Ablation Index-Guided High-Power Radiofrequency Application Shortens the Procedure Time With Similar Outcomes to Conventional Power Application in Atrial Fibrillation Ablation

Background: Although high power, shorter duration (HPSD) ablation and low power, longer duration (LPLD) ablation strategies for atrial fibrillation (AF) are frequently advocated to enhance safety and efficacy, there exists a need for comparative data from large populations. We performed a meta-analysis to compare arrhythmia-free survival, procedure time and complications rates between the two strategies. Methods: We searched the databases of MEDLINE and EMBASE from inception to April 2020. Included studies were case-control studies, cohort studies, or randomized controlled trials that compared patients undergoing HPSD and LPLD strategies for AF ablation and reported either of the following outcomes: freedom from atrial tachyarrhythmia (AT) including AF and atrial flutter, procedure time, or periprocedural complications. Data from each study were combined using the random-effects model to calculate odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI). Results: Ten studies from 2006 to 2020 involving 2,189 patients were included (1,350 patients underwent HPSD strategy and 839 patients underwent LPLD strategy). Both HPSD and LPLD strategies resulted in a similar freedom from AT at 12-month follow-up (OR=1.36, 95% CI:0.91-2.04, p=0.13, Figure 1A). HPSD strategy did result in a significant reduction in total procedure time (WMD=47.34, 95% CI:29.47-65.21, p<0.001, Figure 1B) compared to LPSD. HPSD wasn’t associated with reduction in esophageal ulcer/arterioesophageal fistula (OR=0.35, 95%CI=0.12-1.06, p=0.06) or pericardial effusion/cardiac tamponade (OR=0.96, 95%CI: 0.24-3.79, p=0.95) Conclusions: In this large meta-analysis both LPLD and HPSD are equally effective and safe. Although HPSD is often advocated to reduce esophageal injury, risk was similar between approaches. However, HPSD strategy significantly lowers procedure times.

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Incidence of acute thermal esophageal injury after atrial fibrillation ablation guided by prespecified ablation index

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.14193 ◽

2019 ◽

Vol 30 (11) ◽

pp. 2256-2261 ◽

Cited By ~ 10

Author(s):

Philipp Halbfass ◽

Artur Berkovitz ◽

Borche Pavlov ◽

Kai Sonne ◽

Karin Nentwich ◽

...

Keyword(s):

Atrial Fibrillation ◽

Atrial Fibrillation Ablation ◽

Esophageal Injury ◽

Ablation Index

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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 ◽

10.1093/europace/euaa162.238 ◽

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 < 1 mm (red): 300; 1-2 mm (yellow): 350; 2-3 mm (green): 400; 3-4 mm (blue): 450; > 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

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Predictive Value of Thromboembolic Risk Scores Before an Atrial Fibrillation Ablation Procedure: Time for a Consensus?

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.12137 ◽

2013 ◽

Vol 24 (5) ◽

pp. E8-E8 ◽

Cited By ~ 1

Author(s):

MOISÉS RODRÍGUEZ-MAÑERO ◽

LUIS MARTÍNEZ-SANDE ◽

JOSÉ RAMÓN GONZÁLEZ-JUANATEY

Keyword(s):

Atrial Fibrillation ◽

Predictive Value ◽

Atrial Fibrillation Ablation ◽

Risk Scores ◽

Procedure Time ◽

Ablation Procedure ◽

Thromboembolic Risk

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CATHETER ABLATION FOR ATRIAL FIBRILLATION USING THE ABLATION INDEX-HIGH POWER STRATEGY. Do we have the ideal target?

10.22541/au.161049312.25368016/v1 ◽

2021 ◽

Author(s):

oluwaseun adeola ◽

asad Al Aboud ◽

Travis Richardson ◽

Gregory Michaud

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

High Power ◽

Posterior Wall ◽

Comparable Efficacy ◽

Rf Ablation ◽

Total Procedure Time ◽

Ablation Index ◽

Evaluation Feedback

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF) However AF recurrence after a single ablation procedure is common and often attributed to ineffective lesion delivery during PVI. In this issue of the Journal of Cardiovascular Electrophysiology, Chen et al reported their experience with 122 patients who underwent an ablation index-high power (AI-HP) strategy RF ablation for AF using 50W power, targeting AI values of 550 on the anterior left atrium (LA), 400 on the posterior wall and inter-lesion distance (ILD) 6mm. They achieved 1st pass PVI in 96.7% of cases, mean RF time was 11.5min and total procedure time was only 55.8min. All patients had 72h-Holter monitor and trans-telephonic follow up. They reported 89.4% arrhythmia free survival among patients with paroxysmal AF and 80.4% among patients with persistent AF at 15-month follow up. Sixty (49%) patients had luminal esophageal temperature (LET) >390C out of which 3 (2.5%) had asymptomatic endoscopic esophageal erosions/erythema. Four (3%) patients had clinically apparent steam pops during ablation with no adverse clinical sequela. While AI-HP guided RF ablation may be an attractive strategy for PVI that likely reduces procedure times and probably has comparable efficacy to conventional ablation settings, its safety requires further evaluation. Feedback from the ablated tissue may need to be incorporated into optimized ablation energy parameters to further improve outcomes.

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Cryoballoon Versus High-Power, Short-Duration Radiofrequency Ablation for Pulmonary Vein Isolation in Patients With Paroxysmal Atrial Fibrillation

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.121.010040 ◽

2021 ◽

Vol 14 (9) ◽

Cited By ~ 1

Author(s):

Hui-Nam Pak ◽

Je-Wook Park ◽

Song-Yi Yang ◽

Tae-Hoon Kim ◽

Jae-Sun Uhm ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Rate ◽

Heart Rate Variability ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

High Power ◽

Paroxysmal Atrial Fibrillation ◽

Antiarrhythmic Drugs ◽

Procedure Time

Background: The efficacy of cryoballoon pulmonary vein isolation (Cryo-PVI) is equivalent to that of radiofrequency pulmonary vein isolation in patients with paroxysmal atrial fibrillation (AF). We aimed to compare the efficacy and safety profile of Cryo-PVI and high-power, short-duration (HPSD) radiofrequency catheter ablation (RFCA) in patients with AF. Methods: We prospectively randomized 314 patients with paroxysmal AF (men, 71.3%; 59.9±10.9 years old) to either the Cryo-PVI group (n=156) or HPSD-RFCA group (n=158). Cavotricuspid isthmus ablation and linear ablation from the superior vena cava to the right atrial septum in addition to pulmonary vein isolation were carried out in the majority of patients in the HPSD-RFCA group. The primary end point was AF recurrence after a single procedure; secondary end points were the recurrence pattern, cardioversion rate, follow-up heart rate variability, and response to antiarrhythmic drugs. Results: After a mean follow-up of 9.8±5.1 months, the clinical recurrence rate did not significantly differ between the two groups (log-rank P =0.840). The rate of recurrence as atrial tachycardia ( P >0.999), cardioversion ( P =0.999), and 3-month heart rate variability (high frequency; P =0.506) did not significantly differ. During the final follow-up, sinus rhythm was maintained without antiarrhythmic drugs in 70.5% of the Cryo-PVI group and 73.4% of the HPSD-RFCA group ( P =0.567). No significant difference was found in the major complication rate between the two groups (3.8% versus 0.6%; P =0.066), but total procedure time was significantly shorter in the Cryo-PVI group (78.5±20.2 versus 124.5±37.1 minutes; P <0.001). Conclusions: In patients with paroxysmal AF, the Cryo-PVI is an effective rhythm-control strategy with a shorter procedure time compared with the HPSD-RFCA. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03920917.

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