Safety, efficacy, and reproducibility of cavotricuspid isthmus ablation guided by the ablation index: acute results of the FLAI study

EP Europace ◽  
2020 ◽  
Author(s):  
Graziana Viola ◽  
Giuseppe Stabile ◽  
Stefano Bandino ◽  
Luca Rossi ◽  
Natale Marrazzo ◽  
...  
Keyword(s):  
Waiting Time ◽  
Randomized Study ◽  
Structural Heart Disease ◽  
Cavotricuspid Isthmus ◽  
Primary Endpoints ◽  
Ablation Index ◽  
First Pass ◽  
Fluoroscopic Time ◽  
Force Time ◽  
Acute Results

Abstract Aims Ablation index (AI) is a marker of lesion quality during catheter ablation that incorporates contact force, time, and power in a weighted formula. This index was originally developed for pulmonary vein isolation as well as other left atrial procedures. The aim of our study is to evaluate the feasibility and efficacy of the AI for the ablation of the cavotricuspid isthmus (CTI) in patients presenting with typical atrial flutter (AFL). Methods and results This prospective multicentre non-randomized study enrolled 412 consecutive patients with typical AFL undergoing AI-guided cavotricuspid isthmus ablation. The procedure was performed targeting an AI of 500 and an inter-lesion distance measurement of ≤6 mm. The primary endpoints were CTI ‘first-pass’ block and persistent block after a 20-min waiting time. Secondary endpoints included procedural and radiofrequency duration and fluoroscopic time. A total of 412 consecutive patients were enrolled in 31 centres (mean age 64.9 ± 9.8; 72.1% males and 27.7% with structural heart disease). The CTI bidirectional ‘first-pass’ block was reached in 355 patients (88.3%), whereas CTI block at the end of the waiting time was achieved in 405 patients (98.3%). Mean procedural, radiofrequency, and fluoroscopic time were 56.5 ± 28.1, 7.8 ± 4.8, and 1.9 ± 4.8 min, respectively. There were no major procedural complications. There was no significant inter-operator variability in the ability to achieve any of the primary endpoints. Conclusion AI-guided ablation with an inter-lesion distance ≤6 mm represents an effective, safe, and highly reproducible strategy to achieve bidirectional block in the treatment of typical AFL.

scholarly journals Impact of cavotricuspid isthmus depth on the ablation index for successful first-pass typical atrial flutter ablation

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Manabu Kashiwagi ◽  
Akio Kuroi ◽  
Yosuke Katayama ◽  
Kosei Terada ◽  
Suwako Fujita ◽  
...  
Keyword(s):  
Success Rate ◽  
Atrial Flutter ◽  
Vena Cava ◽  
Receiver Operating Curve ◽  
Cavotricuspid Isthmus ◽  
Ablation Index ◽  
Typical Atrial Flutter ◽  
Linear Ablation ◽  
First Pass ◽  
Atrial Flutter Ablation

AbstractCavotricuspid isthmus (CTI) linear ablation has been established as the treatment for typical atrial flutter. Recently, ablation index (AI) has emerged as a novel marker for estimating ablation lesions. We investigated the relationship between CTI depth and ablation parameters on the procedural results of typical atrial flutter ablation. A total of 107 patients who underwent CTI ablation were retrospectively enrolled in this study. All patients underwent computed tomography before catheter ablation. From the receiver-operating curve, the best cut-off value of CTI depth was < 4.1 mm to predict first-pass success. Although the average AI was not different between deep CTI (DC; CTI depth ≥ 4.1) and shallow CTI (SC; CTI depth < 4.1), DC required a longer ablation time and showed a lower first-pass success rate (p < 0.01). In addition, the catheter inversion technique was more frequently required in the DC (p < 0.01). The lowest AI sites of the first-pass CTI line were determined in both the ventricular (2/3 segment of CTI) and inferior vena cava (IVC, 1/3 segment of CTI) sides. The best cut-off values of the weakest AIs at the ventricular and IVC sides for predicting first-pass success were > 420 and > 386, respectively. Among patients with these cut-off values, the first-pass success rate was 89% in the SC and 50% in the DC (p < 0.01). Although ablation parameters were not significantly different, the first-pass success rate was lower in the DC than in the SC. Further investigation might be required for better outcomes in deep CTIs.

scholarly journals Impact of Cavotricuspid Isthmus Anatomy on the Ablation Index For Successful First-Pass Typical Atrial Flutter Ablation

2021 ◽  
Author(s):  
Manabu Kashiwagi ◽  
Akio Kuroi ◽  
Yosuke Katayama ◽  
Kosei Terada ◽  
Suwako Fujita ◽  
...  
Keyword(s):  
Success Rate ◽  
Atrial Flutter ◽  
Receiver Operating Curve ◽  
Cavotricuspid Isthmus ◽  
Ablation Index ◽  
Typical Atrial Flutter ◽  
Linear Ablation ◽  
First Pass ◽  
The Relationship ◽  
Atrial Flutter Ablation

Abstract Cavotricuspid isthmus (CTI) linear ablation has been established as the treatment for typical atrial flutter. Recently, ablation index (AI) has emerged as a novel marker for estimating ablation lesions. We investigated the relationship between CTI anatomy and ablation parameters. In addition, we focused on the influence of AI on the procedural results of typical atrial flutter ablation. A total of 107 patients who underwent CTI ablation were retrospectively enrolled in this study. All patients underwent computed tomography before catheter ablation. From the receiver-operating curve, the best cut-off value of CTI depth was < 4.1 mm to predict first-pass success. The patients were divided into two groups according to the CTI depth: the concave group (CG) and straight group (SG). Although the average AI was not different between both groups, the CG required a longer ablation time and showed a lower first-pass success rate (p < 0.01). In addition, the catheter inversion technique was more frequently required in the CG (p < 0.01). The best cut-off values of the weakest AIs at the anterior and posterior lesions for predicting first-pass success were >420 and >386, respectively. Among patients with these cut-off values, the first-pass success rate was 88% in the SG and 50% in the CG (p < 0.01). Although ablation parameters were not significantly different, the first-pass success rate was lower in the CG than in the SG. AI-guided CTI may be useful in straight CTIs, but a modified approach might be required for concave CTIs.

scholarly journals Randomized study defining the optimum target interlesion distance in ablation index-guided atrial fibrillation ablation

EP Europace ◽  
2020 ◽  
Vol 22 (10) ◽  
pp. 1480-1486
Author(s):  
Philipp Hoffmann ◽  
Ivan Diaz Ramirez ◽  
Gerd Baldenhofer ◽  
Karl Stangl ◽  
Lluís Mont ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Study Protocol ◽  
Randomized Study ◽  
Procedure Time ◽  
Af Ablation ◽  
Study Protocols ◽  
Ablation Index ◽  
First Pass ◽  
First Time

Abstract Aims While the CLOSE protocol proposes a maximally tolerable interlesion distance (ILD) of 6 mm for ablation index ablation index-guided atrial fibrillation (AF) ablation, a target ILD has never been defined. This randomized study sought to establish a target ILD for ablation index-guided AF ablation. Methods and results Consecutive patients scheduled for first-time pulmonary vein (PV) isolation (PVI) were randomly assigned to ablation protocols with a target ILD of 5.0–6.0 mm or 3.0–4.0 mm, with the primary endpoint of first-pass PVI. In compliance with the CLOSE protocol, the maximum tolerated ILD was 6.0 mm in both study protocols. A target ablation index of ≥550 (anterior) or ≥400 (posterior) was defined for the ‘5–6 mm’ protocol and ≥500 (anterior) or ≥350 (posterior) for the ‘3–4 mm’ protocol. The study was terminated early for superiority of the ‘3–4 mm’ protocol. Forty-two consecutive patients were randomized and 84 ipsilateral PV pairs encircled according to the study protocol. First-pass PVI was accomplished in 35.0% of the ‘5–6 mm’ group and 90.9% of the ‘3–4 mm’ group (P &lt; 0.0001). Median ILD was 5.2 mm in the ‘5–6 mm’ group and 3.6 mm in the ‘3–4 mm’ group (P &lt; 0.0001). In line with the distinct ablation index targets, median ablation index was lower in the ‘3–4 mm’ group (416 vs. 452, P &lt; 0.0001). While mean procedure time was shorter in the ‘3–4 mm’ group (149 ± 27 vs. 167 ± 33min, P = 0.004), fluoroscopy times did not differ significantly (4.7 ± 2.2 vs. 5.1 ± 1.8 min, P = 0.565). Conclusion In ablation index-guided AF ablation, an ILD of 3.0–4.0 mm should be targeted rather than 5.0–6.0 mm. Moreover, the lower target ILD may allow for less extensive ablation at each given point.

scholarly journals B-PO05-108 SAFETY, EFFICACY, AND REPRODUCIBILITY OF FAST CAVOTRICUSPID ISTHMUS ABLATION: ACUTE RESULTS OF THE FACTI STUDY

Heart Rhythm ◽  
2021 ◽  
Vol 18 (8) ◽  
pp. S415-S416
Author(s):  
Vincenzo Schillaci ◽  
Giuseppe Stabile ◽  
Alberto Arestia ◽  
Alessia Agresta ◽  
Gergana Shopova ◽  
...  
Keyword(s):  
Cavotricuspid Isthmus ◽  
Acute Results

scholarly journals A multi-centre experience of ablation index for evaluating lesion delivery in cavotricuspid isthmus dependent atrial flutter

2020 ◽  
Author(s):  
Edd Maclean ◽  
Ron Simon ◽  
Richard Ang ◽  
Gurpreet Dhillon ◽  
Syed Ahsan ◽  
...  
Keyword(s):  
Atrial Flutter ◽  
Cavotricuspid Isthmus ◽  
Ablation Index

scholarly journals The use of a high‐power (50 W), ablation index‐guided protocol for ablation of the cavotricuspid isthmus

2020 ◽  
Vol 36 (6) ◽  
pp. 1045-1050
Author(s):  
Verena Tscholl ◽  
Paul Kamieniarz ◽  
Patrick Nagel ◽  
Ulf Landmesser ◽  
Philipp Attanasio ◽  
...  
Keyword(s):  
High Power ◽  
Cavotricuspid Isthmus ◽  
Ablation Index

scholarly journals Standardized pulmonary vein isolation workflow to enclose veins with contiguous lesions: the multicentre VISTAX trial

EP Europace ◽  
2020 ◽  
Vol 22 (11) ◽  
pp. 1645-1652
Author(s):  
Mattias Duytschaever ◽  
Johan Vijgen ◽  
Tom De Potter ◽  
Daniel Scherr ◽  
Hugo Van Herendael ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Randomized Study ◽  
Standard Of Care ◽  
Posterior Wall ◽  
Anterior Wall ◽  
Atrial Arrhythmia ◽  
Clinical Trial Registration ◽  
First Pass

Abstract Aims To evaluate the safety and effectiveness of pulmonary vein isolation in paroxysmal atrial fibrillation (PAF) using a standardized workflow aiming to enclose the veins with contiguous and optimized radiofrequency lesions. Methods and results This multicentre, prospective, non-randomized study was conducted at 17 European sites. Pulmonary vein isolation was guided by VISITAG SURPOINT (VS target ≥550 on the anterior wall; ≥400 on the posterior wall) and intertag distance (≤6 mm). Atrial arrhythmia recurrence was stringently monitored with weekly and symptom-driven transtelephonic monitoring on top of standard-of-care monitoring (24-h Holter and 12-lead electrocardiogram at 3, 6, and 12 months follow-up). Three hundred and forty participants with drug refractory PAF were enrolled. Acute effectiveness (first-pass isolation proof to a 30-min wait period and adenosine challenge) was 82.4% [95% confidence interval (CI) 77.4–86.7%]. At 12-month follow-up, the rate of freedom from any documented atrial arrhythmia was 78.3% (95% CI 73.8–82.8%), while freedom from atrial arrhythmia by standard-of-care monitoring was 89.4% (95% CI 78.8–87.0%). Freedom fromrepeat ablations by the Kaplan–Meier analysis was 90.4% during 12 months of follow-up. Of the 34 patients with repeat ablations, 14 (41.2%) demonstrated full isolation of all pulmonary vein circles. Primary adverse event (PAE) rate was 3.6% (95% CI 1.9–6.3%). Conclusions The VISTAX trial demonstrated that a standardized PAF ablation workflow aiming for contiguous lesions leads to low rates of PAEs, high acute first-pass isolation rates, and 12-month freedom from arrhythmias approaching 80%. Further research is needed to improve the reproducibility of the outcomes across a wider range of centres. Clinical trial registration: ClinicalTrials.gov, number NCT03062046, https://clinicaltrials.gov/ct2/show/NCT03062046.

1244Feasibility, safety and efficacy of tailoring ablation index to left atrial wall thickness (lawt) during atrial fibrillation ablation. The Ablate By-LAW Study

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
C Teres ◽  
B Jauregui ◽  
D Soto-Iglesias ◽  
A Ordonez ◽  
A Chauca ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Wall Thickness ◽  
Left Atrial ◽  
Atrial Fibrillation Ablation ◽  
High Rate ◽  
Atrial Wall ◽  
Left Atrial Wall ◽  
Ablation Index ◽  
First Pass ◽  
Catheter Stability

Abstract Funding Acknowledgements Dr Teres was funded by Swiss Heartrhythm Foundation Introduction Circumferential pulmonary vein isolation (PVI) has become a mainstay in the treatment of atrial fibrillation (AF). The utility of ablation index (AI) to dose radiofrequency delivery for the reduction of AF recurrences has already been proven with a target AI ≥ 400 at the posterior wall and ≥550 at the anterior Wall. Nevertheless, the left atrial wall is a thin, heterogeneous structure with an important inter and intra-patient variability of LAWT. Objective To determine if adapting AI to atrial wall thickness (AWT) is feasible, effective and safe during AF ablation. Methods Single-Center study that included 80 consecutive patients referred for a first paroxysmal AF ablation that was performed with a single catheter approach with the intention to reduce vascular access complication rate. All patients had a MDCT prior to the ablation procedure. LAWT maps were semi-automatically computed from the MDCT as the local distance between the LA endo and epicardium. All procedures were performed under general anesthesia with a high-rate low-volume ventilation protocol for obtaining higher catheter stability. The transeptal puncture was TEE-guided. During the procedure, the WT map was fused with the LA anatomy using CARTO-merge. LAWT was categorized into 1mm-layers and the AI was titrated to the local atrial WT as follows: Thickness &lt; 1 mm (red): 300; 1-2 mm (yellow): 350; 2-3 mm (green): 400; 3-4 mm (blue): 450; &gt; 4 mm (purple): 450 (Figure). Maximal inter-lesion distance was set at 6 mm. VisiTag settings were: catheter position stability: minimum time 3 s, maximum range 4 mm; force over time: 25%, minimum force 3 g; lesion tag size: 3 mm. Respiration training was not possible due to the high catheter stability.  The circumferential ablation line was designed in a personalized fashion to avoid thicker regions. Results 80 patients [41 (51,2 %) male, age 60± 11 years] were included. Mean LVEF was 59 ± 5 %, Mean LA diameter 39,1 ± 5,8 mm, Mean LAWT was 1.36 ± 0.63 mm. Mean AI was 352 ± 36 on the RPVs and 356 ± 36 on the LPVs. Procedure time was 60,0 min (IQR 51-70). Fluoroscopy time was 58,5 s (35-97,5). First pass isolation was obtained in 72 (90%) of the RPVs and 75 (93,8%) of the LPVs. Conclusions the present study, assessing a novel, personalized protocol for radiofrequency titration during atrial fibrillation ablation, shows a high rate of first pass isolation with a lower need for RF energy delivery and lower procedure requirements, as compared to previous PV ablation protocols. Further studies are needed to evaluate the long-term results of this approach. Abstract Figure. LAWT-map Visitag points with tailored AI

scholarly journals Choosing an Effective and Safe Direct Aspiration Setup for Tortuous Anatomy in Acute Ischemic Stroke: In vitro Study in a Physiological Flow Model

2020 ◽  
Author(s):  
Jawid Madjidyar ◽  
Lars Nerkada ◽  
Naomi Larsen ◽  
Fritz Wodarg ◽  
Johannes Hensler ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
In Vitro Study ◽  
Primary Endpoints ◽  
Key Points ◽  
First Pass ◽  
Stent Retrievers ◽  
Almost All ◽  
Number Of Passes

Purpose A direct aspiration first pass technique (ADAPT) is an effective thrombectomy option in patients with acute ischemic stroke. Balloon guide catheters (BGC) seem to improve the efficacy of stent retrievers and ADAPT. The last generation 6F aspiration catheters require 9F BGCs, which are rigid devices that are challenging to position in a tortuous anatomy. In this experimental study the efficacy of 6F ADAPT alone and 5F ADAPT combined with 8F BGC was evaluated. Materials and Methods Either a fibrin rich (white) clot or an RBC rich (red) clot was placed in the M1 segment of a transparent silicon phantom. Physiological hemodynamic conditions were maintained. The clots were retrieved by 6F aspiration catheter via 8F long sheath or 5F aspiration catheter via a flexible 8F BGC. Thrombectomy was performed under direct visual control. The primary endpoints were the number of passes and the number of distal emboli. Results Ten experiments were made with each clot model and thrombectomy technique (n = 40). Full recanalization could be achieved in every experiment. First pass mTICI 3 could be achieved by 6F ADAPT in 80 % of red clots and 90 % of white clots. Distal emboli were caused in 10 % and 20 %, respectively. When using 5F ADAPT combined with BGC, a first pass mTICI 3 rate of 90 % in red clots and 100 % in white clots could be achieved. A 10 % rate of distal emboli occurred in both groups. In almost all experiments (both techniques), the thrombi clogged the aspiration catheter. No statistically significant differences could be found between the techniques and clot models. Conclusion 6F ADAPT without BGC was as effective as 5F ADAPT combined with a flexible 8F BGC, with both techniques showing high first-pass recanalization rates and low distal emboli rates. Especially in the case of a tortuous anatomy, these setups should be considered as alternatives to a rigid 9F BGC. The thrombus compositions seemed to be irrelevant in this setting. Key Points:  Citation Format

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