A Novel Alternately Energy Source Strategy for Re-Ablation of Patients with Recurrent Atrial Fibrillation—Cryoballoon or Radiofrequency Current Energy Ablation. A Case-Control Study

Background: Atrial fibrillation recurrence after circumferential pulmonary vein (PV) isolation was common. Which ablation technique is better for repeat ablation in patients with recurrent atrial fibrillation (AF) remains unclear. We aimed to investigate long-term efficacy of repeat ablation using a novel alternately energy source sequence for re-ablation of patients with recurrent atrial fibrillation: cryoballoon (CB) re-ablation for patients with a failed radiofrequency (RFC) ablation (RFC-CB redo group); radiofrequency energy re- ablation for patients with a failed cryoballoon ablation (CB-RFC redo group).Method: Recurrent AF patients received a repeat ablation procedure in our hospital were enrolled into the study. Demographic and re-ablation procedural characteristics and outcomes were compared among groups.Results: A total of 156 patients were enrolled into the study, 60 patients (38.5%) were in the CB-RFC-redo group and 96 patients (61.5%) were in the RFC-CB-redo group. Longer duration of AF (69.31±64.69 vs 50.78 ±51.48 months; P=0.039) and longer time from first ablation to re-ablation (54.02 ±38.10 vs 14.2 ±10.5 months; P=0.001) were observed in the RFC-CB-redo group as compared with the CB-RFC redo group. Early recurrence rates of atrial fibrillation following initial ablation were equal among groups (RFC-CB-redo group: 42.7% vs CB-RFC-redo group:48.3% , p=0.515).The number of reconnected PVs was significantly higher in the RFC-CB redo group than the CB-RFC redo group (3.36 ± 0.96 vs 1.50 ± 0.81, p=0.01). During the average follow-up of 10.7 ±2.41 months, significantly less AF recurrence was observed in the CB-RFC redo group (16.7% vs 31.3%, p=0.045). In the multivariate analysis, different energy ablation sequence, AF type and early recurrence after the initial ablation were independent predictors of AF recurrence after re-ablation.Conclusions: Alternate energy source sequence strategy for re-ablation of patients with recurrent atrial fibrillation was safe and moderately effective. However, Large multi-center studies must be warranted to provide conclusive evidence.

671 First-in-man mapping and ablation of ventricular tachycardia using a novel ablation catheter with microelectrodes and thermocouples

Aims Catheter ablation (CA) is an important therapeutic option for patients with recurrent ventricular tachycardia (VT). Recently, a novel contact-force sensing catheter (QDOT, Biosense Webster) allowing radiofrequency ablation in a temperature-controlled fashion, equipped with microelectrodes and thermocouples has been developed and tested in very-high power short duration CA of atrial fibrillation. As of today, this catheter has never been used for VT ablation. To describe the safety and short-term clinical performance of the novel QDOT catheter for the ablation of recurrent VT/electrical storm. Methods and results Case 1: a 43-year-old male patient with prior anterior myocardial infarction (MI), left ventricular (LV) dysfunction with an apical aneurysm, and recurrent VT episodes was admitted to our hospital for CA of VT. The patient underwent high-density electroanatomical mapping of the left ventricle using a multipolar catheter (PentaRay, Biosense Webster), which showed an extensive apical dense scar region, corresponding to the ventricular aneurysm. When the QDOT catheter was advanced in that region, late/fragmented potentials were detected by microelectrodes as well as by conventional electrodes. During the procedure, a sustained VT with right bundle branch block (RBBB)-inferior axis morphology and transition in V2 could be induced. We recorder diastolic fragmented potentials inside the aneurysm, where the novel catheter previously showed late/fragmented potentials; radiofrequency energy delivery with conventional settings (40 W) in that area led to rapid arrhythmia termination (Figure A). At the end of the procedure, VTs were no more inducible. Case 2: a 79-year-old male patient with prior inferior MI, mild LV dysfunction with a 5 cm × 5 cm × 3 cm aneurysm of the basal-mid inferior wall, and two previous CAs for recurrent VT presented to our hospital for electrical storm due to multiple episodes of slow VT (cycle, 470 ms, RBBB morphology, inferior axis, transition in V6), which were refractory to antiarrhythmic drug treatment. We decided to perform redo CA using the QDOT catheter, which revealed long and fragmented low-amplitude diastolic potentials inside the LV aneurysm (Figure B). VT was rapidly terminated by means of radiofrequency energy delivery with usual settings (40 W) in this region, and was no more inducible afterwards. Conclusions The novel ablation catheter showed favourable manoeuverability in the ventricle, while also allowing a precise characterization of the tachycardia circuitry and of the arrhythmogenic myocardial substrate, which was enhanced by the availability of microelectrodes. We believe that this preliminary experience may pave the way for further assessments of this new technology in the so far unexplored ventricular milieu.

Redo accessory pathway ablation in the pediatric population

Background Literature reports 5% of recurrence/failure in paediatric accessory pathway ablations. Our aim was to investigate the reasons underlying this finding and share techniques to obtain long-term success. Methods Thirty-nine paediatric patients referred for a repeat procedure were analysed: characteristics of the pathways and the initial and redo procedures were identified. Results Mean age was 11.9 ± 3.3 years (59% males). Three patients (8%) had multiple accessory pathways. The most frequent location was left lateral (26%). Left sided pathway recurrence was caused mainly by poor contact (60%) and inadequate mapping (40%). For right lateral accessory pathways, poor contact accounted for 70% of failures. For antero-septal and para-Hisian locations, the use of cryoablation and choice of low radiofrequency energy delivery accounted for > 75% of failures. Long-term success strategies included choice of contact force catheters and radiofrequency applications at the ventricular insertion of the pathway and in the aortic coronary cusps. In postero-septal substrates, the main reason accounting for failure was deep or epicardial location of the pathway (37%), solved by using an irrigated tip catheter or applying lesions within the coronary sinus, or applications from both right and left postero-septal areas. Conclusion Acute failure and post-procedure recurrence in paediatric accessory pathway ablations have multiple reasons related to the characteristics of the pathway and the technology available. Accurate understanding of the anatomy, careful mapping and pacing manoeuvers, and incorporation of new technologies contribute to achieve a definitive success in > 98% of procedures.

Radiofrequency Energy-Assisted Wire Atrial Septostomy to Easily Create a Large Atrial Septal Defect

Wire atrial septostomy, a new transcatheter technique, combines 2 atrial septal defects (ASDs) into a large one in a thickened atrial septum. Although the thin-wire-looped atrial septum between ASDs needs to be pulled deeply into a hard catheter to tear the septum, this action might harm the surrounding cardiac structures. We utilized radiofrequency wire energy to facilitate the tearing of the septum, making the procedure easier and safer. This technical article presents the modified procedure in detail; the procedure was performed in a 6-month-old boy with double outlet right ventricle and intact ventricular septum. Mini-abstract This technical article describes modified wire atrial septostomy for thickened atrial septum in detail. Radiofrequency energy facilitated a thin wire-loop in tearing the septum between 2 atrial septal defects to combine the defects into a large one. We believe that this transcatheter procedure is easier and safer than the original one not using a radiofrequency wire energy.

Applications of Helium Plasma in Rejuvenation of the Face and Neck

Energy based devices have been developed for the purposes of tissue contraction and skin tightening. Its application in the face and neck have been explored using lasers, temperature controlled monopolar and bipolar radiofrequency, and ultrasound. The purpose of this chapter is to explore the various applications for the face and neck using Renuvion™, a unique energy driven device based on plasma generated from the combination of helium gas and radiofrequency energy. The advantage of this technology is its ability to offer precise delivery of heat to tissue with minimal thermal spread, in part due to the rapid cooling aided by the helium gas. We will explore the options in which this technology can be incorporated to rejuvenate the face and neck, the patient selection considerations in choosing method of approach, surgical technique, anticipated outcomes, potential concerns and or complications associated with this and expected perioperative care. Applications in the face and neck include: (1) Subdermally in the neck as a stand alone procedure with or without liposuction. (2) Subdermally in a limited incision, non-excisional technique with a concomitant platysmaplasty either with an open approach or percutaneous use of suture suspension for the platysmal muscle. (3) Subdermally in conjunction with an open traditional rhytidectomy involving skin excision. (4) Ablative resurfacing—fractional or pulsed and full continuous modalities (non-FDA cleared at the time of this writing). It is the authors’ experience that with appropriate patient selection this can be a powerful tool that can deliver skin tightening and rhytid reduction not seen by other technologies available.

History of Body Contouring

The evolution of body contouring follows decades of procedures and technologic advances in body shaping. Beginning many decades ago with extensive surgical resections of skin and subcutaneous fat, the evolution was dramatically changed with the introduction of suction assisted lipectomy (liposuction). Further refinement in the technique of liposuction allowed more precise sculpting of the body and, most recently, has evolved to high definition liposuction. Following the introduction of liposuction in the early 1980s, energy based devices were developed to allow non or minimally invasive procedures to sculpt the body. The energy sources include laser energy, radiofrequency energy, ultrasonic energy, and plasma based energy. This evolution has provide the cosmetic surgeon with a variety of options to obtain optimal body contouring in a variety of clinical presentations. The safety and the efficacy of these procedures are the most important considerations in adopting new technology and techniques.

Pulmonary artery radiofrequency ablation in an acute porcine model of pulmonary arterial hypertension

Introduction Pulmonary hemodynamics improvement after pulmonary artery denervation (PADN) was demonstrated in PAH. Questions arise regarding PADN perioperative effectiveness and the accuracy of the target nerves damage. The aim of the study was to evaluate whether PADN decreases pulmonary artery pressure (PAP) in acute thromboxane A2 (U46619)–induced PAH, and damages PA perivascular nerve fibers. Materials and methods 10 male Landrace swine (34.7±5.1 kg). In 6 swine acute reversible target mean PAP of 40 mm Hg was induced with synthetic thromboxane A2 infusion (U46619). Control group: 4 swine with PADN. Hemodynamics was assessed throughout the study, PAH modeling was done before and 20 min after PADN (radiofrequency energy, 40 Watts), followed by pathology and immunohistochemical studies. Results The mean number of RF applications was 17.5±3.6. Pulmonary embolism (PE) was observed after PADN in 3 swine with U46619 infusion, which were excluded. There was no differences in mPAP, PVR and U46619 dosage after PADN in PAH model (12.3±3.5 vs 12.1±1 mm Hg, p=0.2; 150.4±48.7 vs 129.2±64.1 dynes s cm–5; p=0.2; 24.9±3.3 vs 22.4±4.1 mcg; p=0.18; respectively). Similar hemodynamic results were observed in the control group after PADN (mPAP; p=0.3; PVR; p=0.58). S100 expression was evident in the majority of RFA PA species and in some species loss in tyrosine hydroxylase and M1 acetylcholine receptors expression was detected with no hemodynamic correlation. Conclusions PADN using an electrophysiological catheter with unipolar energy does not lead to an acute PA perivascular nerve fibers destruction and detectable mPAP changes in U46619-induced PAH. Delayed nerve damage might be attributable to PADN effects observed in previous studies. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant from the Ministry of Science and Higher Education of the Russian Federation (agreement #075-15-2020-800).

Acute change in parasympathetic cardiac innervation after pulmonary vein isolation by pulse-field and radiofrequency energy

Background In patients with atrial fibrillation (AF), pulmonary vein isolation (PVI) by radiofrequency (RF) energy is associated with a significant change of cardiac autonomic regulations due to collateral ganglionic plexi ablation. Pulse-field (PF) ablation energy presumably spares neural tissue. Purpose We compared the effect of PVI by PF and RF energy on cardiac autonomic function. Methods A study enrolled 23 patients who underwent PVI in general anaesthesia. In 12 patients, a novel lattice-tip catheter and PF energy were used for ablation while 11 patients were ablated using a conventional irrigated-tip catheter and RF energy. The response of the sinus node (SAN) and atrioventricular node (AVN) to extracardiac high-frequency vagal stimulation (ECVS) was tested before and after PVI (via right internal jugular vein; stimulation frequency of 50 Hz; pulse width of 0.05 ms; output of 1 V/kg (<70V); train duration of 5 s). Results At baseline, physiological massive response to ECVS (sinus arrest and/or AV block) was demonstrated in the majority of patients. After PVI, complete loss of autonomic response of the SAN in 11/11 (100%) and 3/12 (25%) patients (p=0.003), and the AVN in 9/11 (82%) and 3/12 (25%) patients (p=0.01) was observed in RF and PF groups, respectively. The figure shows the maximum duration of the pause in sinus rhythm (maximum P-P interval) and AVN block (maximum R-R interval during atrial pacing) induced by ECVS after PVI. Conclusion Cardiac vagal response is preserved in a considerable proportion of AF patients after PF ablation which is in contrast with a significantly stronger effect of RF energy. This may influence the clinical outcome of AF ablation procedures. FUNDunding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Institute for Clinical and Experimental Medicine, Prague