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

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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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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P1023Comparison of gap identification using three technologies for confirmation of pulmonary vein isolation

EP Europace ◽

10.1093/europace/euaa162.075 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

C Porterfield ◽

A Wystrach ◽

P Rossi ◽

M Rillo ◽

F Sebag ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

De Novo ◽

The United States ◽

Simultaneous Recording ◽

Density Mapping ◽

Diagnostic Catheter ◽

Tools And Techniques ◽

Mapping Catheter

Abstract Background Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Tools and techniques used for confirmation of PVI vary greatly, and it is unclear whether the use of any particular combination of tools and techniques provides greater sensitivity for identifying gaps periprocedurally. A high-density mapping catheter enabling simultaneous recording of adjacent bipolar EGMs in two directions is now available in multiple geographies, and it has been suggested that this technology may provide improved sensitivity for gap identification. Purpose To identify trends in the incidence of gaps identified in de novo PVI lines using three diagnostic catheter technologies, which may be suggestive of improved sensitivity for gap identification. Methods Self-reported procedural data was prospectively collected in de novo atrial fibrillation ablation cases utilizing one of three technologies to confirm PVI: 10-pole circular mapping catheter (CMC10), 20-pole circular mapping catheter (CMC20), and Advisor HD Grid catheter (HD Grid). Techniques for PVI confirmation were analyzed for each group, and the incidence and location of gaps identified by each technology was quantified. Results Data was collected in 99 cases across 11 centers in Europe and the United States. PVI was confirmed via entrance and/or exit block in all cases. CMC10 was utilized in 30 cases, CMC20 in 36, and HD Grid in 33. Use of adenosine varied across groups (CMC10: 6.7%; CMC20: 86.1%; HD Grid: 41.7%), as did application of a waiting period (CMC10: 96.7%; CMC20: 2.8%; HD Grid: 11.1%). Gaps were identified in in 36.7%, 38.9%, and 81.8% of cases using CMC10, CMC20, and HD Grid, respectively. HD Grid identified significantly more gaps than the other two technologies (p = 0.015), identifying an average of 49.0% and 139.1% more gaps per patient than CMC20 and CMC10, respectively (HD Grid: 2.15/patient; CMC20: 1.44/patient; CMC10: 0.9/patient). The location and incidence of gaps identified by each technology is shown in Figure 1. Conclusions Significantly more gaps were identified by the Advisor HD Grid catheter, as compared to a 10-pole or 20-pole circular mapping catheter. While this does not represent a direct comparison of the sensitivity for identification of gaps across these three technologies, and results could be impacted by other factors (e.g., operator, ablation technique, PVI confirmation technique, etc.), the strong trend toward an increased number of gaps identified with the HD Grid is striking. This may warrant further study including direct comparison of gap identification across technologies, and the resulting impact on long-term clinical outcomes when these additional gaps are ablated during the index procedure. Abstract Figure.

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High-density mapping in patients undergoing ablation of atrial fibrillation with the fourth-generation cryoballoon and the new spiral mapping catheter

EP Europace ◽

10.1093/europace/euaa160 ◽

2020 ◽

Vol 22 (11) ◽

pp. 1653-1658

Author(s):

Giulio Conte ◽

Kyoko Soejima ◽

Carlo de Asmundis ◽

Jolie Bruno ◽

Fabio Cattaneo ◽

...

Keyword(s):

Atrial Fibrillation ◽

Persistent Atrial Fibrillation ◽

High Density ◽

Fourth Generation ◽

Cryoballoon Ablation ◽

Density Mapping ◽

Basket Catheter ◽

Significant Difference ◽

Discrepancy Rate ◽

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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Incidence of residual gaps identified by a high-density grid-style catheter post-cryoballoon ablation for atrial fibrillation

EP Europace ◽

10.1093/europace/euab116.197 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

RS Gaitonde ◽

JA Martel ◽

A Kobori ◽

NS Koide ◽

GT Altemose ◽

...

Keyword(s):

De Novo ◽

Diagnostic Techniques ◽

High Density ◽

Cryoballoon Ablation ◽

Single Shot ◽

True Incidence ◽

Density Mapping ◽

Large Patient ◽

Diagnostic Catheter ◽

Mapping Catheter

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite advances in cardiac ablation technologies and the introduction of single-shot ablation devices such as the cryoballoon, the ability to consistently achieve complete and durable PVI remains elusive. While this is often attributed to PV reconnections that develop after the index procedure, recent data has suggested that traditional diagnostic techniques and technologies may in fact fail to identify gaps that remain upon completion of the index ablation. Initial observations in a small cohort of patients suggested that these residual gaps could be detected by a high-density, grid-style mapping catheter (HD Grid) post-cryoballoon ablation (CBA). The true incidence of these residual gaps as identified in a large patient population has not been previously reported. Purpose To quantify in a large cohort of CBA procedures, the presence of residual gaps identified by HD Grid which are missed by standard techniques of PVI confirmation using a 3.3F circular mapping catheter (CMC). Methods Self-reported data was prospectively collected in CBA procedures in which PVI was first confirmed using CMC followed by assessment using the HD Grid. Procedural characteristics and acute outcomes, including the incidence and location of residual gaps were analyzed. Results Data was collected in 150 CBA procedures performed in 24 centers across the US, Europe and Japan. De novo and repeat ablations represented 78.7% and 12.0% of cases, respectively (9.3% NR). A left common PV was present and ablated in 5.3%; right common in 0.7%. The CMC was used to confirm isolation in all cases using a variety of techniques including voltage mapping (73.3%), exit block (54.7%), and entrance block (29.3%); note: total exceeds 100% as >1 technique may be used in a single case. PVI was then reassessed with HD Grid, enabling a direct comparison of the two technologies. The HD Wave configuration, measuring simultaneous orthogonal bipoles, was used in 94.0% of cases. HD Grid identified a total of 119 gaps in 41 (27.3%) patients, which were missed by the CMC (Figure 1). Conclusions Assessment of PVI using the HD Grid identified residual PV conduction gaps that were missed by the CMC and standard diagnostic techniques in over a quarter of the patients evaluated. One limitation of this analysis is that the technique(s) used for confirmation of PVI were left to the discretion of the operator. Additionally, this analysis includes only workflows in which PVI was confirmed with HD Grid after confirmation using the CMC. Considering the prevalence of residual gaps observed, it is reasonable to interpret that new diagnostic catheter technologies could be critical in the pursuit of more complete and durable PVI, potentially impacting long-term clinical outcomes. Further study on other high-density mapping catheter configurations would be warranted before extrapolating these results to different technologies. Abstract Figure.

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Acute and long-term results of PVI at antrum using a novel high-density mapping catheter without help of 3D electro-anatomic mapping in patients with paroxysmal and chronic atrial fibrillation

Journal of Interventional Cardiac Electrophysiology ◽

10.1007/s10840-009-9459-7 ◽

2010 ◽

Vol 27 (2) ◽

pp. 101-108 ◽

Cited By ~ 7

Author(s):

Thomas Neumann ◽

Malte Kuniss ◽

Damir Erkapic ◽

Sergey Zaltsberg ◽

Alexander Berkowitsch ◽

...

Keyword(s):

Atrial Fibrillation ◽

Chronic Atrial Fibrillation ◽

High Density ◽

Long Term Results ◽

Density Mapping ◽

Mapping Catheter

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Fracture and retrieval of an Achieve circular mapping catheter in and from a pulmonary vein during cryoballoon ablation for atrial fibrillation

HeartRhythm Case Reports ◽

10.1016/j.hrcr.2014.11.001 ◽

2015 ◽

Vol 1 (1) ◽

pp. 31-33 ◽

Cited By ~ 2

Author(s):

Richard C. Massaro ◽

James A. Burke ◽

Gregory T. Altemose

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Cryoballoon Ablation ◽

Mapping Catheter

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Atrial Fibrillation Electroanatomical 3D Mapping Optimisation Thanks to a Novel High-density Mapping Catheter – The Inquiry™ AFocus™ II

European Cardiology Review ◽

10.15420/ecr.2010.6.3.63 ◽

2010 ◽

Vol 6 (3) ◽

pp. 63

Author(s):

Albenque Jean-Paul ◽

Arnaud Chaumeil ◽

Stephane Combes ◽

David Senouf ◽

Luis Martins ◽

...

Keyword(s):

Atrial Fibrillation ◽

Persistent Atrial Fibrillation ◽

Double Loop ◽

3D Mapping ◽

Ablation Catheter ◽

Density Mapping ◽

Atrial Electrogram ◽

Diagnostic Catheter ◽

Mapping Catheter ◽

Complex Fractionated Atrial Electrogram

The OneMap™ tool, a new software feature of the EnSite Velocity™ System, and the new Inquiry™ AFocus™ II double loop duodecapolar diagnostic catheter (DDC) were created to provide faster data collection to efficiently deal with complex arrhythmias such as persistent atrial fibrillation ablation (AF). Our study was performed to compare acquisition criteria, time needed to create the maps, number of collected points, relevance of complex fractionated atrial electrogram (CFE) mapping and correlation between CFE maps with the new DDC and a 4mm irrigated ablation catheter (ABL), Therapy™ Cool Path™ Duo, using the OneMap tool. Ten patients undergoing persistent AF ablation were enrolled. With the DDC, more points were collected (485±173 versus 183±37) and the time needed to create CFE maps was shorter (12±4 versus 24±2 minutes). There were 39 zones detected with the DDC against 35 with the ABL. The correlation between the maps was 80%; however, four additional regions were detected with the DDC (an 11% increase). In conclusion, the Inquiry AFocus II DDC is a feasible, fast and accurate tool for automatic CFE mapping using OneMap.

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