-freedom after initial RFA treatment was estimated with Kaplan-Meier analysis. Results: 27 patients underwent RFA from 1994 to 2002. There were 14 female (52%) patients. 24 (89%) had mesial temporal sclerosis. Mean age at time of RFA was 33.1 years (range 12-45 years). 17 (63%) patients underwent left-sided RFA. 15 (56%) patients had further interventions: 4 (15%) underwent only repeat RFA, 1 (4%) had repeat RFA and anterior temporal lobectomy (ATL), and 10 (37%) underwent subsequent ATL only. Mean follow-up was 9.0 years (range 0.5-22.7 years). At last follow-up, 16 (59%) patients were seizure-free: 5 (19%) received one RFA treatment and 11 (41%) underwent additional procedures. Conclusions: Based on the original series describing the technique, stereotactic RFA for TLE is a safe, minimally-invasive procedure. The role of stereotactic RFA in the treatment of TLE remains to be determined.

The effect of an initial catheter ablation with an adjunctive ethanol infusion into the vein of Marshall on persistent atrial fibrillation.

Some previous studies have reported that a first-step ethanol infusion into the vein of Marshall (EIVOM) with touch-up radiofrequency (RF) ablation can facilitate mitral isthmus (MI) block and improves the ablation outcomes in persistent atrial fibrillation (PeAF) patients. However, the effect of an initial RF ablation with an adjunctive EIVOM has not been fully investigated. This study enrolled 233 PeAF patients undergoing pulmonary vein isolation and linear ablation including an MI, roof line, and cavotricuspid isthmus ablation. An EIVOM was performed when endocardial ablation with or without coronary sinus ablation failed to create MI block. Bidirectional MI block was achieved in 224 patients (96.1%). Among them, MI block was obtained by only RF ablation in 174/224 patients (77.7%) (RF group) and an adjunctive EIVOM was needed in 50/224 (22.3%) (EIVOM group). During the follow-up, 113 (64.9%) RF group patients were free from AF/atrial tachycardia compared to 41 (82.0%) EIVOM group patients (log-rank p = .045). In a multivariate Cox regression analysis, an adjunctive EIVOM was associated with a lower recurrence rate (hazard ratio = 0.39, 95% confidence interval = 0.17-0.78, p = .006). An initial RF ablation with an adjunctive EIVOM strategy improved MI ablation's acute success rate and was associated with better clinical outcomes.

Pulsed field ablation for atrial tachycardia following prior persistent atrial fibrillation ablation and resistant to radiofrequency energy

Abstract Funding Acknowledgements Type of funding sources: None. Background There is a limited knowledge of immediate and long-term efficacy of pulsed field ablation for residual atrial tachycardia (AT) following (longstanding) persistent atrial fibrillation (AF) ablation and resistant to prior radiofrequency ablation (RFA). Purpose To present immediate effects of PFA (Farapulse) in a series of patients with repeat ablation for residual atrial tachycardia (AT) resistant to prior RFA. Methods and results In 5-11/2022, of 23 patients scheduled for PFA, 19 patients (64±7 years, 3 females) underwent PFA for left atrial (LA) AT resistant to RFA in first (n=4), second (n=11), third (n=3), and fourth (n=1) repeat ablation, respectively, after primary persistent AF ablation (4 patients were redirected to RFA for septal/right atrial AT source found by 3D mapping). At the procedure onset, persistent AT was ongoing (n=15) or was induced (n=4; AF induced and subsequently converted into AT in 3 patients). Mapping/ablation strategy was directed according to CS activation/entrainment to: 1) no 3D mapping and direct PFA (n=11); 2) PFA directly after 3D LA mapping (n=5); 3) PFA following RFA after 3D LA mapping (n=3). Total of 29 ATs was found (1,2, and 3 ATs in 12, 4, and 3 patients, respectively). Localized AT sources (n=16) dominated over macroreentry (MR) ATs (8 perimitral, 4 roof-dependent, 1 typical flutter). Only MR ATs, only localized ATs, and both MR+localized ATs were present in 7, 4, and 8 patients, respectively. All ATs were stopped with 5±9 PFA applications at the site of AT source and remained non-inducible. In 3 patients with initial ineffective RFA (6, 11, 6 minutes) within the same procedure, subsequent PFA terminated the AT with 1, 4, and 1 application respectively. Procedure and fluoroscopy times were 104±29 and 12±4 minutes, no complication occurred. Conclusion PFA with catheter Farapulse can affect complex/epicardial AT sources resistant to RFA in prior or present ablation procedure.

Cost-utility analysis of radiofrequency ablation versus optimal medical therapy in managing supraventricular tachycardia among Filipinos.

Radiofrequency ablation (RFA) is the standard of care in the management of supraventricular tachycardia (SVT). Its cost-effectiveness in an emerging Asian country has not been studied. A cost-utility analysis of RFA versus optimal medical therapy (OMT) among Filipinos with SVT was conducted using the public healthcare provider's perspective. A simulation cohort using a lifetime Markov model was constructed using patient interviews, a review of literature, and expert consensus. Three basic health states were defined: stable, SVT recurrence, and death. The incremental cost per quality-adjusted life year (ICER) was determined for both arms. Utilities for the entry states were derived from patient interviews using the EQ5D-5L tool; utilities for other health states were taken from publications. Costs were assessed from the healthcare payer perspective. A sensitivity analysis was done. Base case analysis showed that RFA versus OMT is both highly cost-effective at 5 years and over a lifetime. RFA at 5 years costs about PhP276,913.58 (USD5,446) versus OMT of PhP151,550.95 (USD2,981) per patient. Discounted lifetime costs were PhP280,770.32 (USD5,522) for RFA, versus PhP259,549.74 (USD5,105) for OMT. There was improved quality of life with RFA (8.1 vs. 5.7 QALYs per patient). The 5-year and lifetime incremental cost-effectiveness ratios were PhP148,741.40 (USD2,926) and Php15,000 (USD295), respectively. Sensitivity analysis showed 56.7% of simulations for RFA fell below a GDP-benchmarked willingness-to-pay (WTP) threshold. Despite the initial higher cost, RFA versus OMT for SVT is highly cost-effective from the Philippine public health payer's perspective.

Indirect Comparison of Cryoablation and Radiofrequency Ablation as Initial Therapy for Symptomatic Paroxysmal Atrial Fibrillation: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Introduction: Data on first-line ablation treatment for patients with symptomatic atrial fibrillation (AF) are scarce. This study indirectly compared the efficacy and safety of cryoballoon ablation (CBA) versus radiofrequency ablation (RFA) as initial therapy for symptomatic AF. Methods: We searched the EMBASE, PubMed, Cochrane Library, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) that compared CBA or RFA with antiarrhythmic drugs (AADs) as first-line treatment for AF from the time of database establishment up to December 2021. The odds ratio (OR) with a 95% confidence interval (CI) was used as a measure of the treatment effect. Results: Six RCTs (3 CBA, 3 RFA) that enrolled a total of 1,215 patients were included in this analysis. There were no significant differences in atrial arrhythmia (AA) (OR 0.993, 95% CI: 0.602–1.638), symptomatic AA (OR 0.638, 95% CI: 0.344–1.182), or serious adverse events (OR 1.474, 95% CI: 0.404–5.376) between the two ablation techniques. The incidences of additional CBA therapy (OR 2.693, 95% CI: 1.277–5.681) and patients who crossed over to AAD therapy (OR 0.345, 95% CI: 0.179–0.664) in the CBA group were significantly lower than those in the RFA group. Conclusion: Among patients with paroxysmal AF receiving initial therapy, CBA and RFA share a similar efficacy and safety profile. When pulmonary vein isolation is performed by CBA, study crossover and the need for additional ablation are substantially lower.

A New Perspective for Predicting the Therapeutic Success of RFA in Solid BTNs: Quantitative Initial RFA Ratio by Contrast-Enhanced Ultrasound.

ObjectiveThe short-term therapeutic success of radiofrequency ablation (RFA) in solid benign thyroid nodules is of great concern. The aim of this study was to investigate a new method, initial radiofrequency ablative ratio (IRAR) using contrast-enhanced ultrasound (CEUS), for predicting therapeutic success of RFA in solid benign thyroid nodules (BTNs) immediately and effectively after RFA.MethodsA total of 813 nodules in 776 patients with benign thyroid nodules were treated with RFA from January 2014 to August 2018, among which 120 patients (M:F=41:79) with 120 solid BTNs (small: ≤10ml, n=57; medium: 10-30ml, n=42; large: >30ml, n=21) were enrolled in our study according to the inclusion criteria. The IRAR was defined as the ablative volume ratio immediately after RFA displayed by CEUS. The therapeutic success was evaluated at the 6-month follow-up. The relationship between the IRAR and volume reduction ratio (VRR) at 6-month was analyzed. The marginal regrowth of solid BTNs was also examined by CEUS at the 6 and 12 months of follow-up.ResultsIn medium and large nodules, the IRAR was significantly and positively correlated with VRR (r= 0.69, P < 0.001) at 6 months after RFA. There was a tendency to achieve therapeutic success (50% VRR: 55/63, 87.3%) when the IRAR exceeded 75%, and marginal regrowth was also relatively slow within 12 months after a single session treatment. No significant correlation between IRAR and VRR of small nodules was found. In conclusion, IRAR is significantly and positively correlated with VRR, which may indicate therapeutic success when it exceeds 75%.ConclusionsCEUS can be used to accurately quantify the IRAR, which is positively correlated with the VRR. Moreover, the IRAR may be used as a parameter to predict the short-term therapeutic success of RFA in solid BTNs.

Outcomes of posterior wall isolation with pulmonary vein isolation for paroxysmal atrial fibrillation

Prior studies have shown that addition of posterior wall isolation (PWI) may reduce atrial fibrillation recurrence in patients with persistent atrial fibrillation. No data on PWI in paroxysmal AF (pAF) patients with normal left atrial voltage is available, to date. This study sought to evaluate the efficacy of PWI in addition to pulmonary vein isolation (PVI) in patients presenting with pAF and normal left atrial voltage. Consecutive patient registry analysis was performed on all patients with pAF and normal left atrial voltage undergoing initial radiofrequency ablation from November 1, 2018 to November 15, 2019. Primary endpoint was recurrence of atrial arrhythmia including AF, atrial tachycardia (AT), or atrial flutter (AFL). A total of 321 patients were studied, 214 in the PVI group and 107 in the PWI + PVI group. Recurrence of any atrial arrhythmia occurred in 18.2% of patients in the PVI group and 16.8% in the PVI + PWI cohort (p = 0.58). At 1 year, recurrence was 14.0% in the PVI group and 15.0% in the PWI + PVI group (p = 0.96). There was a lower AT/AFL recurrence in the PVI + PWI group, not reaching significance (3.7% in the PWI + PVI group vs. 7.9% in PVI group, p = 0.31). Need for carina lesions predicted recurrence in the PVI-only group. Addition of PWI to PVI in pAF patients undergoing their first ablation did not reduce the frequency of atrial arrhythmia recurrence. This warrants further study in a prospective trial.

Machine Learning–Based Personalized Prediction of Hepatocellular Carcinoma Recurrence After Radiofrequency Ablation

<h3>Background and Aims</h3> Radiofrequency ablation (RFA) is a widely accepted, minimally invasive treatment for hepatocellular carcinoma (HCC). This study aimed to develop a machine learning (ML) model to predict the risk of HCC recurrence after RFA treatment for individual patients. <h3>Methods</h3> We included a total of 1778 patients with treatment-naïve HCC who underwent RFA. The cumulative probability of overall recurrence after the initial RFA treatment was 78.9% and 88.0% at 5 and 10 years, respectively. We developed a conventional Cox proportional hazard model and 6 ML models—including the deep learning–based DeepSurv model. Model performance was evaluated using Harrel's c-index and was validated externally using the split-sample method. <h3>Results</h3> The gradient boosting decision tree (GBDT) model achieved the best performance with a c-index of 0.67 from external validation, and it showed a high discriminative ability in stratifying the external validation sample into 2, 3, and 4 different risk groups (<i>P</i> < .001 among all risk groups). The c-index of DeepSurv was 0.64. In order of significance, the tumor number, serum albumin level, and des-gamma-carboxyprothrombin level were the most important variables for the prediction of HCC recurrence in the GBDT model. Also, the current GBDT model enabled the output of a personalized cumulative recurrence prediction curve for each patient. <h3>Conclusion</h3> We developed a novel ML model for the personalized risk prediction of HCC recurrence after RFA treatment. The current model may lead to the personalization of effective follow-up strategies after RFA treatment according to the risk stratification of HCC recurrence.

Predicting Values of Neutrophil-to-Lymphocyte Ratio (NLR), High-Sensitivity C-Reactive Protein (hs-CRP), and Left Atrial Diameter (LAD) in Patients with Nonvalvular Atrial Fibrillation Recurrence After Radiofrequency Ablation.

BackgroundThe purpose of this study was to evaluate the predictive values of lipid level, inflammatory biomarkers, and echocardiographic parameters in late NVAF (nonvalvular atrial fibrillation) recurrence after RFA (radiofrequency ablation).Material/MethodsThis retrospective single-center study enrolled 263 patients with paroxysmal or persistent NVAF who underwent initial RFA from Jan 2017 to Jan 2019. The patients were divided into a Recurrent group (n=70) and a Nonrecurrent group (n=193). Univariate and multivariate logistic regression analyses were used for evaluating the predictive factors of late NVAF recurrence. Receiver operating characteristic (ROC) curves were constructed to assess the predictive performance and the optimum cut-off level of variables.ResultsLate NVAF recurrence occurred in 70 patients (26.6%) after initial RFA within 12-month follow-up. Patients in the Recurrent group had significant higher NLR (neutrophil-to-lymphocyte ratio), hs-CRP (high-sensitivity C-reactive protein), LVEDD (left ventricular end-diastolic dimension), LVESD (left ventricular end-systolic dimension), and LAD (left atrial diameter) than those in the Nonrecurrent group (P<0.05). In multivariate analysis, increased NLR (HR=1.438, 95% CI: 1.036–1.995, P<0.05), hs-CRP (HR=1.137, 95% CI: 1.029–1.257, P<0.05) and LAD (HR=1.089, 95% CI: 1.036–1.146, P<0.05) were independent predictors of NVAF recurrence. The area under the curve (AUC) of NLR and hs-CRP was 0.603 (95% CI 0.525–0.681) and 0.584 (95% CI 0.501–0.666), respectively. The combination of NLR, hs-CRP, and LAD revealed an AUC of 0.684 (95% CI 0.611–0.757), with cut-off values of 2.33, 2.025 ng/L, and 44.5 mm, respectively.ConclusionsThe combination of preoperative NLR, hs-CRP, and LAD can predict late NVAF recurrence.

Results of catheter ablation in patients with idiopathic premature ventricular contractions depending on the use of fluoroscopy

Premature ventricular contractions (PVC) is a very common type of arrhythmia. Some patients require surgical treatment. The search for the safest methods of surgical treatment is an important research task.Aim. To evaluate the efficacy and safety of catheter ablation in patients with idiopathic ventricular arrhythmias depending on the implementation of X-ray control.Material and methods. The study included 183 patients admitted to the Federal Center for Cardiovascular Surgery for elective surgery, with frequent idiopathic PVC and indications for surgical treatment of arrhythmia. In the majority of patients with idiopathic PVC, the central origin of ectopia is the right ventricular outflow tract (RVOT). The patients were divided into two groups: group 1 (n=90) — patients with idiopathic PVC after fluoroscopy-guided radiofrequency ablation (RFA); group 2 (n=93) — patients after RFA without fluoroscopy. All patients underwent electrocardiography, echocardiography, and electrophysiological testing. All patients before and after RFA underwent 24-hour Holter monitoring.Results. Among patients of group 1, the initial success of RFA was 62,2%, and in group 2 — 71% (p=0,21). Surgery complications were registered in 3,3% and 4,3% of patients of groups 1 and 2. No deaths have been reported. The duration of surgery did not depend on the use of fluoroscopy. Among patients with failed initial RFA, the effectiveness of subsequent interventions was 88,6%. The greatest efficiency of initial RFA was observed when the ectopic ventricular focus was located in RVOT The lowest efficiency of RFA was observed when the focus was located in the left ventricular papillary muscles.Conclusion. RFA in patients with idiopathic PVC without fluoroscopy does not increase the complication rate and the duration of surgery and have a comparable efficacy compared to fluoroscopy-guided RFA.

Long-Term Follow-Up Results of Ultrasound-Guided Radiofrequency Ablation for Low-Risk Papillary Thyroid Microcarcinoma: More Than 5-Year Follow-Up for 84 Tumors.

Background: Despite reports describing favorable short-term results for thermal ablation of thyroid cancer, there remains a need to evaluate long-term results because of its indolent characteristics. The purpose of this study was to evaluate the long-term efficacy and safety of ultrasound (US)-guided radiofrequency ablation (RFA) for low-risk papillary thyroid microcarcinoma (PTMC) over a follow-up period of more than five years. Methods: From a cohort of patients under surveillance after US-guided RFA for primary low-risk PTMC, those with a record of follow-up data of more than five years were selected for this study. Before RFA, all patients underwent US and computed tomography to evaluate the PTMC and the presence of neck metastasis. RFA was performed using thyroid-dedicated electrodes. Follow-up US was performed 6 and 12 months after initial RFA, and then every 12 months. The status of ablated tumors was evaluated according to volume reduction, local tumor progression, newly developed cancers, lymph node (LN) or distant metastasis, and delayed surgery during follow-up. Complications during the procedure and follow-up period were evaluated. Results: A total of 84 nodules from 74 patients were included in this study. All patients tolerated RFA, and the mean follow-up duration was 72 months. After RFA, complete disappearance rates of 98.8% and 100% were achieved at 24 and 60-month follow-up, respectively. Additional ablations were performed in 13 of 84 tumors. The mean number of RFA sessions was 1.2. There were four newly developed cancers in three patients, and these were also treated with RFA and completely disappeared. During the follow-up period, there was no local tumor progression, no LN or distant metastasis, and no patients underwent delayed surgery. The major complication rate was 1.4% (1/74), and there was no delayed complication or procedure-related death. Conclusions: RFA is effective for treating low-risk PTMC patients, without occurrence of local tumor progression, LN or distant metastasis, delayed complications, procedure-related death, or delayed surgery over more than five years of follow-up.

Simultaneous Stereotactic Radiofrequency Ablation of Multiple (≥ 4) Liver Tumors: Feasibility, Safety, and Efficacy

PurposeTo assess feasibility, safety, and clinical outcome of simultaneous stereotactic radiofrequency (RF) ablation of multiple (≥ 4) primary and metastatic liver tumors. Materials and MethodsThis retrospective observational study included 92 patients (29 women, 62 men), 35 with ≥ 4 hepatocellular carcinomas (HCCs) and 57 with ≥ 4 metastatic liver tumors at initial stereotactic RF ablation between 2005 and 2018. The median size of 178 HCCs and 371 metastases was 2.2 cm (range, 1.0–8.5 cm) and 3.0 cm (range, 0.5–13 cm), respectively. At initial stereotactic RF ablation, 17 (48.6%) patients with HCC and 19 (33.3%) with metastases had 4 liver tumors, 11 (31.4%) and 19 (33.3%) had 5 tumors, and 7 (20%) and 19 (33.3%) had ≥ 6 tumors. ResultsMajor complications occurred in 2 of 35 ablations (5.4%) in patients with HCCs and in 7 of 63 (10%) with metastases. The primary technical efficacy rate (ie, successful initial ablation) was 100% (178/178) in HCCs and 98.8% (363/371) in metastases. Local recurrence was observed in 4 of 178 (2.2%) HCCs and in 17 of 371 (4.6%) metastases. Overall survival (OS) rates at 1, 3, and 5 years from the date of the first stereotactic RF ablation were 88.0%, 54.0%, and 30.4% for patients with HCCs with a median OS of 38.2 months and 86.1%, 53.1%, and 37.3% for patients with metastases with a median OS of 37.4 months. ConclusionsStereotactic RF ablation is a feasible, safe, and efficacious option in simultaneous management of multiple primary and metastatic liver tumors.

Percutaneous Radiofrequency Ablation for Metachronous Hepatic Metastases after Curative Resection of Pancreatic Adenocarcinoma

ObjectiveTo retrospectively evaluate the safety and efficacy of percutaneous radiofrequency ablation (RFA) in patients with metachronous hepatic metastases arising from pancreatic adenocarcinoma who had previously received curative surgery.Materials and MethodsBetween 2002 and 2017, percutaneous RFA was performed on 94 metachronous hepatic metastases (median diameter, 1.5 cm) arising from pancreatic cancer in 60 patients (mean age, 60.5 years). Patients were included if they had fewer than five metastases, a maximum tumor diameter of ≤ 5 cm, and disease confined to the liver or stable extrahepatic disease. For comparisons during the same period, we included 66 patients who received chemotherapy only and met the same eligibility criteria described.ResultsTechnical success was achieved in all hepatic metastasis without any procedure-related mortality. During follow-up, local tumor progression of treated lesions was observed in 38.3% of the tumors. Overall median survival and 3-year survival rates were 12 months and 0%, respectively from initial RFA, and 14.7 months and 2.1%, respectively from the first diagnosis of liver metastasis. Multivariate analysis showed that a large tumor diameter of > 1.5 cm, a late TNM stage (≥ IIB) before curative surgery, a time from surgery to recurrence of < 1 year, and the presence of extrahepatic metastasis, were all prognostic of reduced overall survival after RFA. Median overall (12 months vs. 9.1 months, p = 0.094) and progression-free survival (5 months vs. 3.3 months, p = 0.068) were higher in the RFA group than in the chemotherapy group with borderline statistical difference.ConclusionRFA is safe and may offer successful local tumor control in patients with metachronous hepatic metastases arising from pancreatic adenocarcinoma. Patients with a small diameter tumor, early TNM stage before curative surgery, late hepatic recurrence, and liver-only metastasis benefit most from RFA treatment. RFA provided better survival outcomes than chemotherapy for this specific group with borderline statistical difference.

Clinical Outcomes and Techniques for Radiofrequency Ablation of Lung Tumors Smaller than 1 cm.

Purpose: To evaluate the outcomes of radiofrequency ablation (RFA) on lung tumors < 1 cm in maximum diameter. Materials and Methods: Twenty-eight patients (12 male, 16 female; median age, 59 years; mean age, 58 ± 16 years; range, 16-78 years) who underwent RFA for lung tumors < 1 cm in diameter between November 2009 and September 2018 were included in this study. Thirty-five tumors (median size, 8.4 mm; mean size, 7.7 ± 1.9 mm; range, 3.6-9.9 mm) were treated with 33 sessions of RFA. Technique efficacy and safety were subsequently evaluated. Initial and secondary technique efficacy were defined as complete ablation without residual tumor or local tumor progression after initial and repeat RFA, respectively. Safety was evaluated according to the Common Terminology Criteria for Adverse Events, version 5.0. Results: Residual tumor remained for 1 tumor (3%, 1/35) and local tumor progression was found in 2 tumors (6%, 2/35). Initial technique efficacy rate was therefore 91% (32/35). The remaining 3 tumors were treated by repeat RFA (secondary technique efficacy rate: 100%, 35/35). Initial technique efficacy rate was significantly lower for tumors treated with starting energy ≥ 20 W (P = 0.02) and showing a quick increase in tissue impedance (P = 0.01). There were 4 grade 2 adverse events (12%, 4/33) comprising pneumothorax requiring chest tube placement, and 14 grade 1 adverse events comprising self-limiting pneumothorax (36%, 12/33) and pulmonary parenchymal hemorrhage (6%, 2/33). Conclusion: To achieve good outcomes for lung tumors < 1 cm, radiofrequency energy should be started at < 20 W. Application of manual mode ablation might be considered when delivery of power cannot be continued due to a quick increase in tissue impedance.

Repeat procedures and prescription opioid use after lumbar medial branch nerve radiofrequency ablation in commercially insured patients

PURPOSEAlthough the effectiveness of medial branch nerve radiofrequency ablation (RFA) for lumbosacral facet pain has been described, little is known regarding patterns of repeat RFA utilization and prescription opioid use afterward. DESIGNRetrospective cohort analysis. PATIENT SAMPLEPatients undergoing lumbosacral RFA in MarketScan from 2007 to 2016. METHODSThe time until and number of staged RFAs (<180 days after initial RFA) and repeat RFAs (≥180 days after initial RFA), as well as opioid use at 90 and 180 days after RFA were assessed. Survival analyses were employed to estimate subsequent RFA rates, whereas subsequent RFA frequencies were estimated with inverse probability weighting. Repeated measures testing was performed comparing opioid use pre- and post-RFA. RESULTSInitial RFAs were identified in 44,936 patients. Staged RFAs were performed in 33.1% of patients. Repeat RFAs through 1, 3, and 7 years were performed for 14.6%, 33.5%, and 45.7% of patients, respectively. Within 3 years, 12.2% of patients underwent one repeat RFA, whereas 13.2% of patients underwent two or more. Post-RFA opioid use was examined in 128,310 patients, 32.2% of whom used opioids pre-RFA. By 180 days post-RFA, 8.1% of patients discontinued opioids and 6.7% started opioids (p<.001). Exclusively examining pre-RFA opioid users, 24.9% stopped filling opioid prescriptions 180 days after RFA. CONCLUSIONSThis study delineates utilization rates of repeat RFA in the commerciall y insured population, with one-third undergoing repeat RFA within 3 years. Additionally, the present data indicate that lumbosacral RFA is associated with reduced filling of opioid prescriptions through 180 days.

1712 Detection of Sub-Surface High-Grade Dysplasia Following Radiofrequency Ablation (RFA) of Barrett’s Esophagus

INTRODUCTION: Barrett's esophagus (BE) occurs when intestinal epithelium replaces squamous epithelium normally lining the distal esophagus. BE is associated with an increased risk of esophageal adenocarcinoma (EAC). While traditionally associated with Caucasian males, prevalence of BE and EAC in Asian populations is projected to rise, associated with increasing prevalence of gastroesophageal reflux disease (GERD), which is associated with obesity and hiatal hernia. Radiofrequency ablation (RFA) is an endoscopic treatment modality shown to be safe and effective in inducing reversion to squamous epithelium, with a treatment depth of 500-1000 microns. We present a case of BE with high-grade dysplasia identified on random forceps biopsy after RFA for BE with low grade dysplasia, after which significant sub-surface disease was detected by volumetric laser endomicroscopy (VLE). CASE DESCRIPTION/METHODS: A 72 yo Chinese male was diagnosed with short-segment BE containing low grade dysplasia, and was treated with 2 sessions of focal RFA 5 months apart. He was lost to follow up and re-established care two years later. At presentation, the patient denied any heartburn, dysphagia or weight loss. Surveillance endoscopy with white light and narrow band imaging (Figure 1) revealed short tongues of salmon-colored mucosa suspicious for residual BE. Forceps biopsy confirmed BE with high grade dysplasia at the 12:00 position. Repeat endoscopy using VLE demonstrated suspicious-appearing glands, primarily sub-surface, which were laser marked and resected with band ligation and snare instead of forceps biopsy (Figure 2). Pathology results confirmed high-grade dysplasia within BE (Figure 3). Due to the presence of dysplasia deeper into the epithelium, in the setting of prior RFA, the patient was referred for liquid nitrogen spray cryotherapy. DISCUSSION: Residual or recurrent BE following RFA is a relatively common finding, but it is uncommon to see disease with a higher dysplasia grade than what was found pre-treatment. In this case, the use of VLE to evaluate these findings identified deeper disease that may not have been amenable to initial RFA treatment, with the lesion becoming “buried” after incomplete ablation. VLE, which visualizes the esophageal wall to a depth of 3 mm, should be considered as part of the evaluation of residual BE, especially when dysplasia is present. Its use may improve patient outcomes by leading to an alternate approach to both tissue sampling and further treatment selection.

Efficacy of transarterial chemoembolization compared with radiofrequency ablation for the treatment of recurrent hepatocellular carcinoma after radiofrequency ablation

Purpose: To compare the efficacy and outcome of transarterial chemoembolization (TACE) with radiofrequency ablation (RFA) in the treatment of recurrent hepatocellular carcinoma (HCC) after initial RFA.Material and methods: From January 2008 to December 2014, 199 consecutive patients with primary HCC underwent percutaneous RFA as initial treatment. One hundred and fourteen patients developed intrahepatic recurrent HCC after initial RFA. The patients with recurrent tumor size ≤3 cm and tumor numbers ≤3 who underwent RFA (n = 47) or TACE (n = 31) were included in study. Progression-free survival (PFS), tumor response to treatment and overall survival (OS) were assessed. Prognostic factors for OS were analyzed using multivariate Cox proportional hazard models.Results: The baseline data of initial HCC and the first recurrence of HCC were comparable in both groups. The complete response (CR) rate in the RFA group and the TACE group was 95.7% and 50%, respectively (p < .001). The PFS time in the RFA group and the TACE group was 424 days and 275 days, respectively (p = .004). The one-year and three-year cumulative overall survival rate was 93.5% and 45% in the TACE group, 91.3% and 68.8% in the RFA group (p = .49), respectively. Significant predictive factors for OS were tumor size (HR = 1.951, 95%CI 1.061–3.687, p = .032), prothrombin time (HR = 1.59, 95%CI 1.012–2.498, p = .044) and response to treatment (HR = 0.267, 95%CI 0.092–0.78, p = .016).Conclusion: Repeated RFA is still considered to be the first treatment choice for patients with post-RFA intrahepatic recurrence. However, TACE should also be considered due to comparable overall survival benefits. The advantages of being less invasive and highly repeatable may render TACE to be a preferred treatment for some patients with recurrent HCC after RFA.

The association between alcohol consumption, cardiac biomarkers, left atrial size and re-ablation in patients with atrial fibrillation referred for catheter ablation.

BackgroundInformation on alcohol consumption in patients undergoing radiofrequency ablation (RFA) of atrial fibrillation (AF) is often limited by the reliance on self-reports. The aim of this study was to describe the long-term alcohol consumption, measured as ethyl glucuronide in hair (hEtG), in patients undergoing RFA due to AF, and to examine potential associations with cardiac biomarkers, left atrial size and re-ablation within one year after the initial RFA.MethodsThe amount of hEtG was measured in patients referred for RFA, and a cut-off of 7 pg/mg was used. N-terminal pro B-type natriuretic peptide (NT-proBNP) and the mid-regional fragment of pro atrial natriuretic peptide (MR-proANP) were examined and maximum left atrium volume index (LAVI) was measured. The number of re-ablations was examined up to one year after the initial RFA. Analyses were stratified by gender, and adjusted for age, systolic blood pressure, body mass index, presence of heart failure and heart rhythm for analyses regarding NT-proBNP, MR-proANP and LAVI and heart rhythm being replaced by type of AF for analyses regarding re-ablation.ResultsIn total, 192 patients were included in the study. Median (25th– 75th percentile) NT-proBNP in men with hEtG ≥ 7 vs. < 7 pg/mg was 250 (96–695) vs. 130 (49–346) pg/ml (p = 0.010), and in women it was 230 (125–480) vs. 230 (125–910) pg/ml (p = 0.810). Median MR-proANP in men with hEtG ≥ 7 vs. < 7 pg/mg was 142 (100–224) vs. 117 (83–179) pmol/l (p = 0.120) and in women it was 139 (112–206) vs. 153 (93–249) pmol/l (p = 0.965). The median of maximum LAVI was 30.1 (26.7–33.9) vs. 25.8 (21.4–32.0) ml/m2 (p = 0.017) in men, and 25.0 (18.9–29.6) vs. 25.7 (21.7–34.6) ml/m2 (p = 0.438) in women, with hEtG ≥ 7 vs. < 7 pg/ml, respectively. Adjusted analyses showed similar results, except for MR-proANP turning out significant in men with hEtG ≥ 7 vs. < 7 pg/mg (p = 0.047). The odds ratio of having a re-ablation was 3.5 (95% CI 1.3–9.6, p = 0.017) in men with hEtG ≥ 7 vs. < 7 pg/mg, while there was no significant difference in women.ConclusionsIn male patients with AF and hEtG ≥ 7 pg/mg, NT-proBNP and MR-proANP were higher, LA volumes larger, and there was a higher rate of re-ablations, as compared to men with hEtG < 7 pg/mg. This implies that men with an alcohol consumption corresponding to an hEtG-value ≥ 7, have a higher risk for LA remodelling that could potentially lead to a deterioration of the AF situation.

Whole tumor ablation of locally recurred hepatocellular carcinoma including retained iodized oil after transarterial chemoembolization improves progression-free survival.

To evaluate and compare clinical outcomes of two different radiofrequency ablation (RFA) methods for locally recurred hepatocellular carcinoma (LrHCC) after locoregional treatment. Our institutional review board approved this study with a waiver of informed consent. A total of 313 patients previously treated with transarterial chemoembolization (TACE) (n = 167) and RFA (n = 146) with a single LrHCC ≤ 3cm was included from five tertiary referral hospitals. RFA was done for LrHCCs using either viable tumor alone ablation (VTA) method (VTA: n = 61 in the TACE group and n = 127 in the RFA group) or whole tumor ablation (WTA) method which includes both viable tumor and retained iodized oil or previously ablated zone (WTA: n = 106 in the TACE group and n = 19 in the RFA group). Local tumor progression (LTP)-free survival as well as progression-free survival (PFS) were estimated using the Kaplan-Meier method, and prognostic factors were evaluated using the Cox proportional hazards regression model. In 167 patients with LrHCC who underwent TACE, the 5-year LTP-free survival after RFA was significantly higher with the VTA method than with the WTA method (26.9% vs. 87.8%; p < 0.001; hazard ratio (HR) = 8.53 [4.16-17.5]). The estimated 5-year PFS after RFA for LrHCC after TACE using the VTA method was 5.7%, which was significantly lower than that with the WTA method (26.4%) (p = 0.014; HR = 1.62 [1.10-2.38]). However, in 146 patients with LrHCC after initial RFA, there were no significant differences in cumulative incidence of LTP (p = 0.514) or PFS (p = 0.905) after RFA between the two ablation methods. For RFA of LrHCC after TACE, the WTA method including both viable tumor and retained iodized oil could significantly lower LTP and improve PFS than VTA. • Whole tumor ablation (WTA) could provide significantly better local tumor control for locally recurred HCC (LrHCC) after TACE than viable tumor alone ablation (VTA). • WTA for LrHCC after TACE could also provide significantly better progression-free survival than VTA. • Regarding LrHCC after RFA, VTA would provide a comparable clinical outcome to WTA.