Persistent atrial fibrillation originating from prominent Eustachian ridge: Precise identification of non-pulmonary vein foci using a high-density grid mapping catheter

Abstract Aims To assess the value of high-density mapping (HDM) in revealing undetected incomplete pulmonary vein isolation (PVI) after the fourth-generation cryoballoon (CB4G) ablation compared to the previous cryoballoon’s versions. Methods and results Consecutive patients with paroxysmal or early-persistent atrial fibrillation (AF) undergoing CB ablation as the index procedure, assisted by HDM, were retrospectively included in this study. A total of 68 patients (52 males; mean age: 60 ± 12 years, 58 paroxysmal AF) were included, and a total of 272 veins were mapped. Fourth-generation cryoballoon with the new spiral mapping catheter (SMC) was used in 35 patients (51%). Time to PVI was determined in 102/132 (77%) and in 112/140 (80%) veins during second-generation cryoballoon/third-generation cryoballoon (CB2G/CB3G) and CB4G ablation, respectively (P = 0.66). There was a statistically significant difference in terms of discrepancy rate between the SMC and the mini-basket catheter in PV detection after CB4G and CB2G/CB3G ablation(1.4% vs. 7.6%; P = 0.01). A total of 57 patients (84%) remained free of symptomatic AF during a mean follow-up of 9.8 ± 4.6 months. Conclusion High-density mapping after cryoballoon ablation using CB4G and the new SMC identifies incomplete PVI, not detected by the new SMC, in a significantly lower proportion of veins compared to HDM performed after the other generation CB ablation.

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COMPARISON OF CIRCUMFERENTIAL PULMONARY VEIN ANATOMY MAPPING IN PATIENTS WITH ATRIAL FIBRILLATION GUIDED BY CARTO MAPPING SYSTEM AND HIGH-DENSITY MESH MAPPING CATHETER

Heart ◽

10.1136/heartjnl-2012-302920m.6 ◽

2012 ◽

Vol 98 (Suppl 2) ◽

pp. E219.1-E219

Author(s):

Yan yiwen ◽

Liu shaowen

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

High Density ◽

Mapping System ◽

Mesh Mapping ◽

Mapping Catheter ◽

Pulmonary Vein Anatomy

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P1028Incidence and location of residual gaps identified by a high-density grid-style mapping catheter after PVI is confirmed by pacing the ablation lines

EP Europace ◽

10.1093/europace/euaa162.074 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

M Giuggia ◽

M Volpicelli ◽

N Bottoni ◽

P Gora ◽

M Mantica

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

De Novo ◽

Clinical Success ◽

The United States ◽

Small Sample ◽

High Density ◽

Ablation Line ◽

Mapping Catheter

Abstract Background Durable pulmonary vein isolation (PVI) is critical to the clinical success of ablation for treatment of atrial fibrillation (AF). Pacing along the ablation line (often using the ablation catheter), is one technique that is commonly used for confirmation of PVI. While this technique is common in practice, it has not been systematically evaluated against other methods for confirming PVI. A high-density grid-style mapping catheter (HD Grid) enabling simultaneous recording of adjacent bipolar EGMs in two directions (HD Wave) is now available in multiple geographies. The sensitivity of this technology for periprocedural identification of gaps in PVI lines has not previously been compared to the technique of pacing the ablation lines. Purpose To assess the utility of a high-density grid-style catheter for confirming PVI, and to evaluate sensitivity for identification of gaps relative to a technique of pacing the ablation lines. Methods Self-reported procedural data was prospectively collected in atrial fibrillation ablation procedures. Cases in which pulmonary vein isolation was confirmed by pacing the ablation line and subsequently assessed with HD Grid were selected for analysis. Techniques for PVI confirmation were analyzed and the incidence and location of residual gaps following PVI confirmation via pacing was quantified. Results A total of 22 AF ablation procedures (age 60.1 ± 9.0 years, LVEF 59.3 ± 5.7%, CHADS 1.5 ± 1.4, hypertension 45.5%) across 5 centers in Italy and the United States were analyzed. De novo and repeat ablations represented 72.7% and 22.7% of cases, respectively (4.5% not reported). PVI was confirmed by pacing along the ablation line with an average output of 8.8 ± 1.9mV and pulse width of 2.2 ± 0.7ms (10mv at 2ms utilized in 59.1%). Subsequent PVI assessment was performed with HD Grid using the HD Wave configuration in all cases. PVI confirmation techniques included exit block confirmation (90.9%), voltage mapping (59.1%), loss of pace capture along ablation lines (40.9%), entrance block confirmation (18.2%), and activation mapping (4.5%); note: total exceeds 100% as more than one technique may be employed in a single case. The HD Grid identified a total of 30 gaps in 15 (68.2%) patients, which were initially missed by pacing along the ablation lines. No adenosine or isoproterenol use was documented in any case. Conclusion(s): Use of the HD Grid appears to increase substantially, the sensitivity for identifying gaps in PVI lesion sets relative to a technique of pacing the ablation line. Limitations of this analysis include small sample size and workflows which consistently assessed PVI with the HD grid following confirmation of isolation by pacing the ablation lines. Despite these limitations, the high prevalence of residual gaps is quite provocative and may warrant additional study. Abstract Figure.

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P1061Incidence and location of PVI gaps identified post-cryoballoon ablation for atrial fibrillation

EP Europace ◽

10.1093/europace/euaa162.073 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

Z Eldadah ◽

C Jons ◽

Z Hollis ◽

L Dekker ◽

S Mathew ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Single Case ◽

The United States ◽

Small Sample ◽

High Density ◽

Cryoballoon Ablation ◽

Density Mapping ◽

Diagnostic Catheter ◽

Mapping Catheter

Abstract Background Successful delivery of continuous and durable pulmonary vein isolation (PVI) lesion sets is recognized as being critical to long-term clinical outcomes following ablation for atrial fibrillation (AF). Confirmation of PVI following cryoballoon ablation is commonly achieved using a 3.3F circular mapping catheter (CMC) which can be delivered through the central lumen of the cryoballoon, but other diagnostic tools may be used alone or in conjunction with the 3.3F CMC. A high-density, grid-style mapping catheter is now available in multiple geographies; use in cryoballoon ablation procedures and associated outcomes has not been previously reported. Purpose To evaluate diagnostic catheter usage patterns in cryoablation procedures and identify associated trends in procedural characteristics and acute outcomes. Methods Self-reported procedural data was prospectively collected in AF cryoablation cases utilizing various diagnostic catheter tools, including the 3.3F CMC and high-density, grid-style mapping catheter (HD Grid). Procedural characteristics and acute outcomes, including the incidence and location of gaps post-ablation, were recorded and analyzed. Results Data was collected in 23 cryoablation procedures performed in 7 centers across the United States and Europe. De novo and repeat ablations represented 65.2% and 21.7% of cases, respectively (13.0% not reported). 3D mapping was employed in 95.7% of cases. A left common pulmonary vein was present and ablated in 8.7% (2/23). The 28mm cryoballoon was utilized in all cases, with a single case using both a 23mm and 28mm cryoballoon. The 3.3F CMC was used to confirm isolation in all cases using a variety of techniques: voltage mapping (60.9%), exit block (56.5%), entrance block (30.4%), propagation mapping (4.3%), and activation mapping (4.3%); note: total exceeds 100% as more than one technique may be employed in a single case. In 18 cases, PVI was confirmed using a 3.3F CMC followed by secondary confirmation with HD Grid, enabling a direct comparison of the two technologies. The HD Grid identified a total of 12 gaps in 4 (22.2%) patients, which were missed by the 3.3F CMC (Figure 1). No adenosine or isoproterenol use was documented in any case. Conclusion(s): The 3.3F CMC is routinely used to confirm PVI following cryoballoon ablation for atrial fibrillation, but it may fail to identify gaps in some patients. Subsequent assessment of PVI using the HD Grid identified residual gaps in nearly a quarter of patients, suggesting that sensitivity for gap detection may be improved with this tool. Limitations of this analysis include the small sample size and workflows which consistently assessed PVI with the high-density mapping catheter after confirming isolation with the 3.3F CMC. Despite these limitations, the incidence of residual gaps observed is noteworthy and may warrant additional study. Abstract Figure.

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Pulmonary Vein Isolation With Single Pulse Irreversible Electroporation

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.119.008192 ◽

2020 ◽

Vol 13 (10) ◽

Cited By ~ 3

Author(s):

Peter Loh ◽

René van Es ◽

Marijn H.A. Groen ◽

Kars Neven ◽

Wil Kassenberg ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Irreversible Electroporation ◽

Human Study ◽

Single Pulse ◽

Persistent Atrial Fibrillation ◽

Ablation Catheter ◽

Peak Voltage ◽

Waiting Period ◽

Mapping Catheter

Background: Irreversible electroporation (IRE) is a promising new nonthermal ablation technology for pulmonary vein (PV) isolation in patients with atrial fibrillation. Experimental data suggest that IRE ablation produces large enough lesions without the risk of PV stenosis, artery, nerve, or esophageal damage. This study aimed to investigate the feasibility and safety of single pulse IRE PV isolation in patients with atrial fibrillation. Methods: Ten patients with symptomatic paroxysmal or persistent atrial fibrillation underwent single pulse IRE PV isolation under general anesthesia. Three-dimensional reconstruction and electroanatomical voltage mapping (EnSite Precision, Abbott) of left atrium and PVs were performed using a conventional circular mapping catheter. PV isolation was performed by delivering nonarcing, nonbarotraumatic 6 ms, 200 J direct current IRE applications via a custom nondeflectable 14-polar circular IRE ablation catheter with a variable hoop diameter (16–27 mm). A deflectable sheath (Agilis, Abbott) was used to maneuver the ablation catheter. A minimum of 2 IRE applications with slightly different catheter positions were delivered per vein to achieve circular tissue contact, even if PV potentials were abolished after the first application. Bidirectional PV isolation was confirmed with the circular mapping catheter and a post ablation voltage map. After a 30-minute waiting period, adenosine testing (30 mg) was used to reveal dormant PV conduction. Results: All 40 PVs could be successfully isolated with a mean of 2.4±0.4 IRE applications per PV. Mean delivered peak voltage and peak current were 2154±59 V and 33.9±1.6 A, respectively. No PV reconnections occurred during the waiting period and adenosine testing. No periprocedural complications were observed. Conclusions: In the 10 patients of this first-in-human study, acute bidirectional electrical PV isolation could be achieved safely by single pulse IRE ablation.

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