The Full Circle: Back into the Pulmonary Veins: A New Possibility in AF Ablation?

Abstract Background It has been reported that frequent use of touch-up focal ablation catheters was related to worse outcomes after cryoballoon (CB) atrial fibrillation (AF) ablation. It is unknown whether non-use of touch-up focal ablation catheters strategy affects the outcome of AF ablation. Therefore, this study aimed to assess whether non-use of touch-up focal ablation catheters strategy improve clinical outcome after AF ablation using CB. Methods A total of 151 consecutive patients who received CB ablation from February 2017 to August 2019 were enrolled. Non-use of a touch-up focal ablation catheters strategy was started from February 2018. Patients were divided into 2 groups according to the type of strategy. In the non-touch-up group, pulmonary veins were isolated without touch-up focal ablation catheters as much as possible and in conventional group, touch-up focal ablation catheters were used as required. The 1-year atrial tachyarrhythmia free survival without class 1 or 3 antiarrhythmic drugs after a 90-day blanking period was assessed between the 2 groups. Results The conventional group consisted of 76 patients and the non-touch-up group consisted of 75 patients. Baseline characteristics were comparable between 2 groups. Touch-up focal ablation catheters were used more in the conventional group (11 patients, 14%) than non-touch-up group (0 patients, 0%) (p<0.001). Pulmonary isolation was achieved in all patients of both groups. Atrial tachyarrhythmia recurrence occurred more frequently in the non-touch-up group (15/75 patients, 20%) than conventional group (7/76 patients, 9%) (p=0.045). Conclusion Non-use of a touch-up focal ablation catheters strategy may be related to worse outcome after CB AF ablation. Funding Acknowledgement Type of funding source: None

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Epicardial Box Lesion Using Bipolar Biparietal Radiofrequency and Multimodality Scar Evaluation - a case series

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab530 ◽

2021 ◽

Author(s):

G P Bijvoet ◽

S M Chaldoupi ◽

E Bidar ◽

R J Holtackers ◽

J G L M Luermans ◽

...

Keyword(s):

Pulmonary Veins ◽

Case Series ◽

Small Population ◽

Surgical Ablation ◽

Af Ablation ◽

Surgical Tool ◽

Atrial Remodelling ◽

Magnetic Resonance Imaging Mri ◽

Thoracoscopic Procedure

Abstract Background Surgical epicardial AF ablation can be performed as a stand-alone (thoracoscopic) procedure or concomitant to other cardiac surgery. In hybrid AF ablation thoracoscopic surgical epicardial ablation is combined with a percutaneous endocardial ablation. The Medtronic Gemini-S clamp is a surgical tool that uses irrigated bipolar biparietal RF energy applied with two clamp lesions that overlap to create one epicardial box lesion including the posterior LA wall and the pulmonary veins. Case summary We describe three patients with therapy-refractory persistent AF and different stages of atrial remodelling in whom the Medtronic Cardioblate Gemini-S Irrigated RF Surgical Ablation System was used for hybrid AF ablation. Acute endocardial validation at the end of the hybrid ablation revealed a complete box lesion in all three cases. At 2-year follow-up, two out of three patients had recurrence of atrial arrhythmias. Invasive electro-anatomical mapping confirmed persistence of the box lesion, and the mechanism of arrhythmia recurrence in both patients was unrelated to posterior left atrium or the pulmonary veins. The third patient has been without arrhythmia symptoms since the ablation procedure. A 3D late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) illustrates the ablation scar non-invasively in two cases. Discussion Thoracoscopic biparietal RF AF ablation with the Medtronic Cardioblate Gemini-S Irrigated RF Surgical Ablation System results in permanent transmural scar formation, irrespective of the stage of atrial remodelling, as shown in this small population by means of multimodality scar evaluation.

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Abstract 12600: Microrna From Atrial Tissue Harvested During Transseptal Puncture as a Predictor for Non-pv Trigger in Patients Undergoing Af Ablation: Preliminary Results From a Pilot Study

Circulation ◽

10.1161/circ.130.suppl_2.12600 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Luigi Di Biase ◽

Aaron Baker ◽

Xue Yan ◽

Jason Lee ◽

Francesco Santoro ◽

...

Keyword(s):

Therapeutic Option ◽

Standard Procedure ◽

Expression Patterns ◽

Pulmonary Veins ◽

Challenge Test ◽

Inverse Correlation ◽

Patient Specific ◽

Af Ablation ◽

Atrial Tissue ◽

Nonparametric Correlation

Introduction: Catheter ablation of atrial fibrillation (AF) is the most valid therapeutic option to achieve rhythm control. Pulmonary veins (PV) are the most known trigger of AF, although recently we have become more aware of the importance of non-PV triggers. Expression of microRNA (miRNA) has been shown to be regulated in many cardiovascular disease. We sought to study expression patterns of miRNA in patients (pts) with AF undergoing ablation to facilitate their application as both diagnostic and prognostic markers. Methods: As part of the standard procedure for AF ablation a double transseptal sample of myocardial tissue is obtained via a transseptal needle. The small piece of atrial septal tissue can be retrieved from the needle as a result of piercing the atrial septum. MiRNA was hybridized to microarrays to determine relative levels of miRNAs in the samples. For a subset of the miRNAs we validated expression through quantitative real time PCR. All pts underwent PV-antrum and non-PV trigger ablation guided by isoproterenol challenge test. Results: Atrial tissue of 11 pts undergoing AF ablation has been utilized for MiRNA assessment. Mean age was 61.27 ± 10.5 years and 8 (72.7%) pts were male. Six (54.5 %) pts had paroxysmal AF. During the ablation non-PV triggers were detected in 8 (72.7 %) pts. Recurrence of AF occurred in 3(27.3 %) pts. Expression of miR-21, miR-26a and miR-29a was higher in pts with non-PV triggers, while miR-30c had lower expression in pts who had recurrence of atrial tachyarrhythmias. Spearman’s nonparametric correlation coefficient was calculated and miR-21, miR-26a, miR-29a were positively correlated with non-PV triggers (r = 0.58, p=0.06 for all three miRNAs), while miR-30c level had inverse correlation (r = (-) 0.78 %, p=0.005) with recurrence (Figure). Conclusions: Expression of miR-21, miR-26a, miR-29a correlates with the presence of non-PV triggers. This information could be clinically relevant in planning patient specific procedures.

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Abstract 16237: Zero Fluoroscopy Ablation of Atrial Fibrillation: A Safety and Feasibility Study

Circulation ◽

10.1161/circ.130.suppl_2.16237 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Luigi Di Biase ◽

Rodney Horton ◽

Chintan Trivedi ◽

Prasant Mohanty ◽

Sanghamitra Mohanty ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Pulmonary Veins ◽

Radiation Risk ◽

Control Group ◽

Short Term ◽

Af Ablation ◽

And Control ◽

Zero Fluoroscopy

Introduction: Radiofrequency catheter ablation of atrial fibrillation is performed under fluoroscopic guidance and therefore carries radiation risk exposure for the both the patient and the operator. Three-dimensional mapping systems and newer technologies to allow non-fluoroscopic catheter visualization together with intracardiac echo have reduced but not abolished the fluoroscopy exposure. We aim to demonstrate the feasibility, the safety and the efficacy of catheter ablation for atrial fibrillation without the use of fluoroscopy. Methods: A totally fluoro-less approach was developed for AF ablation at our Institution. 94 consecutive AF patients underwent zero fluoroscopy catheter ablation for atrial fibrillation. In the zero fluoroscopy cases, the fluoroscopy arm was kept far away from the patient table. Access including double trans-septal, mapping with the Carto 3 system and ablation were all performed without fluoroscopy with the use of ICE and the Carto 3 system. These 94 patients were compared with 94 control patients matched for age, sex and type of AF who underwent AF ablation by the same operator with the use of fluoroscopy. Results: Baseline characteristics were similar between fluoroless (N=94, Age=64.5 ± 10.1, 75.5% male, 48% paroxysmal) and control (N=94, Age=65.1 ± 9.9, 72.3% male, 50% paroxysmal) group. Non-PV triggers were detected and ablated in 51 (54.3%) and 56 (59.6%) patients in fluoroless and control group respectively (p=0.5). Average fluoro time in control group was 10.1 ± 4.7 minutes. Procedure duration was comparable (120.4 ± 25.8 vs. 122.2 ± 28.7, p =0.6). After the short term median follow-up of 4.5 (4 – 6.5) months, 10 (10.6 %) patients in flourless and 9 (9.6%) patients in control group experienced recurrences (p=0.8).One pericardial effusion requiring pericardiocenteis occurred in the fluoroless group. Conclusions: Our series show that zero fluoroscopy ablation of atrial fibrillation with the use of newer technologies is feasible, safe and efficacious at the short term follow up. Importantly in our series the double transeptal was performed without fluoroscopy and the ablation was not limited to the pulmonary veins only but included ablation of the posterior wall, the coronary sinus and the left atrial appendage.

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Abstract 4653: Isolation Of Pulmonary Veins Using A Novel Decapolar Catheter For Mapping And Ablation

Circulation ◽

10.1161/circ.118.suppl_18.s_925-b ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Stefan Weber ◽

Sabine Fredersdorf ◽

Clemens Jilek ◽

Norbert Heinicke ◽

Carsten Jungbauer ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Veins ◽

High Volume ◽

Procedure Time ◽

Ablation Procedure ◽

Catheter Position ◽

3D Navigation ◽

Af Ablation ◽

Ablation Success ◽

Increasing Demand

Background: Ablation of atrial fibrillation (AF) is one of the most time consuming procedures in interventional electrophysiology. Currently, the selection of catheters and ablation techniques is still a matter of debate. Due to the rapidly increasing demand of ablation procedures, technical advances would be helpful to reduce complexity and procedure time in AF ablation. Therefore we investigated the feasibility of a novel decapolar ablation catheter (PVAC) combined with a duty-cycled, low-power RF generator for pulmonary vein (PV) isolation. The system does not require 3D mapping and is the first to enable mapping, pacing and circular as well as segmental ablation with a single catheter. Methods: AF mapping and ablation was performed in 15 consecutive patients with intermittent AF (mean age 58±12 years, 6 males) using the PVAC- catheter. To visualize the pulmonary vein anatomy, CT or MRI scan was performed in addition to PV angiography before ablation procedure. Additionally all patients underwent transesophageal echocardiography to rule out left atrial (LA) thrombi. Ablation procedure was performed by introducing the PVAC to the LA via single transseptal puncture. An optimal and stable catheter position for mapping and ablation was achieved by using a steerable sheath and an over the wire technique. RF energy was typically delivered for 60s for circular and 30 to 60s for segmental ablations. Ablation success was defined by disappearance of PV signals and complete exit block obtained by PVAC stimulation. Results: Isolation of all four PVs could be achieved in 59/60 veins (98%). A very small and hypoplastic right inferior PV could not be reached. The median RF application time until all PV were isolated successfully was 23±7 min. First half of ablations were performed by circular RF application, second half with segmental applications until isolation. Procedure time for ablation was 81±14 min. Total fluoroscopy time was 31±9 min. There were no procedural complications. Conclusion: Mapping and ablation of pulmonary veins can be performed safe and fast, with low procedure times using a single catheter without 3D navigation or assisted steering. Thus this system may be of high interest not only for high volume but all centers performing AF ablation.

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Vorhofflimmern: Wie wichtig ist der Erhalt des Sinusrhythmus?

DMW - Deutsche Medizinische Wochenschrift ◽

10.1055/a-0969-6352 ◽

2020 ◽

Vol 145 (08) ◽

pp. 543-549

Author(s):

Christian Meyer ◽

Andreas Metzner ◽

Paulus Kirchhof

Keyword(s):

Quality Of Life ◽

Antiarrhythmic Drugs ◽

Pulmonary Veins ◽

Left Ventricular ◽

Rhythm Control ◽

Af Ablation ◽

Stroke Risk Factors ◽

Control Therapy ◽

Rhythm Stability

AbstractRhythm control therapy, comprising antiarrhythmic drugs, cardioversion, and AF ablation, is an important component in the management of patients with atrial fibrillation (AF). Catheter ablation for AF, mainly targeting isolation of the pulmonary veins (AF ablation), has markedly improved the effectiveness of rhythm control therapy. Rhythm control improves symptoms and quality of life in patients with symptomatic AF. AF ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy. Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Different lifestyle interventions might additionally improve symptoms and rhythm stability in patients with AF. AF ablation appears to improve left ventricular function in a subset of patients. Summarized, rhythm control therapy in patients with symptomatic AF is safe and improves quality of life, including elderly patients with stroke risk factors. Further studies are needed to determine whether rhythm control therapy reduces AF-related complications while improving patient outcome with regard to prognosis.

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Redo ablation for atrial fibrillation recurrence post radiofrequency or cryoballoon ablation: a high volume single-centre experience

EP Europace ◽

10.1093/europace/euab116.102 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

M Ribeiro Da Silva ◽

G Santos Silva ◽

P Ribeiro Queiros ◽

R Teixeira ◽

J Almeida ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Veins ◽

High Volume ◽

Cryoballoon Ablation ◽

Single Centre ◽

Electrophysiologic Study ◽

Electroanatomic Mapping System ◽

Af Ablation ◽

Funding Sources ◽

Time To Recurrence

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation (AF) ablation is a well-established procedure for the treatment of AF. The cornerstone of AF ablation is the complete and durable isolation of pulmonary veins (PV) through radiofrequency (RF) or cryoballoon (CB) ablation. However, PVI durability between RF or CB was not yet established, as reablation strategy and outcomes in patients (pt) undergoing a redo ablation. Purpose To compare RF versus CB regarding PVI status, reablation procedure and outcomes in pts undergoing a second procedure. Methods Single-centre retrospective study of consecutive pts who underwent a redo between 2016 and 2020. PVI status was assessed during electrophysiologic study with electroanatomic mapping system. Index procedures included second generation CB, conventional RF before 2018 and CLOSE protocol guided RF ablation after 2018. We assessed time-to-redo, number and location of reconnected PVs, procedural characteristics, acute and long-term outcomes between RF and CB index PVI. Results Seventy-four (55 RF and 19 CB) pts were included, 68,9% were male, most pts had paroxysmal AF (71,6%) and a mean CHA2DS2-VASc score of 1,14 ± 1,0. No statistically significant differences were noticed in clinical and echocardiographic characteristics between pts within RF or CB cohorts. Median time to reablation was significantly longer in the RF cohort (38,6 months ±33,6) compared to CB (17,0 months ±9,5) (p = 0,014). The number of reconnected PV was higher in CB than the RF cohort, although not significant (2,37 ±1,2 vs 1,75 ±1,4;p = 0,080). Right inferior PV was significantly more reconnected in pts within the CB compared to RF group (73,7% vs 45,6%;p = 0,034), without differences in the other PV reconnection rates. Regarding reablation procedure, all pts were submitted to RF-redo. Fluoroscopy time was shorter for CB than RF cohort (7,4 ±2,9 vs 13,3 ±8,4;p = 0,002). There were no significant differences between the type of reablation (PVI only vs PVI plus other lesions or cavotricuspid isthmus ablation), with no difference in overall acute success. After the redo procedure, no differences were observed in recurrence rate in the blanking period and after 91 days from reablation. Nevertheless, time-to-recurrence (>91 days) was longer for RF than CB group (13,4 months ±10,7 vs 4,3 months ±1,5;p = 0,016). There were 2 pts in the RF group that were submitted to a third ablation procedure (p = 0,725). There were no differences between groups in the composite of adverse cardiovascular (CV) outcomes (stroke/transient ischemic attack, emergency room visit for AF, hospitalization for AF or CV death); p = 0,715. Conclusions After the index procedure, reablation occur later in RF than CB cohort. Although the number of reconnected PV were similar between groups, right inferior PV was significantly more reconnected in pts originally treated with CB. After redo, time-to-recurrence was shorter for CB cohort. Recurrence and composite of adverse CV outcomes were similar.

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Shorter interlesion distance is associated with a longer procedure time but not with poorer acute results of pulmonary vein isolation: results from a prospective ablation index registry

EP Europace ◽

10.1093/europace/euab116.238 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

N Gasimova ◽

EB Kropotkin ◽

EA Ivanitsky ◽

GV Kolunin ◽

AA Nechepurenko ◽

...

Keyword(s):

Multicenter Study ◽

Pulmonary Veins ◽

Anterior Wall ◽

Procedure Time ◽

Af Ablation ◽

Ablation Index ◽

First Pass ◽

The Mean ◽

Group 2 ◽

Group 1

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): This work was supported by the Ministry of Science and Higher Education grant (Russian Federation President Grant) #MD-2314.2020.7. Background/Introduction. Radiofrequency ablation (RFA) is the mainstay of invasive management of atrial fibrillation (AF). Amongst a variety of performance indicators, interlesion distance (ILD) has a potential to become a guiding one. Uptodate clinical AF RFA protocols suggest that ILD has to be less than 6 mm, however the research is still lacking in regard to its actual targeted value. Purpose. The aim of the research is to study a relationship between ILD and first-pass isolation (FPI) in ablation-index guided AF ablation procedures. Methods. This was a prospective observational multicenter study. Data were derived from the web-based system. Pulmonary veins (PV) isolation procedures were performed according to the local practice, and RFA settings depended on operators’ preferences. A total of 446 patients were enrolled, 407 of them underwent first-time AF ablation, data on ILD available in 322 subjects (177 (55%) males, mean age 62 ± 9 years old, 259 (80%) with paroxysmal AF). A mean ILD was calculated manually in each case as a sum of all ILDs divided by number of ablation tag points. FPI was considered in cases when no additional applications were required for bidirectional PV block following creation of a one circle around ipsilateral PVs and after a 20-min waiting period. Patients were divided into two groups according to ILD (Group 1 ILD≤ 4 mm, 163 patients and Group 2 ILD > 4m, 159 patients) post-procedurally. Results. The mean procedure time was 102 ± 52 min, the median fluoro time was 9 min [IQR 6; 15]. The following VisiTag parameters were used: the median target ablation index 400 [IQR 400; 500] on the left atrial anterior wall and 380 [IQR 380; 400] on the posterior segments, the median minimal contact force 3g [IQR 3; 4], median minimal time per a point - 4 sec [IQR 3; 15], mean catheter stability 3 mm (ranged between 2.5 and 3 mm). In 261 (81%) cases operators used 3 mm ablation tag size, and in 19% - 2 mm. The mean ILD was 4,1 ± 1,0 mm (3,2 ± 0,5 mm in Group 1 vs 4,6 ± 0,5 mm Group 2). FPI was achieved in 189 (59%) cases. In the "ILD ≤ 4 mm" group FPI was achieved in 93 (49,2%) cases and there were 96 (50,8%) cases of durable FPI in the "ILD >4 mm" group (χ2 = 2,4, p = 0,124). The mean procedure time was 111 ± 46 min and 100 ± 35 min in Group 1 and 2 (p = 0,01), respectively. The mean fluoro time was 13 ± 4 min and 11 ± 4 min in Group 1 and 2 (p = 0,08), respectively Conclusion(s). The results of our multicenter study suggest that shortening of the distance ≤4 mm has no effect on the achievement of first-pass PV isolation, but required more procedure and relatively more X-ray exposure time.

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Abstract 2755: Increased Efficacy of Catheter Ablation Of Atrial Fibrillation by Using Adenosine to Reveal Dormant Pulmonary Vein Conduction

Circulation ◽

10.1161/circ.118.suppl_18.s_772-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Laurent Macle ◽

Atul Verma ◽

Paul Novak ◽

Paul Khairy ◽

Mario Talajic ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Pulmonary Vein ◽

Pulmonary Veins ◽

Historical Control Group ◽

Historical Control ◽

Control Group ◽

Af Ablation ◽

Dormant Conduction ◽

Af Recurrence

Recurrences of atrial fibrillation (AF) after catheter ablation are frequently associated with recovery of conduction between the pulmonary veins (PV) and the atrium. The recovery of PV conduction could be explained by the presence of dormant conduction between the PV and the atrium. Adenosine can be used during AF ablation procedures to reveal transient re-conduction of the isolated pulmonary vein (dormant PV conduction). We prospectively evaluate the utility of iv adenosine to guide elimination of dormant PV conduction by additional radiofrequency (RF) applications during AF ablation procedures. Thirty-four consecutive patients (30 male; age 51+/−8 years) referred for catheter ablation of drug-refractory AF (Paroxysmal 31/Persistent 3) were studied. Electrical PV isolation (PVI) was performed using Irrigated-tip radiofrequency (RF) ablation and was guided by a circular mapping catheter. After PVI, the presence of dormant conduction in each vein was assessed by injection of 12 mg of adenosine. If dormant conduction was present, additional RF energy was delivered at sites of transient re-conduction. Abolition of the dormant conduction was then demonstrated by repeated injections of adenosine. The recurrence rate of arrhythmia after one procedure was evaluated. The results were compared to an historical control group comprising the previous 34 consecutive patients who underwent PVI without the use of adenosine. Electrical PVI was achieved in 100% of PV’s and all 34 patients underwent the adenosine evaluation. Dormant PV conduction was observed in 17/34 patients and could be eliminated in all by additional RF delivery. Procedural and fluoroscopy times were 163±30 and 49±13 minutes, respectively. After a mean follow-up of 8.0±3.1 months, 6/34 (18%) patients experienced AF recurrence with 28/34 (82%) remaining free of arrhythmia without the use of antiarrhythmic drugs. When compared to the 14/34 patients (41%) from the historical control group who had AF recurrence, a significant reduction was observed (P<0.01). The use of adenosine to guide elimination of dormant PV conduction increases the success rate of AF ablation procedures. This needs to be evaluated in a randomized multicenter trial.

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Current Ablation Strategies for Persistent and Long-Standing Persistent Atrial Fibrillation

Cardiology Research and Practice ◽

10.4061/2011/376969 ◽

2011 ◽

Vol 2011 ◽

pp. 1-9 ◽

Cited By ~ 5

Author(s):

Konstantinos P. Letsas ◽

Michael Efremidis ◽

Charalampos Charalampous ◽

Spyros Tsikrikas ◽

Antonios Sideris

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Veins ◽

Persistent Atrial Fibrillation ◽

Initial Step ◽

Af Ablation ◽

Linear Lesions ◽

Increased Risk ◽

Single Strategy ◽

Overall Mortality ◽

Complex Fractionated Atrial Electrograms

Atrial fibrillation (AF) is associated with an increased risk of cardiac and overall mortality. Restoration and maintenance of sinus rhythm is of paramount importance if it can be accomplished without the use of antiarrhythmic drugs. Catheter ablation has evolved into a well-established treatment option for patients with symptomatic, drug-refractory AF. Ablation strategies which target the pulmonary veins are the cornerstone of AF ablation procedures, irrespective of the AF type. Ablation strategies in the setting of persistent and long-standing persistent AF are more complex. Many centers follow a stepwise ablation approach including pulmonary vein antral isolation as the initial step, electrogram-based ablation at sites exhibiting complex fractionated atrial electrograms, and linear lesions. Up to now, no single strategy is uniformly effective in patients with persistent and long-standing persistent AF. The present study reviewed the efficacy of the current ablation strategies for persistent and long-standing persistent AF.

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