Esophageal temperature dynamics during high-power short-duration posterior wall ablation

Background: High-power short-duration (HP-SD) radiofrequency ablation (RFA) has been proposed as a method for producing rapid and effective lesions for pulmonary vein isolation. The underlying hypothesis assumes an increased resistive heating phase and decreased conductive heating phase, potentially reducing the risk for esophageal thermal injury. The objective of this study was to compare the esophageal temperature dynamic profile between HP-SD and moderate-power moderate-duration (MP-MD) RFA ablation strategies. Methods: In patients undergoing pulmonary vein isolation, RFA juxtaposed to the esophagus was delivered in an alternate sequence of HP-SD (50 W, 8–10 s) and MP-MD (25 W, 15–20 s) between adjacent applications (distance, ≤4 mm). Esophageal temperature was recorded using a multisensor probe (CIRCA S-CATH). Temperature data included magnitude of temperature rise, maximal temperature, time to maximal temperature, and time return to baseline. In swine, a similar experimental design compared the effect of HP-SD and MP-MD on patterns of esophageal injury. Results: In 20 patients (68.9±5.8 years old; 60% persistent atrial fibrillation), 55 paired HP-SD and MP-MD applications were analyzed. The esophageal temperature dynamic profile was similar between HP-SD and MP-MD ablation strategies. Specifically, the magnitude of temperature rise (2.1 °C [1.4–3] versus 2.0 °C [1.5–3]; P =0.22), maximal temperature (38.4 °C [37.8–39.3] versus 38.5 °C [37.9–39.4]; P =0.17), time to maximal temperature (24.9±7.5 versus 26.3±6.8 s; P =0.1), and time of temperature to return to baseline (110±23.2 versus 111±25.1 s; P =0.86) were similar between HP-SD and MP-MD ablation strategies. In 6 swine, esophageal injury was qualitatively similar between HP-SD and MP-MD strategies. Conclusions: Esophageal temperature dynamics are similar between HP-SD and MP-MD RFA strategies and result in comparable esophageal tissue injury. Therefore, when using a HP-SD RFA strategy, the shorter application duration should not prompt shorter intervals between applications.

Download Full-text

P4763High power radiofrequency ablation with fixed short duration is rapid, efficient and safe for circumferential pulmonary vein isolation

European Heart Journal ◽

10.1093/eurheartj/ehz745.1139 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J Schreieck ◽

M Duckheim ◽

U Yurtbil ◽

J Flassak ◽

C Scheckenbach ◽

...

Keyword(s):

Left Atrium ◽

Short Duration ◽

Temperature Rise ◽

Posterior Wall ◽

Rf Ablation ◽

Esophageal Temperature ◽

Single Spot ◽

Rf Applications ◽

Circumferential Pulmonary Vein Isolation

Abstract Background Short duration 50 Watt radiofrequency (RF) ablation has been shown to be feasible for atrial fibrillation (AF) ablation with short procedure times. Purpose We evaluated 50 Watt RF power with a different fixed short application duration at the anterior and posterior left atrial wall using contact force (CF) sensing catheters for circumferential pulmonary vein isolation (PVI). Methods Consecutive patients (pts) with indication for de novo AF ablation (n=40, age 64±12 years) with paroxysmal (n=23) or persistent (n=17) AF underwent high density 3D mapping of the left atrium. Low voltage areas of more than 5% of the left atrium were only found in 20% of pts. Thereafter, circumferential PVI using CF sensing catheters was performed. For each RF application (50 Watt, RF duration 11–13s at the anterior wall, 9–11s at the posterior wall) a stable catheter tip position with minimal mean CF of 3g was required and application was stopped in case of CF more than 30g. Esophageal temperature measurement was performed with temperature cut off 39.0°C. In case of temperature rise, ablation protocol was switched to conventional 20 Watt RF applications for ablation adjacent to the esophagus. Results Complete PVI was achieved in all pts with 81±29 short RF applications resulting in cumulative RF applications duration of 13.1±4.2min and an ablation duration of 59±17min for complete PVI. Even RF application with low CF (3–5g) were effective. Due to esophageal temperature rise, switch to conventional RF application with 20 Watt was performed in 43% of pts at least at one posterior PV entrance. After a waiting period of 20 min only in 33% of pts any PV conduction recurs, in 28% of pts only at a single spot and reconnected fibers were not associated with low CF application at that spot, but clearly associated with low energy application at the posterior wall. All PV were successfully re-isolated in most of pts with a single spot high energy RF application. No serious complications occurred in association with PVI. Follow up will be available at presentation time. Conclusion RF ablation with 50 Watt fixed short duration is efficient and safe for circumferential PVI. Ablation procedure durations are shorter and early recurrence rates are lower compared to reported conventional ablation procedures. The importance of CF titration seems to be diminished by 50 Watt RF applications in the left atrium. Further follow up have to be waited.

Download Full-text

Esophageal temperature evolution during high power short duration ablation: Numerical simulations and clinical suggestions

Journal of Cardiovascular Medicine and Cardiology ◽

10.17352/2455-2976.000126 ◽

2020 ◽

Vol 7 (2) ◽

pp. 125-128

Author(s):

Fasano Antonio ◽

Anfuso Luca

Keyword(s):

Numerical Simulations ◽

Short Duration ◽

High Power ◽

Temperature Evolution ◽

Esophageal Temperature

Download Full-text

High-power short-duration radiofrequency ablation for atrial fibrillation

EP Europace ◽

10.1093/europace/euab116.257 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

K Kassa ◽

Z Nagy ◽

B Kesoi ◽

Z Som ◽

C Foldesi ◽

...

Keyword(s):

Atrial Fibrillation ◽

Radiofrequency Ablation ◽

Short Duration ◽

Contact Force ◽

High Power ◽

Posterior Wall ◽

Pericardial Tamponade ◽

Fluoroscopy Time ◽

Control Group

Abstract Funding Acknowledgements Type of funding sources: None. Introduction In recent times, high-power short-duration (HPSD) radiofrequency ablation (RFA) has emerged as an alternative strategy for pulmonary vein isolation (PVI) in atrial fibrillation (AF). Purpose We aimed to compare HPSD approach and conventional, ablation-index (AI) guided PVI using contact force sensing ablation catheters in respect of efficacy, safety, procedural characteristics, and outcome. Methods A total of 184 consecutive AF patients with first PVI were enrolled (age: 60 ± 11 years, paroxysmal: 56.5%, persistent: 43.5%) between November 2016 and December 2019. An ablation protocol of 50W energy with 15-20 g contact force was used for a duration of 8-12 sec based on the loss of capture concept in the HPSD group (n = 91) meanwhile, PVI was achieved according to the conventional power settings (posterior wall 25W, AI: 400, anterior wall 35W, AI: 550 ) in the control group (n = 93). During 1-year follow-up, documented AF for more than 30 seconds was considered as recurrence. Results Radiofrequency time and procedural time were significantly shorter using HPSD ablation (26.0 ± 12.7 min vs. 42.9 ± 12.6 min, p < 0.001, and 91 ± 30.1 min vs. 105.3 ± 28 min, p < 0.001). The HPSD strategy significantly lowered fluoroscopy time and radiation dose (5.47 ± 4.07 min vs. 8.15 ± 10.04 min, p = 0.019, and 430.2 ± 534.06 cGycm2 vs. 604.2 ± 633.9 cGycm2, p = 0.046). The HPSD group showed significantly less arrhythmia recurrence during 1-year follow-up with 76.9% of patients free from AF compared to 66.7% in the control group (p = 0.037). No pericardial tamponade, periprocedural thromboembolic complication, or atrio-oesophageal fistula occurred in the HPSD group. We observed 2 pericardial tamponade and 1 periprocedural stroke in the control group. Conclusions HPSD RFA for AF was demonstrated to be safe, and lead to significantly improved 1-year outcome in our mixed patient population. HPSD protocol significantly shortened procedural and radiofrequency time with decreased fluoroscopy time and radiation exposure.

Download Full-text

Relationship between luminal esophageal temperature and volume of esophageal injury during RF ablation: In silico study comparing low power‐moderate duration vs. high power‐short duration

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.15311 ◽

2021 ◽

Author(s):

Juan J. Pérez ◽

Ana González‐Suárez ◽

Timothy Maher ◽

Hiroshi Nakagawa ◽

Andre d'Avila ◽

...

Keyword(s):

Low Power ◽

Short Duration ◽

High Power ◽

In Silico ◽

Esophageal Injury ◽

Rf Ablation ◽

Esophageal Temperature ◽

In Silico Study

Download Full-text

1249Acute efficacy and safety of pulmonary vein isolation for atrial fibrillation in patients alternatively assigned to high power short duration (70W, 8s) vs lesion index guided (35W) ablation

EP Europace ◽

10.1093/europace/euaa162.360 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

M Brunelli ◽

M Schwaar ◽

C Isensee ◽

W Opara ◽

T Michael ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Short Duration ◽

High Power ◽

Persistent Atrial Fibrillation ◽

Posterior Wall ◽

Similar Rate ◽

Complication Rates ◽

Reconnection Rate ◽

Lesion Index

Abstract Background permanent trans-mural lesions not affecting surrounding anatomical structures is the goal of safe and effective wide antral pulmonary vein (PV) isolation in patients with paroxysmal and persistent atrial fibrillation (AF) undergoing catheter ablation (CA). Time, energy and contact force are parameters related to lesion goodness and incorporated in a complex formula (i.e. the lesion index, LSI™, Abbott). This parameter is emerging as the gold standard for PV isolation. Recently, the shallower but wider lesions created by high power short duration (HPSD) ablation has came to attention. Purpose to compare acute reconnection rate, procedural parameters, and complication rates in patients with paroxysmal or persistent AF undergoing CA. Methods one-hundred patients with paroxysmal and 100 with persistent AF will be alternatively assigned to undergo PV isolation with the FlexAbility™ (HPSD group, 70W, 41°, 8 seconds) or the TactiCath™ (LSI-group: 35W, 41°, LSI: 5-5.5 posterior wall, up to ≥6 anywhere else) catheter. A 3-D mapping system (Ensite Precision™) and a steerable sheath (Agilis™, both Abbott) were always used. Adenosine (30mg) is given after PV isolation and ≥ 20 minutes waiting time. Posterior wall isolation was added in all, and patients with persistent AF were additionally treated with mitral and cavotricuspid isthmus ablation. Results: between June and October 2019, 71 patients (68 ± 10 years old, 32 (45%) female, 44 (60%) paroxysmal AF, AF duration 58 ± 81 months) were alternatively assigned to HPSD (36, 51%) or LSI-guided (35, 49%) ablation. No difference in clinical characteristics was found between groups. After 44 ± 18 and 30 ± 14min of procedural and RF time, all PVs were isolated, and all 17 (24%) reconnections treated with an additional 4 ± 3 and 3 ± 2min, respectively. In 8 ± 3 and 7 ± 3 min of procedural and RF time, the PW was successfully isolated in all. PV isolation (34 ± 12min vs. 56 ± 16min; P<.0001), RF (18 ± 5min vs. 41 ± 9min; P<.0001), and total procedural (138 ± 34min vs. 162 ± 34min; P=.0026) time were shorter in the HPSD group. X-Ray time and effective dose did not differ. A similar rate of acute reconnections (9, 25% vs. 8 23%) was found when HPSD and LSI were compared. A higher, although statistically not significant, number of steam pops was observed in the HPSD (14, 39%) vs. LSI (8, 23%) group, possibly related to the higher incidence of moderate pericardial effusion (>0.5mm, <20mm) found the day following the ablation (10, 28% vs. 2, 6%; P=.0238). No further complications related to CA were detected. Conclusions in patients with paroxysmal and persistent AF undergoing their first CA, HPSD ablation is faster than an LSI-guided approach. Acute efficacy (reconnection rate) is similar. Although a higher rate of haemodynamically non-relevant pericardial effusions were seen in the HPSD group, these were all treated medically and the general safety profile of this approach is excellent and comparable to LSI ablation.

Download Full-text

Efficacy of high-power and short-duration ablation in patients with atrial fibrillation: a prospective randomized controlled trial

EP Europace ◽

10.1093/europace/euaa144 ◽

2020 ◽

Vol 22 (10) ◽

pp. 1495-1501 ◽

Cited By ~ 1

Author(s):

Dong Geum Shin ◽

Jinhee Ahn ◽

Sang-Jin Han ◽

Hong Euy Lim

Keyword(s):

Atrial Fibrillation ◽

Short Duration ◽

High Power ◽

Controlled Trial ◽

Posterior Wall ◽

Complication Rates ◽

Related Complication ◽

Af Ablation ◽

Ablation Index ◽

Significant Difference

Abstract Aims The formation of radiofrequency lesions depends on the power and duration of ablation, and the contact force (CF). Although high power (HP) creates continuous and transmural lesions, most centres still use 25–30 W for 30–40 s for safety reasons. We evaluated the clinical efficacy and safety of a HP and short-duration (HPSD) strategy for atrial fibrillation (AF) ablation. Methods and results One hundred and fifty patients [58.2 ± 10.0 years, 48% with paroxysmal AF (PAF)] scheduled for index AF ablation using a CF-sensing catheter were randomly assigned to three groups [30 W, 40 W, and 50 W at ablation sites of anterior, roof, and inferior segments of pulmonary vein (PV) antra and roof line between each upper PV]. In 25–30 W for ≤20 s was applied at posterior wall ablation site in all subjects. Compared with the 30 W and 40 W groups, procedure (P < 0.001) and ablation times (P < 0.001) were shorter and ablation number for PV isolation (P < 0.001) was smaller in the 50 W group. There were no significant differences in the CF and ablation index (AI) among the three groups. There were no significant differences in the procedure-related complication rates. During the 12-month follow-up, AF recurred in 24 (16%) patients with no significant difference among the groups (P = 0.769). In the multivariate analysis, non-PAF [hazard ratio (HR) 2.836, P = 0.045] and AI (HR 0.983, P = 0.001) were independent risk factors for AF recurrence. Conclusion Radiofrequency ablation with HPSD is a safe and effective strategy with reduced ablation number and shortened procedure time compared to conventional ablation.

Download Full-text

Very (70W) vs. LSI guided (5-6) high power short duration ablation in patients with paroxysmal atrial fibrillation undergoing pulmonary vein vs. pulmonary vein and posterior wall isolation

EP Europace ◽

10.1093/europace/euab116.082 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

M Brunelli ◽

M Schwaar ◽

C Isensee ◽

S Goth ◽

H Schmidt ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Short Duration ◽

High Power ◽

Paroxysmal Atrial Fibrillation ◽

Posterior Wall ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Procedure Time ◽

Procedural Time

Abstract Funding Acknowledgements Type of funding sources: None. Background high power short duration (HPSD) ablation is at least as safe while reducing procedure time than radiofrequency (RF) ablation with lower power in pts undergoing pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF). Purpose: to compare safety and efficacy of 2 different: 1) RF energy set up (FlexAbility: 70W, 41°, 6-10s, 11ml/h vs. TactiCath: 50W, 41°, LSI 5-6, 17ml/h, both Abbott), and 2) ablation strategies (posterior wall isolation (PWI) in addition to PVI vs. PVI) in pts undergoing their first ablation for paroxysmal AF. Methods: since June 2020 pts are prospectively assigned to alternatively undergo their RF catheter ablation with the FlexAbility (v-HPSD) or the TactiCath (LSI-HPSD) catheters (aim 200 pts). In addition, pts were alternatively assigned to PVI + PWI vs. PVI. All procedures were done using a 3D-mapping system (Ensite Precision), the ablation catheter was stabilized with a long sheath (Agilis) and a continuous series of lesions (4mm) were plotted around the PV, at the roof and between the 2 inferior PVs. On the PW, RF lesions were limited to 6s and 5 LSI for the v-HPSD and LSI-HPSD groups. Endoscopy was performed shortly after ablation in all pts and thermal esophageal lesion (TEL) characterized with the Kansas classification. Results: since June 2020 56 pts [61 ± 13 years old, 17 (30%) female, CHA2DS2-Vasc 2.3 ± 1.5, 55 ± 77 left ventricular ejection fraction] underwent v-HPSD (#28) and LSI-HPSD (#28) ablation. In 2/14 (14%) and in 3/15 (20%) pts (v-HPSD and LSI-HPSD groups, respectively) initially assigned to undergo simple PVI, PWI was added due to PW dependent flutter or evidence of pro-arrhythmic slow conduction on the PW. A shorter RF time to achieve PVI (17 ± 3 vs. 25 ± 6 min; P<.0001) was found for the v-HPSD group, although acute reconnection were numerically higher (9 vs. 4) and procedural time did not differ (32 ± 8 vs. 35 ± 9 min). Whenever attempted, PWI (#16 for each v-HPSD and LSI-HPSD group) was always successful. When v-HPSD and LSI-HPSD group were compared, no differences were found in RF and procedure time both at the roof (2.3 ± 0.9 vs. 2.7 ± 1.1 min and 3 ± 1.4 vs. 3.4 ± 1 min, respectively) and between the 2 inferior PVs (2.6 ± 0.6 vs. 2.9 ± 0.7 min and 4.3 ± 1.9 vs. 3.8 ± 1.2 min, respectively). Total RF (19.7 ± 4.5 vs. 28.5 ± 6.6 min, P<.0001) was shorted in the v-HPSD, but X-Ray (1.4 ± 0.7 vs. 1.2 ± 0.8 min) and total procedural time (102 ± 17 vs. 110 ± 20 min) did not differ. Rate of TELs was not different and found in 18% (#5: 4 I, 1 IIA) and 14% (all IIA) pts assigned to v-HPSD and LSI-HPSD respectively. A numerically higher number of TELs (6 vs. 3) was seen when PWI was pursued, although this did not prolong total RF and procedure time. Conclusion: a shorter RF time is associated with v-HPSD vs. LSI-HPSD strategy, although procedural time did not differ. TELs are a relative rare finding, and only numerically higher when isolation of the PW is pursued in addition to PV isolation.

Download Full-text