Radiofrequency Ablation For Atrial Fibrillation Research Articles

A meta-analysis and cost-minimization analysis of cryoballoon ablation versus radiofrequency ablation for paroxysmal atrial fibrillation.

Previous studies have shown inconsistent results in clinical effectiveness between cryoballoon ablation (CBA) and radiofrequency ablation (RFA), and cost assessment between the procedures is important. The aim of this study was to evaluate the clinical effectiveness and cost-effectiveness between the procedures in patients with paroxysmal atrial fibrillation (AF) refractory to antiarrhythmic drug therapy. A systematic review and meta-analysis were performed. The primary outcome for the meta-analysis was long-term AF recurrence. Following the results of the meta-analysis, the cost-effectiveness of CBA versus RFA in Japan was assessed. The meta-analysis included 12 randomized controlled trials and six propensity-score matching cohort studies. AF recurrence was slightly lower in patients referred for CBA than for RFA, with an integrated risk ratio of 0.93 (95% confidence interval: 0.81-1.07) and an integrated hazard ratio of 0.96 (95% confidence interval: 0.77-1.19), but no significant difference was found. A cost-minimization analysis was conducted to compare the medical costs of CBA versus RFA because there was no significant difference in the risk of AF recurrence between the procedures. The estimated costs for CBA and RFA were JPY 4 858 544 (USD 32 390) and JPY 4 505 255 (USD 30 035), respectively, with cost savings for RFA of JPY 353 289 (USD 2355). Our meta-analysis suggests that CBA provides comparable benefits with regard to AF recurrence compared with RFA, as shown in previous studies. Although the choice of treatment should be based on patient and treatment characteristics, RFA was shown that it might be cost saving as compared to CBA.

Pulsed field vs very high-power short-duration radiofrequency ablation for atrial fibrillation: Results of a multicenter, real-world experience

BackgroundPulsed field ablation (PFA) and very high-power short-duration (vHPSD) radiofrequency ablation are the most recently introduced technologies for atrial fibrillation (AF) ablation. The procedural performance, safety, and effectiveness of PFA vs vHPSD are currently unknown. ObjectiveThe study aimed to compare PFA with vHPSD for the treatment of paroxysmal or persistent AF. MethodsWe conducted an observational, multicenter study enrolling 534 consecutive patients (63 ± 9 years; 36% female) with paroxysmal (n = 368 [69%]) or persistent (n = 166 [31%]) AF undergoing ablation by either PFA (Farapulse; n = 192) or vHPSD (90 W/4 seconds; QDOT Micro; n = 342) between 2020 and 2023. Atrial tachyarrhythmia recurrence after a 1-month blanking period was the primary efficacy end point and was assessed both overall and in propensity score–matched patients. The primary safety end point was a composite of procedure-related complications. ResultsSuccessful pulmonary vein isolation was achieved in all patients, with shorter procedure duration (PFA,70 minutes; vHPSD, 100 minutes; P < .001) but longer fluoroscopy time (PFA, 15 minutes; vHPSD, 7 minutes; P < .001) in the PFA group. PFA was associated with more frequent use of general anesthesia (P < .001). Primary safety outcome events occurred in 19 patients (3.5%), with similar prevalence in both groups (PFA, 4%; vHPSD, 3%; P = .745). After a median follow-up of 12 (9–12) months, survival free from recurrent atrial tachyarrhythmia was similar between the PFA and vHPSD groups, both overall (12-month estimate: PFA, 75%; vHPSD, 76%; log-rank P = .73) and in propensity score–matched patients (n = 342; 12-month estimate: PFA, 75%; vHPSD, 77%; log-rank P = .980). ConclusionIn a large, multicenter experience, PFA was associated with more common use of general anesthesia, shorter procedural times, and longer fluoroscopy exposure compared with vHPSD ablation, with both techniques displaying superimposable safety and efficacy.

Correlation between Lesions Size Index (LSI) and impedance dynamics during radiofrequency ablation for atrial fibrillation: impact of lesion duration and contact force

Abstract Introduction Impedance drop has been employed as a surrogate marker for lesion formation with its magnitude correlated to lesion size in in-vitro studies. The Lesion Size Index (LSI), and algorithm from Abbott Medical, serves as a predictor for lesion formation during radiofrequency (RF) ablation. While this formula integrates contact force (CF), lesion duration and power, it currently leaks impedance information. The new module of Ensite Cardiac Mapping system (Abbot) is capable of measuring the "filtered" impedance during each RF lesion, effectively eliminating artifacts from cardiac and respiratory oscillations. The objective of this study is to examine the correlation between the LSI and the average impedance drop during RF lesion formation. Methods We included a total of 18 consecutive patients who underwent catheter ablation for atrial fibrillation (AF) with Ensite Mapping System (Abbot). In all cases, 40 watts (W) were applied and the target LSI was set as 5 for the posterior wall and 6 for the anterior wall. For each lesion, the software automatically annotated the initial impedance, final impedance, average impedance drop (filtered), lesion duration and average contact forced (CF). The correlation between LSI, impedance drop and CF was assessed. Results A total of 1300 RF lesions delivered during AF ablation were analyzed. Mean LSI was 5.3 ± 0.8, mean average impedance drop was 10.9± 5 ohms and mean CF 12.3±6 grams (g). The LSI showed a weak but statistically significant correlation with the impedance drop (Person correlation=0.3; p&amp;lt;0.001). When ablation lesions were grouped by duration (&amp;lt;20 seconds, 21-40, 41-60, &amp;gt;60 seconds), the correlation between LSI and impedance drop remained weak but statistically significant for lesions shorter than 20 seconds (p&amp;lt;0.001) and lesions between 21 and 40 seconds (p&amp;lt;0.001). However, there was no longer correlation for lesions between 40-60 seconds and those longer than 60 seconds (Figure1). Mean CF for each group (from &amp;lt;20 to &amp;gt;60 seconds) was 15 ±7 g vs 11 ±5 g vs 9 ± 3 g vs 7± 3g respectively (p&amp;lt;0.001) (Figure 2), suggesting that the CF is key to improve the predictive value of LSI. Conclusions The LSI shows a weak correlation with the average impedance drop during AF ablation. This correlation is influenced by lesion duration, which is ultimately dependent on CF. These findings emphasize the ongoing need to optimize predictive models for RF lesion formation in the ever-evolving landscape of AF treatment.Figure 1Table 1

Pulsed field ablation versus very high power short duration radiofrequency ablation in atrial fibrillation: what is better?

Abstract Background The newly introduced non-thermal pulsed field ablation (PFA) is a promising technology for catheter ablation (CA) of atrial fibrillation (AF) with high acute success rates and good safety features. However studies have shown that very high power short duration (VHPSD) ablation is also highly effective and fast with potentially less arrhythmia recurrence compared to conventional radiofrequency ablation. Data comparing this two methods are lacking Objective The aim of this study is to compare two source of energy used for CA of AF in terms of procedural, clinical and outcome data Methods We conduced a retrospective observational study enrolling all patients (pts) from september 2021 to may 2023 who underwent CA of AF with PFA system and VHPSD. In the PFA group pulmonary veins isolation (PVI) was obtained using 2KV with eight application each vein, posterior wall isolation (PWI) of left atrium (LA) was obtained with application in the flower configuration of the catheter and then additional lesion were deployed at the operator’s discretion. In the VHPSD group the encircling of PV was obtained with 90W for 4 seconds radiofrequency pulses in posterior portions of the LA including LA PW, whereas 50W with ablation index target of 500 was used in the anterior portions of the PV and additional lesions. General anesthesia or deep sedation was carried out in all pts Results A total of 205 pts were included, n = 86 (42%) in the PFA group and N = 119 (58%) in the VHPSD group: paroxysmal (n = 62[72%], N = 64[54%]), persistent (n = 19[22%], N = 43[36%]), long standing persistent (n = 5[5%], N = 10[8%]). PVI was successful in all pts and additional lesions were delivered in n = 26 (30%) in PFA group and N = 76 (64%) in HVPSD group, mostly at the PW (n = 24[92%]; N = 50[66%]). The PFA group revealed a shorter procedura duration (80 ± 29 min vs 108 ± 39 min; p = 0,00001) but longer fluoroscopic time (21 ± 8 min vs 14 ± 10 min; p = 0,00001). The VHPSD group revealed more complications (N = 7[6%] vs n = 3[3%]) but without statistically significant difference (p = 0,43), the most frequent in the PFA group was vascular access complications instead in the VHPSD group was post-procedural pericarditis. Only one patient in VHPSD group had major complication with a post-procedural stroke but without residual neurological deficits. At follow-up after median of 14 (26-6) months, n = 61 pts in the PFA group (71%) and N = 91 in the VHPSD group (76%) were free from atrial arrhythmia (p = 0,79). In both group 7 pts recurrenced as atypical atrial flutter (n = 7[28%] PFA; N = 7[25%] VHPSD; p = 0,061) Conclusion PFA and VHPSD are effective and safe to CA of AF with comparable arrhythmia recurrenses. However procedure duration with PFA is significantly shorter and therefore may be of potential benefit in particular for elderly and frail pts. Further research, including randomized controlled trials, is needed to validate and compare these techniques more comprehensively

Injury to the sinus nodal artery during radiofrequency ablation of atrial fibrillation and atrial tachycardia: its prevalence and treatment with percutaneous coronary intervention

Abstract Background/Introduction Injury to the sinus node artery (SNA) leading to SN dysfunction during radiofrequency catheter ablation (RFCA) of atrial Fibrillation (AF) and atrial tachycardia (AT) has been reported. Purpose The purpose of this study was to elucidate the prevalence and clinical course of SNA injuries during RFCA of AF/AT and examine the efficacy of the percutaneous coronary intervention (PCI) to restore SN function. Methods We retrospectively analyzed data from 6,906 consecutive patients (pts) who underwent RFCA of AF/AT (6,379 pts with AF ablation and 527 pts with AT ablation) in two institutions between January 2013 and December 2022. Results Among 6,906 pts, 9 (0.13%) pts developed SN dysfunction due to SNA injury during RFCA (8 with AF, 1 with AT). Acute SNA injury (total occlusion or severe narrowing of the SNA) was confirmed by coronary angiography (CAG) during the RFCA session in 8/9 pts. In the remaining patient, SNA injury was suspected based on the CT angiography. The culprit sites of the SNA injury were located at the septal site of the superior vena cava-right atrium junction in 4 pts (44%), on the left atrial appendage ridge in 3 (33%), on the roof of the left atrium adjacent to the right superior pulmonary vein in 1 (11%), and in the persistent left superior vena cava in 1 (11%). PCI to the occluded SNA was performed in 8 of the 9 pts: 1) coronary blood flow of the SNA was restored by a 0.014" guidewire advancement into the occluded artery using a micro-catheter followed by direct nitroprusside injection in 4 pts; 2) the direct balloon angioplasty using 0.75-1.5 mm diameter balloons was required to maintain the blood flow of SNA in 3 pts; and 3) CAG revealed spontaneous recovery of the blood flow of SNA in one pt. The remaining patient did not receive the CAG/PCI. All 8 pts who underwent the PCI resulted in restoration of normal sinus rhythm. During a median of 44 months follow-up, all 8 pts who received the PCI maintained normal sinus rhythm, while one patient without PCI demonstrated persistent SN dysfunction. Conclusions SNA injury during RFCA is a rare but critical complication. Prompt recognition by CAG and subsequent PCI effectively restores SN function in pts with unexpected SN dysfunction during RFCA procedures.

Cryoballoon versus radiofrequency catheter ablation: 3-year follow-up data from the prolonged Norwegian randomized study of persistent atrial fibrillation (NO-PERSAF study)

Abstract Background Pulmonary vein isolation (PVI) is still regarded as a cornerstone for treatment of persistent atrial fibrillation (AF). Both radiofrequency ablation (RFA) and cryoballoon ablation (CBA) are frequently employed to achieve PVI. Similar results of both techniques have been reported during short follow-up, but clinical outcomes for long-term follow-up from randomized trials are still missing. Purpose This study aimed to evaluate the effectiveness of PVI performed with CBA compared with RFA in patients with persistent AF over 3 years. Methods For the NO-PERSAF study, 101 patients (63.2±8.6 years old, 80 male, 21 female), with persistent AF (77 persistent AF, 24 long-standing persistent AF) referred to PVI were randomized (1:1) to CBA or RFA and followed for 12 months. All patients participating in the NO-PERSAF study were invited to an extended outpatient evaluation with 12-lead ECG and 7-day Holter. The primary endpoint was any documented recurrent atrial tachyarrhythmia (ATA) lasting longer than 30 s during 3 years after the index ablation procedure (following a 3-month blanking period). The ATA-free survival curves were estimated by Kaplan-Meier method and analyzed by log-rank test. Results One patient crossed over from CBA to RFA group because of equipment problem during index ablation procedure. 99 of the original 101 patients responded (1 died of non-cardiovascular diseases, 1 lost). Freedom from ATA was achieved in 51 (50.5%) of the 101 patients, 28 (54.9%) out of 51 patients in the CBA group and 23 (46.0%) out of 50 patients in the RFA group (Figure 1). No difference of ATA recurrence was found between the two groups (p=0.327). There was significantly (p=0.031) less atrial flutter in the CBA group (7.8%; 4 atypical) compared with the RFA group (22%; 10 atypical, 1 typical). 28 patients received repeat ablations with RFA during the follow-up period, 15 in the CBA group and 13 in the RFA group (1 twice). Freedom from ATA after multiple ablations was achieved in 74 (73.3%) of the 101 patients, 40 (78.4%) out of the 51 patients in the CBA group and 34 (68.0%) out of the 50 patients in the RFA group. No difference of ATA recurrence was found between the two groups (p=0.178, Figure 2) after multiple ablations with RFA for AF and atrial flutter. Noticeably, 2 patients in the CBA group and none in the RFA group received atrioventricular nodal ablation after permanent pacemaker implantation. Conclusions Compared to RFA, PVI performed with CBA showed similar outcome of freedom from ATA over a long-term follow-up of 3 years. However, the incidence of atrial flutter was significantly lower in the CBA group.Figure 1Figure 2

Pulmonary vein isolation using pulsed field ablation versus high-power-short-duration radiofrequency ablation for paroxysmal atrial fibrillation: efficacy, safety, and long-term follow-up

Abstract Background Pulsed field ablation (PFA) is a novel, nonthermal, cardiac tissue selective ablation modality. To date, radio-frequency (RF) guided high-power-short-duration (HPSD) ablation represents the gold standard for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). This study investigated the efficacy of PFA-PVI versus HPSD-PVI in terms of single-procedure arrhythmia-free outcome and safety. Methods Consecutive, paroxysmal AF patients who underwent PVI using PFA or HPSD were enrolled. In group PFA, PVI was performed using a 31/35-mm pentaspline PFA catheter. The ablation procedure in group HPSD was performed with HPSD-RF energy (45 watts), using Ablation Index (AI) and the CLOSE protocol. The CLOSE protocol combines AI and ≤6 mm interlesion distance using a 4-mm surround flow catheter. Results A total of 420 patients (group PFA: 211; group HPSD: 209) were included (55% men; age 67 ± 10 years). There was no difference between both groups with regard to age, gender and CHA2DS2-VASc-Score. Complete isolation of all PVs was achieved in 100% of patients. Procedure time was significantly shorter in group PFA (74 ± 41 min vs. 127 ± 34 min; p &amp;lt; 0.001); fluoroscopy time and dose area product were significantly longer in group PFA (18 ± 7 min vs. 4 ± 3 min; p &amp;lt; 0.01 and 555 ± 460 uGym2 vs. 213 ± 273 uGym2; p &amp;lt;0.01). Overall procedural complications were 1,4% in group PFA and 5,2 % in group HPSD (p &amp;lt; 0.01), driven by a higher tamponade rate in group HPSD. During a mean follow-up of 12 months after a single procedure, 170 (81%) patients of group PFA were free of arrhythmia recurrence versus 160 (76%) patients in group HPSD (p = 0.798) (Figure 1). Conclusions PVI using PFA compared to PVI using HPSD shows a similar acute efficacy but a significantly reduced complication rate and a shorter procedure time. One-year clinical success rates are favorable, but not different between groups.Figure 1

Pulsed field ablation versus very high-power short-duration radiofrequency ablation in persistent atrial fibrillation: a single-centre experience

Abstract Background Pulsed Field ablation (PFA) has recently emerged as a treatment strategy for patients with atrial fibrillation (AF) and early studies showed promising procedural data and durable pulmonary vein isolation (PVI). However, Very High-Power Short-Duration ablation (VHPSD) has previously reported good efficiency and mid-term outcomes, and only a few works compared these two procedures, especially in patients with persistent AF. Objective Our aim is to compare these different modalities of transcatheter ablation in patients with persistent AF, focusing mainly on some procedural aspects, safety and efficacy. Methods We performed a retrospective observational study enrolling all consecutive patients with persistent AF from September 2021 to May 2023 undergoing transcatheter ablation with PFA or VHPSD. In the first group, PVI was achieved by 2kV pulses with eight applications to each vein using both catheter configurations, while isolation of the posterior wall of the left atrium was achieved by applications through the only "flower" configuration; additional lesions were then added at the operator's discretion. In the second group, PVI was achieved by delivering 90W radiofrequency pulses for 4 seconds in the posterior portions of the left atrium and 50W pulses in the anterior region of the pulmonary veins; additional lesions were occasionally applied. All patients received general anaesthesia or deep sedation with fentanyl and dexmedetomidine. Results A total of 79 patients were included, n = 24 (30%) in the PFA group and N = 55 (70%) in the VHPSD one: early persistent AF (n= 2 [8,3%]; N = 7 [12,7%]), persistent AF (n= 17 [70,8%]; N = 36 [65,5%]), long-standing persistent AF (n= 5 [20,8%]; N = 12 [21,8%]). The two populations showed similar clinical features: CHA2DS2-VASc (median value 3 [0-6] in PFA vs 2 [0-6] in VHPSD, p = 0,10), indexed left atrial volume (mean value 42,6 ml/m² in PFA vs 42,4 ml/m² in VHPSD, p = 0,07) and EF (mean value 55,4% in PFA vs 54,8% in VHPSD, p = 0,33). PVI was successfully achieved in all patients. Nevertheless, the PFA group was associated with shorter procedural duration (92,1 ± 36,9 vs 134,2 ± 36,1 minutes, p = 0,00001) but longer fluoroscopy time (25,5 ± 9,3 vs 17,4 ± 11,5 minutes, p = 0,001); it also showed a lower rate of minor complications (n = 1 [4,2%] vs N = 3 [5,5%], p = 0,057), even though serious complications were not observed in either group. After a median follow-up of 14 (9-26) months, n = 19 [79.2%] in the PFA and N = 43 [78.2%] in the VHPSD population were free of any atrial arrhythmia (p = 0,92). Conclusion PFA allows faster procedures, representing a major advantage for the operator and the patient, who is at lower risk of peri-procedural complications. On the other hand, VHPSD correlates with shorter fluoroscopy times, reducing exposure to ionizing radiation. Finally, the two procedures show similar mid-term efficacy in terms of recurrence-free time.

Pulsed field ablation for complex resistant atrial tachycardia recurring after radiofrequency ablation of persistent atrial fibrillation

Abstract Background There is a limited knowledge on immediate and long-term efficacy of pulsed field ablation (PFA) for residual atrial tachycardia (AT) recurring after persistent atrial fibrillation ablation (AF). Purpose To present immediate and medium-term outcome of PFA (Farapulse) for complex AT recurring after ≥1 radiofrequency ablation (RFA) of primary (longstanding) persistent AF. Methods In 5/2022-10/2023, 81 patients (64±8 years, 19 females) underwent PFA for complex AT in 83 PFA procedures after prior RFA procedure(s); in first (n=21), second (n=33), third (n=23), fourth (n=5), or fifth (n=1) repeat ablation procedure, respectively. Mapping/ablation strategy was directed by the CS activation/entrainment to: 1) no 3D mapping and direct PFA in left atrium (n=67); 2) PFA directly after 3D LA mapping (n=9); 3) PFA following RFA after 3D LA mapping (n=7). AT sources were classified as macroreentry (MRAT) (perimitral, roof-dependent, typical flutter) or localized (LOCAT) in case of smaller reentry or ectopic origin. Results At the procedure onset, persistent AT was present in 58 patients, in the remaining cases AT (n=21) or AF (n=4) were induced. AF eventually occurred at some time of procedure in another 10 patients and was terminated by ablation at LA ridge/CS/LOM region 8x, LA posterior wall 3x, LUPV 1x, RUPV 1x, and RA low lateral wall 1x. Only MRAT, only LOCAT, or both AT types were found at 34 (41%), 35 (42%), and 14 (17%) procedures, respectively. A total of 125 ATs was identified (1, 2, and 3 ATs in 52, 20, and 11 patients). MRAT (n=60) included 32 perimitral ATs, 20 roof-dependent ATs, and 8 typical flutters. LOCAT (n=65) included RUPV source (n=1), LA extraPV sources (n=59), and RA sources (n=5). SR was restored with a 5±7 PFA applications at the site of AF source, total of PFA deliveries was 71±27, and procedure and fluoroscopy times were and 89±37 and 9±5 minutes, respectively. In the 7 patients with initial ineffective 6, 6, 11, 5, 18, 10, and 2 minutes of RFA, the AT was converted into SR by subsequent 1, 4, 1, 13, 4, 24, and 20 PFA applications. All ATs were terminated and noninducibility was achieved in 82 (99%) and 74 (89%) procedures, respectively. In 52 patients with &amp;gt;3 month follow-up, 46 (88%) patients remain in stable SR (41 / 79%) off AAD); 3 and 3 patients have paroxysmal or persistent AT. Conclusion PFA with catheter Farapulse can affect complex/epicardial AT sources resistant to RFA in prior or present ablation procedure; however, there is a certain discrepancy between high efficacy in AT terminating and medium-term clinical outcome.

Comparison of pulsed field and radiofrequency ablation for non-paroxysmal atrial fibrillation: a propensity score-matched analysis

Abstract Background Ablation of non-paroxysmal atrial fibrillation (AF) is challenging and often requires left atrial substrate ablation. While the pentaspline, multi-electrode pulsed-field ablation (PFA) catheter is approved for pulmonary vein isolation (PVI), its role in procedures involving substrate ablation for nonparoxysmal forms of AF remains unknown. Purpose We conducted a retrospective study to assess the safety and long-term outcomes of PFA for non-paroxysmal AF. Methods Procedural and follow-up data were retrospectively collected for all patients undergoing a first-time ablation for non-paroxysmal AF across two centers, between November 2021 and December 2022. Patients undergoing PFA consisting of PVI, isolation of the posterior wall (PWI) and ablation of the mitral isthmus (MI) with the pentaspline multi-electrode PFA catheter, were compared with patients undergoing radiofrequency ablation (RFA) involving PVI, a roof line or PWI, alcohol ablation of the vein of Marshal (VOM) and MI ablation. Patients were matched using propensity scores to minimize potential confounders. The primary endpoint was arrhythmia (AF/atrial flutter/atrial tachycardia) recurrence after a 90-day blanking period. Results The baseline characteristics of the 116 matched patients are detailed in Table 1. PVI was successful in all patients. In the PFA group, PWI was additionally performed in all patients and MI ablation in 83% of cases, resulting in acute success rates of 97% and 96%, respectively. In the RFA group lesions beyond PVI included: a roof line (90%), PWI (10%), VOM alcohol ablation (93%) and MI ablation with ablation in the coronary sinus (CS) if needed (97%). Procedural block across the roof and the MI was achieved in 96% and 95%, respectively and complete PWI in 83% of cases. The PFA group had a shorter total procedure (84.2±22.3 vs 117.3±24.8 min, p&amp;lt;0.001) but a longer fluoroscopy time (23.1±7.2 vs 16.8±6.3 min, p&amp;lt;0.001). The difference in radiation dose, however, was not statistically significant (57.7±74.1 Gy.cm2 in the PFA vs 49.8±53.6 Gy.cm2 in the RFA group, p=0.24). The overall periprocedural complication rates were similar in both groups (8.6% PFA vs 12.1% RFA, p=0.76), with no cardiac tamponades or deaths. Group-specific complications included 1 coronary spasm in the PFA group and 1 CS dissection in the RFA group. During a median follow-up of 447 days (IQR: 364-552), 1 stroke occurred in each group and 1 sudden cardiac death in the RFA group, 13 months post-procedure. Both groups had similar rates of recurrences (32.8% PFA vs 25.9% RFA, p=0.54). Arrhythmia-free survival probability at 16 months was estimated at 67.2% for PFA and 77.6% for RFA by Kaplan-Meier analysis (p=0.16, Figure 1). Conclusions In this propensity-matched cohort of patients with non-paroxysmal AF, PFA and RFA demonstrated similar complication rates and arrhythmia-free survival at follow-up. The procedure duration, however, was significantly shorter with PFA.Figure 1

High power short duration and very high power short duration protocol: a comparison between two effective strategies of atrial fibrillation transcatheter ablation with radiofrequency

Abstract Introduction Radiofrequency (RF) is the most widely used technique for atrial fibrillation (AF) ablation. Aiming to achieve durable pulmonary vein isolation (PVI) with reduced procedural time and potential thermal side effects, high power short duration (HPSD) and very-high power short duration (v-HPSD) protocols have been developed, exploiting the use of the latest catheter generations. Purpose To assess safety and efficacy of AF ablation using two distinct HPSD settings, aiming to determine the most effective protocol for trans-catheter RF AF ablation. Methods We conducted a retrospective study including patients with paroxysmal or persistent AF: 100 were treated with the HPSD protocol and 100 patients with the v-HPSD one. In the HPSD protocol, RF energy at 40 W was applied for up to 20 seconds for the anterior segments of the pulmonary vein (PV), and 50 W up to 10 seconds for the posterior segments of the PV and the posterior wall (PW). Conversely, in the v-HPSD protocol RF pulses were applied at 50 W with an ablation index (AI) 500 in the anterior segments of PV and 90 W up to 4 sec for the posterior segment of the PV and the PW. Safety and efficacy were assessed during the procedure, during the hospital stay and throughout the entire follow-up duration. Results No relevant clinical and echocardiographic differences were identified between the two groups. Successful PVI and PW isolation was achieved in all cases. The v-HPSD group demonstrated a higher first-pass isolation (FPI) rate compared to the HPSD group. In contrast, the HPSD group exhibited a greater impedance drop (ID), supported by a higher contact force (CF). The RF total time, the procedural time, and the dose-area product (DAP) were significantly lower in the v-HPSD group. No periprocedural complications were reported. During the follow-up no significant differences in AF recurrence rates have been observed. Conclusions The absence of procedural complications underscores the high safety of both protocols. In our study, the v-HPSD group exhibited a superior FPI rate, indicative of enhanced acute efficacy; however it is crucial to underline that the HPSD group included a higher proportion of patients with a history of prior AF ablation. The more elevated ID observed in the HPSD group, indicating the exceptional quality of lesions, could be related to the major conductive heating component compared to v-HPSD. This results in deeper lesions and a more significant ID. Conversely, the brief duration of applications in the v-HPSD protocol contributes to reduce procedural times and diminish radiation exposure. Despite procedural disparities, the follow-up period reveals a low recurrence rate of AF in both groups, emphasizing the effectiveness of both HPSD and v-HPSD protocols in AF treatment.Kaplan-Meier Curve

Model for predicting the recurrence of atrial fibrillation after monopolar or bipolar radiofrequency ablation in patients with AF and mitral valve disease

ObjectivesThis study aimed to identify the risk factors for postoperative atrial fibrillation in patients with valvular atrial fibrillation, and establish predictive models of atrial fibrillation recurrence.MethodsOverall, 224 patients who underwent radiofrequency ablation of atrial fibrillation from November 2014 to November 2020 were included. The statistical package for social sciences, X-tile, and R-studio were used for statistical analysis.ResultsPatients were divided into training and validation sets according to a ratio of 3:1. The training set was analysed using univariate and multivariate Cox regression analysis and showed that preoperative uric acid > 401 μmol/L (P = 0.006), B-type natriuretic peptide > 202 ng/L (P = 0.042), hypersensitivity C-reactive protein > 6.1 mg/L (P = 0.026), erythrocyte sedimentation rate > 7.0 mm/h (P = 0.016), preoperative left atrial diameter > 48 mm (P = 0.031) were significantly correlated with the recurrence of atrial fibrillation after radiofrequency ablation in patients with valvular atrial fibrillation. In the training set, a Cox regression model of the five related factors was established using the R language. The C-index of the model was 0.82, and the area under the receiver operating characteristic curve was 0.831 (P < 0.001). Internal and external verification was performed in the training and validation sets, respectively, and both showed that the fit of the verification curve was relatively good at 3 months, 6 months, 1 year, and 3 years postoperatively. After calculating the weight of each related factor using the nomogram, a new risk predictive model (BLUCE) for postoperative atrial fibrillation was established.ConclusionsIn patients with atrial fibrillation, preoperative uric acid, B-type natriuretic peptide, hypersensitivity C-reactive protein, erythrocyte sedimentation rate, and left atrial diameter are risk factors for atrial fibrillation or atrial flutter recurrence after radiofrequency ablation. The BLUCE predictive model can distinguish high-risk groups of postoperative atrial fibrillation. High-risk patients in the BLUCE model were more likely to experience recurrence of atrial fibrillation after radiofrequency ablation and a low possibility of maintaining sinus rhythm.

Incidentally Detected Penile Cancer with Inguinal Metastasis Invading Femoral Vessels Following Atrial Fibrillation Radiofrequency Catheter Ablation.

Incidentally Detected Penile Cancer with Inguinal Metastasis Invading Femoral Vessels Following Atrial Fibrillation Radiofrequency Catheter Ablation.

Analysis of the thickness characteristics of the left atrial posterior wall and its correlation with the low and no voltage areas of the left atrial posterior wall in patients with atrial fibrillation

ObjectiveTo analyze the relationship between the thickness of the left atrial posterior wall and the low and no voltage zones in the left atrial posterior wall in patients with atrial fibrillation (AF).Methods61 patients admitted to our cardiology department for AF and radiofrequency ablation of AF from January 1, 2020 to May 30, 2022 were enrolled according to inclusion and exclusion criteria. The atrial wall thickness was measured by CT scan. Baseline data, preoperative cardiac ultrasound data, preoperative biochemical parameters, low voltage zone (fibrotic zone) and no voltage zone (scar zone) in the left atrial posterior wall area, and various parameters of posterior left atrial wall thickness were collected.ResultsThe differences of the thickness between the upper, middle and lower mean levels of the left atrial posterior wall were statistically significant (P = 0.004). The results showed that body mass index was weakly positively correlated with the mean level of total left atrial posterior wall thickness (r = 0.426, P = 0.001) and was statistically significant. The remaining indices were positively or negatively correlated with the mean level of total left atrial posterior wall thickness, but none were statistically significant (P > 0.05).ConclusionsBoth left atrial posterior wall low-voltage zone and voltage-free zone were positively correlated with the mean total left atrial posterior wall thickness, and left atrial posterior wall low-voltage zone and voltage-free zone were significantly positively correlated. Body mass index was weakly positively correlated with total left atrial posterior wall thickness.

Association between triglyceride–glucose index trajectories and radiofrequency ablation outcomes in patients with stage 3D atrial fibrillation

BackgroundThis study investigates the relationship between triglyceride-glucose (TyG) index trajectories and the results of ablation in patients with stage 3D atrial fibrillation (AF).MethodsA retrospective cohort study was carried out on patients who underwent AF Radiofrequency Catheter Ablation (RFCA) at the Cardiology Department of the Fourth Affiliated Hospital of Zhejiang University and Taizhou Hospital of Zhejiang Province from January 2016 to December 2022. The main clinical endpoint was determined as the occurrence of atrial arrhythmia for at least 30 s following a 3-month period after ablation. Using a latent class trajectory model, different trajectory groups were identified based on TyG levels. The relationship between TyG trajectory and the outcome of AF recurrence in patients was assessed through Kaplan-Meier survival curve analysis and multivariable Cox proportional hazards regression model.ResultsThe study included 997 participants, with an average age of 63.21 ± 9.84 years, of whom 630 were males (63.19%). The mean follow-up period for the participants was 30.43 ± 17.75 months, during which 200 individuals experienced AF recurrence. Utilizing the minimum Bayesian Information Criterion (BIC) and the maximum Entropy principle, TyG levels post-AF RFCA were divided into three groups: Locus 1 low-low group (n = 791), Locus 2 low-high-low group (n = 14), and Locus 3 high-high group (n = 192). Significant differences in survival rates among the different trajectories were observed through the Kaplan-Meier curve (P < 0.001). Multivariate Cox regression analysis showed a significant association between baseline TyG level and AF recurrence outcomes (HR = 1.255, 95% CI: 1.087–1.448). Patients with TyG levels above 9.37 had a higher risk of adverse outcomes compared to those with levels below 8.67 (HR = 2.056, 95% CI: 1.335–3.166). Furthermore, individuals in Locus 3 had a higher incidence of outcomes compared to those in Locus 1 (HR = 1.580, 95% CI: 1.146-2).ConclusionThe TyG trajectories in patients with stage 3D AF are significantly linked to the outcomes of AF recurrence. Continuous monitoring of TyG levels during follow-up may help in identifying patients at high risk of AF recurrence, enabling the early application of effective interventions.

Segmentation of the left atrium and proximal pulmonary veins based on dimensional decomposition attention

AbstractPulmonary vein anatomical structure typing plays a crucial role in the preoperative assessment and postoperative evaluation of lung tumor resection, atrial fibrillation radio frequency ablation, and other medical procedures. The accuracy of such typing relies heavily on the segmentation results of the left atrium and proximal pulmonary veins. However, due to the similarities in intensity between the left atrium, proximal pulmonary veins, and adjacent tissues in CT images, segmentation errors often occur, leading to subsequent inaccuracies in pulmonary vein classification. To address this issue, we propose an attention module called Dimensional Decomposition Attention (DDA), which combines Dimensional Decomposition Spatial Attention (DDSA) and Dimensional Decomposition Channel Attention (DDCA). DDA effectively leverages the spatial and channel information of 3D images to enhance the segmentation accuracy of the left atrium and proximal pulmonary veins. In DDSA, the input features are decomposed into three one‐dimensional directional features (height, width, and depth) and fused to generate weights that emphasize spatial shape features and focus on the region of interest. On the other hand, DDCA encodes the input features into dimensional channel features, fuses them with one‐dimensional directional features, and utilizes position encoding to reinforce the channel features and prioritize channels with relevant information. The performance of DDA was evaluated using a two‐stage experimental approach on datasets provided by The People's Hospital of Liaoning Province and the MM‐WHS CT dataset, yielding average Dice values of 93.93% and 90.80%, respectively, demonstrating the effectiveness of DDA.

Clinical outcomes of radiofrequency catheter ablation guided by intracardiac echocardiography for Chinese atrial fibrillation patients: a single-center, retrospective study.

Intracardiac echocardiography (ICE) is a novel technology with certain advantages in treatment of atrial fibrillation (AF), yet there is limited research on the use of ICE in radiofrequency ablation for AF treatment in China. The aim of this study was to investigate the total fluoroscopy time and dose, safety, and effectiveness of ICE guided vs. traditional fluoroscopy (non-ICE) guided radiofrequency ablation for AF in China. We conducted a single-center retrospective analysis of patients who underwent ICE or traditional fluoroscopy-guided radiofrequency ablation for AF. The primary endpoint of this study was total fluoroscopy time, and the secondary endpoints included total fluoroscopy dose, acute surgery failure, transseptal puncture time, ablation time, total procedure time, and 6-month surgery success (no AF recurrence or atrial flutter). As an exploratory analysis, outcomes of interest by different types of AF were examined. A total of 97 patients were included in the analysis. Forty-eight were in the ICE group and 49 were in the non-ICE group with comparable demographic and clinical characteristics at the baseline. None of patients experienced acute surgery failure with no major procedure-related complications occurred. The fluoroscopic time and dose were significantly lower in the ICE group compared to the non-ICE group (0.00 vs. 9.67±4.88 min, P<0.001; 0.00 vs. 77.10±44.28 mGy/cm2, P<0.001, respectively). There were no statistically significant differences in transseptal puncture time, ablation time and total procedure time between the two groups. There were two AF recurrences observed during the 6-month follow-up in each group (P>0.99). ICE significantly reduced the fluoroscopic time and dose for radiofrequency catheter ablation in AF patients. There were no significant differences in safety or effectiveness outcomes between the ICE and non-ICE groups.

Prevention of esophageal lesions during atrial fibrillation catheter ablation using esophageal temperature monitoring: A systematic review and meta-analysis.

The use of esophageal temperature monitoring (ETM) for the prevention of esophageal injury during atrial fibrillation (AF) ablation is often advocated. However, evidence supporting its use is scarce and controversial. We therefore aimed to review the evidence assessing the efficacy of ETM for the prevention of esophageal injury. We performed a meta-analysis and systematic review of the available literature from inception to December 31, 2022. All studies comparing the use of ETM, versus no ETM, during radiofrequency (RF) AF ablation and which reported the incidence of endoscopically detected esophageal lesions (EDELs) were included. Eleven studies with a total of 1112 patients undergoing RF AF ablation were identified. Of those patients, 627 were assigned to ETM (56%). The overall incidence of EDELs was 9.8%. The use of ETM during AF ablation was associated with a non significant increase in the incidence of EDELs (12.3% with ETM, vs. 6.6 % without ETM, odds ratio, 1.44, 95%CI, 0.49, 4.22, p=.51, I2=72%). The use of ETM was associated with a significant increase in the energy delivered specifically on the posterior wall compared to patients without ETM (mean power difference: 5.13 Watts, 95% CI, 1.52, 8.74, p=.005). The use of ETM does not reduce the incidence of EDELs during RF AF ablation. The higher energy delivered on the posterior wall is likely attributable to a false sense of safety that may explain the lack of benefit of ETM. Further randomized controlled trials are needed to provide conclusive results.

An Exploratory Pilot Study on the Application of Radiofrequency Ablation for Atrial Fibrillation Guided by Computed Tomography-Based 3D Printing Technology.

Radiofrequency ablation (RFA) is the treatment of choice for atrial fibrillation (AF). Additionally, the utilization of 3D printing for cardiac models offers an in-depth insight into cardiac anatomy and cardiovascular diseases. The study aims to evaluate the clinical utility and outcomes of RFA following in vitro visualization of the left atrium (LA) and pulmonary vein (PV) structures via 3D printing (3DP). Between November 2017 and April 2021, patients who underwent RFA at the First Affiliated Hospital of Xinxiang Medical University were consecutively enrolled and randomly allocated into two groups: the 3DP group and the control group, in a 1:1 ratio. Computed tomography angiography (CTA) was employed to capture the morphology and diameter of the LA and PV, which facilitated the construction of a 3D entity model. Additionally, surgical procedures were simulated using the 3D model. Parameters such as the duration of the procedure, complications, and rates of RFA recurrence were meticulously documented. Statistical analysis was performed using the t-test or Mann-Whitney U test to evaluate the differences between the groups, with a P-value of less than 0.05 considered statistically significant. In this study, a total of 122 patients were included, with 53 allocated to the 3DP group and 69 to the control group. The analysis of the morphological measurements of the LA and PV taken from the workstation or direct entity measurement showed no significant difference between the two groups (P > 0.05). However, patients in the 3DP group experienced significantly shorter RFA times (97.03 ± 28.39 compared to 120.51 ± 44.76min, t = 3.05, P = 0.003), reduced duration of radiation exposure (2.55 [interquartile range 2.01, 3.24] versus 3.20 [2.28, 3.91] min, Z = 3.23, P < 0.001), and shorter modeling times (7.68 ± 1.03 compared to 8.89 ± 1.45min, t = 5.38, P < 0.001). 3DP technology has the potential to enhance standard RFA practices by reducing the time required for intraoperative interventions and exposure to radiation.

Insomnia is related to long-term atrial fibrillation recurrence following radiofrequency ablation

Objective Atrial fibrillation (AF), the most common cardiac arrhythmia, presents significant health challenges, and the intricate connection between insomnia and AF has garnered substantial attention. This cohort study aims to investigate the relationship between insomnia and AF recurrences following radiofrequency ablation. Materials and Methods Data were retrieved from an electronic database of patients who underwent radiofrequency ablation for AF. The primary endpoint was AF recurrence. We utilized a multivariable Cox model, coupled with three propensity score methods, for analysis. Results Between January 1, 2017, and June 1, 2022, 541 patients who underwent radiofrequency ablation for AF were recorded in the database. After excluding 185 patients, the final cohort comprised 356 patients. Among them, 68 were afflicted by insomnia, while 288 were not. Over a median follow-up of 755 days, one patient died, and 130 (36.5%) experienced AF recurrence. Multivariate Cox regression analysis revealed that the insomnia group had a higher risk of AF recurrence compared to the non-insomnia group (HR: 1.83, 95% CI: 1.16–2.89). Further landmark analysis showed no significant difference in AF recurrence rates during the initial 1-year follow-up. However, beyond 1 year, the insomnia group demonstrated a significantly higher AF recurrence rate. As the number of insomnia symptoms increased, the risk of AF recurrence also rose significantly, indicating a dose-response relationship. Conclusion This study establishes a significant link between insomnia and long-term AF recurrence following radiofrequency ablation. It underscores the importance of identifying and addressing insomnia in patients with AF undergoing radiofrequency ablation.