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Recent Advances in Catheter Ablation of Arrhythmias

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (25 February 2023) | Viewed by 12629

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Dr. Sergio Conti

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Department of Electrophysiology, ARNAS Ospedali Civico Di Cristina Benfratelli, Palermo, Italy
Interests: atrial fibrillation; atrial fibrillation ablation; catheter ablation; ablation technologies; mapping
Special Issues, Collections and Topics in MDPI journals

Dr. Thomas Fink

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Guest Editor

Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bochum, Germany
Interests: catheter ablation; atrial fibrillation ablation; LAA isolation; interventional LAA closure

Special Issue Information

Dear Colleagues,

Atrial fibrillation (AF) is the most common arrhythmia associated with a relevant risk of stroke, heart failure, and mortality. In recent decades, several studies have focused on the mechanisms of AF, treatment strategies, and new techniques and technologies. Following the seminal work of Haissaguerre led to the development of pulmonary vein isolation (PVI), aiming at the electrical disconnection of the pulmonary veins (PVs), catheter ablation is now a well-established treatment for patients with symptomatic, drug-refractory AF. PVI is the cornerstone of any AF ablation procedures, irrespective of the AF type. However, ablation of persistent and long-standing persistent AF is a more complex procedure. Especially in these cases, PVs are not the only source, and non-PV triggers may arise from any part of the atria and atria–vein connection, such as the coronary sinus (CS), posterior wall (PW), left atrial appendage (LAA), and superior vena cava (SVC). These structures may also serve as substrates to maintain AF episodes after they initiate. Given this, it is recommended by the consensus statements that substrate modification should be considered on top of PVI in the ablation of persistent AF. However, there is no univocal consensus on the ablation strategy to be adopted. This Issue mainly focuses on current mapping and ablation techniques for persistent atrial fibrillation, procedural endpoints and outcomes, procedural complications, and prevention strategies.

Dr. Sergio Conti
Dr. Thomas Fink
Guest Editors

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Keywords

atrial fibrillation mechanisms
persistent atrial fibrillation
atrial fibrillation ablation
mapping
new technologies

Published Papers (8 papers)

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Research

11 pages, 6837 KiB

Open AccessArticle

High-Power Short-Duration Lesion Index-Guided Posterior Wall Isolation beyond Pulmonary Vein Isolation for Persistent Atrial Fibrillation

by Sergio Conti, Francesco Sabatino, Fabrizio Fortunato, Giuliano Ferrara, Antonio Cascino and Giuseppe Sgarito

J. Clin. Med. 2023, 12(16), 5228; https://doi.org/10.3390/jcm12165228 - 11 Aug 2023

Cited by 1 | Viewed by 810

Abstract

Background: High-power short-duration (HPSD) radiofrequency (RF) ablation has been adopted to improve atrial fibrillation (AF) ablation. Although the role of HPSD is well-established in pulmonary vein isolation (PVI), fewer data have assessed the impact of HPSD when addressing extra-pulmonary veins (PVs) targets. Therefore, this study aims to determine the safety, effectiveness, and acute outcomes of HPSD lesion index (LSI)-guided posterior wall isolation (PWI) in addition to PVI as an initial strategy in persistent atrial fibrillation (Pe-AF). Methods: Consecutive patients who underwent ablation of Pe-AF in our center between August 2021 and January 2022 were retrospectively enrolled. All patients’ ablation strategy was PVI plus PWI using HPSD LSI-guided isolation. RF parameters included 50 W targeting LSI values of ≥5 on the anterior part of the PVs and anterior roofline and ≥4 for the posterior PVs aspect, bottom line, and within the posterior wall (PW). We compared the LSI values with and without acute conduction gaps after the initial first-pass PWI. Left atrial mapping was performed with the EnSite X mapping system and a high-density multipolar Grid-shaped mapping catheter. We compared the procedural characteristics using HPSD (n = 35) vs. a control group (n = 46). Results: Thirty-five consecutive patients were included in the study. PWI on top of PVI was achieved in all cases in the HPSD group. First-pass PVI was achieved in 93.3% of PVs (n = 126/135). First-pass roofline block was obtained in most patients (n = 31, 88.5%), while first-pass block of the bottom line was only achieved in 51.4% (n = 18). There were no significant differences compared to the control group; first-pass PVI was achieved in 94.9% of PVs (n = 169/178), first-pass roofline block in 89.1%, and bottom-line in 45.6% of patients. To achieve complete PWI with HPSD, scattered RF applications within the PW were necessary. No electrical reconnection of the PW was found after adenosine administration and the waiting period. The procedure and RF times were significantly shorter in the HPSD group compared to the control group, with values of 116.2 ± 10.9 vs. 144.5 ± 11.3 min, and 19.8 ± 3.6 vs. 26.3 ± 6.4 min, respectively, p < 0.001. Fluoroscopy time was comparable between both groups. No procedural complications were observed. At the 12-month follow-up, 71.4% of patients remained free from AF, with no differences between the groups. Conclusions: HPSD LSI-guided PWI on top of PVI seems effective and safe. Compared to a control group, HPSD is associated with similar rates of first-pass PWI and PVI but with a shorter procedural and RF time. Full article

(This article belongs to the Special Issue Recent Advances in Catheter Ablation of Arrhythmias)

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12 pages, 1884 KiB

Open AccessArticle

Efficacy and Safety Ablation Index-Guided High-Energy Linear Ablation for Persistent Atrial Fibrillation: PVI Plus Linear Ablation of Mitral Isthmus and Posterior Box Isolation

by Xi Li, Tao Liu, Bo Cui, Jinlin Zhang, Yanhong Chen and Gang Wu

J. Clin. Med. 2023, 12(2), 619; https://doi.org/10.3390/jcm12020619 - 12 Jan 2023

Viewed by 1676

Abstract

Background: For patients with persistent atrial fibrillation (AF), whether linear ablation should be performed remains controversial, and the efficacy and safety for ablation index (AI)-guided high-energy linear ablation of mitral isthmus (MI) and left atrial (LA) posterior box isolation is still unclear. The aims of this study were to assess the feasibility and clinical success rate of pulmonary veins isolation (PVI) combined with linear ablation of LA roof and posterior inferior (posterior wall isolation) and MI compare with the PVI-alone method in patients of persistent AF. Methods and results: 362 consecutive persistent AF patients were enrolled from two electrophysiology centers. A total of 200 cases were in PVI-plus group and 162 cases were in PVI-alone group. The PVI-alone group received wide circumferential isolation of both ipsilateral pulmonary veins. PVI combined with linear ablation of left atrial posterior wall isolation (LAPWI)and MI were performed in the PVI-plus group. The primary study end point was the first recurrence of an atrial arrhythmia. After 24 months, freedom from the primary endpoint was achieved in 73.5% of the patients in the PVI-plus group and 62.5% in the PVI-alone group (hazard ratio = 0.62, 95% confidence interval: 0.43–0.91, log rank p = 0.012). The procedure-related complication rates were 2.5% in PVI-plus group and 1.9% in PVI-alone group (p = 0.808). Conclusion: In this study, the ablation strategy of ablation (PVI plus linear ablation of mitral isthmus and posterior box isolation) was feasible and safe for persistent AF patients. Compared with the PVI-alone method, it improved outcomes in patients with persistent AF. Full article

(This article belongs to the Special Issue Recent Advances in Catheter Ablation of Arrhythmias)

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9 pages, 677 KiB

Open AccessArticle

Safety and Feasibility of Catheter Ablation Procedures in Patients with Bleeding Disorders

by Marcel Feher, Ardan M. Saguner, Bettina Kirstein, Julia Vogler, Charlotte Eitel, Huong-Lan Phan, Ahmad Keelani, Tolga Cimen, Sascha Hatahet, Darko Trajanoski, Omar Samara, Karl-Heinz Kuck, Roland R. Tilz and Christian-H. Heeger

J. Clin. Med. 2022, 11(23), 6956; https://doi.org/10.3390/jcm11236956 - 25 Nov 2022

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Abstract

Aims/Objectives: Patients with bleeding disorders are a rare and complex population in catheter ablation (CA) procedures. The most common types of bleeding disorders are von Willebrand disease (VWD) and hemophilia A (HA). Patients with VWD or HA tend to have a higher risk of bleeding complications compared to other patients. There is a lack of data concerning peri- and postinterventional coagulation treatment. We sought to assess the optimal management of patients with VWD and HA referred for catheter ablation procedures. Methods and Results: In this study, we analyzed patients with VWD or HA undergoing CA procedures at two centers in Germany and Switzerland between 2016 and 2021. Clotting factors were administered in conjunction with hemostaseological recommendations. CA was performed as per the institutional standard. During the procedure, unfractionated heparin (UFH) was given intravenously with respect to the activated clotting time (ACT). Primary endpoints included the feasibility of the procedure, bleeding complications, and thromboembolic events during the procedure. Secondary endpoints included bleeding complications and thromboembolic events up to one year after catheter ablation. A total of seven patients (three VWD Type I, one VWD Type IIa, three HA) underwent 10 catheter ablation procedures (pulmonary vein isolation (PVI): two × radiofrequency (RF), one × laser balloon (LB), one × cryoballoon (CB); PVI + cavotricuspid isthmus (CTI): one × RF; PVI + left atrial appendage isolation (LAAI): one × RF; Premature ventricular contraction (PVC): three × RF; Atrioventricular nodal reentrant tachycardia (AVNRT): one × RF). VWD patients received 2000–3000 IE Wilate i.v. 30 to 45 min prior to ablation. Patients with HA received 2000–3000 IE factor VIII before the procedure. All patients undergoing PVI received UFH (cumulative dose 9000–18,000 IE) with a target ACT of >300 s. All patients after PVI were started on oral anticoagulation (OAC) 12 h after ablation. Two patients received aspirin (acetylsalicylic acid; ASA) for 4 weeks after the ablation of left-sided PVCs. No anticoagulation was prescribed after slow pathway modulation in a case with AVNRT. No bleeding complications or thromboembolic events were reported. During a follow-up of one year, one case of gastrointestinal bleeding occurred following OAC withdrawal after LAA occlusion. Conclusions: After the substitution of clotting factors, catheter ablation in patients with VWD and HA seems to be safe and feasible. Full article

(This article belongs to the Special Issue Recent Advances in Catheter Ablation of Arrhythmias)

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14 pages, 1390 KiB

Open AccessArticle

Radiofrequency Pulmonary Vein Isolation without Esophageal Temperature Monitoring: Contact-Force Characteristics and Incidence of Esophageal Thermal Damage

by Stefan Hartl, Carsten auf der Heiden, Alexandru Bejinariu, Lukas Clasen, Anna Füting, Stephan vom Dahl, Tom Lüdde, Malte Kelm and Hisaki Makimoto

J. Clin. Med. 2022, 11(23), 6917; https://doi.org/10.3390/jcm11236917 - 23 Nov 2022

Cited by 1 | Viewed by 1146

Abstract

Esophageal thermal lesions following pulmonary vein isolation (PVI) for atrial fibrillation (AF) potentially harbor lethal complications. Radiofrequency (RF)-PVI using contact force-technology can reduce collateral damage. We evaluated the incidence of endoscopically detected esophageal lesions (EDEL) and the contribution of contact force to esophageal lesion formation without esophageal temperature monitoring. One hundred and thirty-one AF patients underwent contact force-guided RF-PVI. Contact force, energy, force-time-integral, and force-power-time-integral were adopted. During PVI at the posterior segment of the wide antral circumferential line, limits were set for energy (30 W), duration (30 s) and contact force (40 g). Ablations were analyzed postero-superior and -inferior around PVs. Endoscopy within 120 h identified EDEL in six patients (4.6%). In EDEL(+), obesity was less frequent (17% vs. 68%, p = 0.018), creatinine was higher (1.55 ± 1.18 vs. 1.07 ± 0.42 mg/dL, p = 0.016), and exclusively at the left postero-inferior site, force-time-integral and force-power-time-integral were greater (2973 ± 3267 vs. 1757 ± 1262 g·s, p = 0.042 and 83,547 ± 105,940 vs. 43,556 ± 35,255 g·J, p = 0.022, respectively) as compared to EDEL(−) patients. No major complications occurred. At 12 months, arrhythmia-free survival was 74%. The incidence of EDEL was low after contact force-guided RF-PVI. Implementing combined contact force-indices on the postero-inferior site of left-sided PVs may reduce EDEL. Full article

(This article belongs to the Special Issue Recent Advances in Catheter Ablation of Arrhythmias)

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11 pages, 797 KiB

Open AccessArticle

Ultrasound-Guided Access Reduces Vascular Complications in Patients Undergoing Catheter Ablation for Cardiac Arrhythmias

by Leonie Foerschner, Nico Erhard, Stephan Dorfmeister, Marta Telishevska, Marc Kottmaier, Felix Bourier, Sarah Lengauer, Carsten Lennerz, Fabian Bahlke, Hannah Krafft, Florian Englert, Miruna Popa, Christof Kolb, Gabriele Hessling, Isabel Deisenhofer and Tilko Reents

J. Clin. Med. 2022, 11(22), 6766; https://doi.org/10.3390/jcm11226766 - 15 Nov 2022

Cited by 7 | Viewed by 1883

Abstract

Background: Femoral vascular access using the standard anatomic landmark-guided method is often limited by peripheral artery disease and obesity. We investigated the effect of ultrasound-guided vascular puncture (UGVP) on the rate of vascular complications in patients undergoing catheter ablation for atrial or ventricular arrhythmias. Methods: The data of 479 patients (59% male, mean age 68 years ± 11 years) undergoing catheter ablation for left atrial (n = 426; 89%), right atrial (n = 28; 6%) or ventricular arrhythmias (n = 28; 6%) were analyzed. All patients were on uninterrupted oral anticoagulants and heparin was administered intravenously during the procedure. Femoral access complications were compared between patients undergoing UGVP (n = 320; 67%) and patients undergoing a conventional approach (n = 159; 33%). Complication rates were also compared between patients with a BMI of >30 kg/m² (n = 136) and patients with a BMI < 30 kg/m² (n = 343). Results: Total vascular access complications including mild hematomas were n = 37 (7.7%). In the conventional group n = 17 (10.7%) and in the ultrasound (US) group n = 20 (6.3%) total vascular access complications occurred (OR 0.557, 95% CI 0.283–1.096). UGVP significantly reduced the risk of hematoma > 5 cm (OR 0.382, 95% CI 0.148, 0.988) or pseudoaneurysm (OR 0.160, 95% CI 0.032, 0.804). There was no significant difference between the groups regarding retroperitoneal hematomas or AV fistulas (p > 0.05). In patients with BMI > 30 kg/m², UGVP led to a highly relevant reduction in the risk of total vascular access complications (OR 0.138, 95% CI 0.027, 0.659), hematomas > 5 cm (OR 0.051, 95% CI 0.000, 0.466) and pseudoaneurysms (OR 0.051, 95% CI 0.000, 0.466). Conclusion: UGVP significantly reduces vascular access complications. Patients with a BMI > 30 kg/m² seem to particularly profit from a UGVP approach. Full article

(This article belongs to the Special Issue Recent Advances in Catheter Ablation of Arrhythmias)

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10 pages, 1699 KiB

Open AccessArticle

An Evaluation of Phase Analysis to Interpret Atrial Activation Patterns during Persistent Atrial Fibrillation for Targeted Ablation

by Seungyup Lee, Celeen M. Khrestian, Jayakumar Sahadevan and Albert L. Waldo

J. Clin. Med. 2022, 11(19), 5807; https://doi.org/10.3390/jcm11195807 - 30 Sep 2022

Viewed by 1254

Abstract

Background: Phase analysis has been used to identify and localize atrial fibrillation (AF) sources for targeted ablation. We previously demonstrated that repetitive wannabe reentry (incomplete reentry) often generated an apparent stable rotor using phase analysis. The misinterpretation caused by phase analysis using atrial electrograms (AEGs) may result from detecting inaccurate time points at phase inversion (π to −π) in the instantaneous phase waveform converted from AEG. The purpose of this study was to evaluate the accuracy of phase analysis to detect atrial activations recorded from the high-density mapping of AF in patients with persistent and long-standing persistent (LSP) AF. Methods and Results: During open heart surgery, we recorded activation from both atria simultaneously using 512 electrodes in 7 patients with persistent and LSP AF. The phase analysis was compared to manual measurements during 4 s of data. For the accuracy of activation sequence maps, a successful recording site was defined as having ≤4 mismatched activation times during the 4 s. In all AF episodes, the accuracy of the phase analysis was only 82% of the total number of activation times due to either activation time differences (14.7%), under-sensing (2.7%), or over-sensing (0.6%). Only 67.9% of the total recording sites met the requirement of a successful recording site by phase analysis. In unsuccessful recording sites, AEG characteristics were relatively irregular cycle length (CL), complex AEG, and double potential AEG. Conclusion: The phase analysis was less accurate in recording sites with a relatively irregular CL, complex AEG, or double potential AEG. As a result, phase analysis may lead to the misinterpretation of atrial activation patterns during AF. A visual review of the original AEG is needed to confirm the detected AF sources of phase analysis before performing targeted ablation. Full article

(This article belongs to the Special Issue Recent Advances in Catheter Ablation of Arrhythmias)

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15 pages, 2570 KiB

Open AccessArticle

Particularities of Catheter Ablation in Women with Atrial Fibrillation and Associated Ischemic Heart Disease

by Diana Andrada Irimie, Adela Viviana Sitar-Tăut, Bogdan Caloian, Florina Frîngu, Gabriel Cismaru, Radu Roşu, Mihai Puiu, Ioan Alexandru Minciună, Gelu Simu, Dumitru Zdrenghea and Dana Pop

J. Clin. Med. 2022, 11(19), 5568; https://doi.org/10.3390/jcm11195568 - 22 Sep 2022

Cited by 1 | Viewed by 871

Abstract

Background: Atrial fibrillation is more common in men, but in the presence of ischemic heart disease, this arrhythmia is more frequent in women. However, like in coronary heart disease, women with atrial fibrillation are suboptimally treated. Methods: To identify particularities of ablation, in women with atrial fibrillation and ischemic heart disease. Results: 29 women and 26 men, with documented ischemic heart disease and atrial fibrillation, who underwent catheter ablation, were admitted in the study. No significant differences were registered regarding the heart rate control treatment. Electrical cardioversion was significantly higher in men, while pharmacological cardioversion was predominantly recommended in women. The ablation was performed later in women, after 2.55 ± 1.84 years versus 1.80 ± 1.05 in men (p = 0.05). The time elapsed until the ablation was performed was statistically correlated with atypical symptomatology and with the number of antiarrhythmics used prior to the ablation. There were no significant differences for the relapse of atrial fibrillation at 3 months. Quality of life at 3 months after ablation was increased in both groups. Conclusion: Catheter ablation is performed much later in women, and the causes responsible for this delay would be more atypical symptoms and a greater number of antiarrhythmics tried before the ablation. Full article

(This article belongs to the Special Issue Recent Advances in Catheter Ablation of Arrhythmias)

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11 pages, 1789 KiB

Open AccessArticle

Ablation Index Predicts Successful Ablation of Focal Atrial Tachycardia: Results of a Multicenter Study

by Paolo Compagnucci, Antonio Dello Russo, Marco Bergonti, Matteo Anselmino, Giulio Zucchelli, Alessio Gasperetti, Laura Cipolletta, Giovanni Volpato, Ciro Ascione, Federico Ferraris, Yari Valeri, Maria Grazia Bongiorni, Andrea Natale, Claudio Tondo, Gaetano Maria De Ferrari and Michela Casella

J. Clin. Med. 2022, 11(7), 1802; https://doi.org/10.3390/jcm11071802 - 24 Mar 2022

Cited by 5 | Viewed by 2020

Abstract

A radiofrequency energy lesion transmurality marker incorporating power, contact force, and time (Ablation Index, AI) was shown to be associated with outcomes of catheter ablation (CA) of multiple arrhythmias, but was never systematically assessed in the CA of focal atrial tachycardias (AT). We aimed to evaluate the role of AI as a predictor of outcomes in focal AT CA, and therefore, retrospectively included 45 consecutive patients undergoing CA for focal AT in four referral electrophysiology laboratories. Clinical and procedural information were collected. For each patient, maximum and mean (by averaging maximum AI values for each radiofrequency ablation lesion) AI were measured. The primary outcome was focal AT-free survival, and was systematically assessed with periodical Holter monitors or cardiac implantable electronic devices. CA was acutely effective in each case; however, 20% (n = 9) of the study population experienced a focal AT recurrence over a median follow-up of 288 days. Both maximum and mean AI values were significantly higher among patients without AT recurrences (maximum AI = 568 ± 91, mean AI = 426 ± 105) than in patients with AT relapses (maximum AI = 447 ± 142, mean AI = 352 ± 76, p = 0.036, and p = 0.028, respectively). The optimal cutoffs associated with freedom from recurrences were 461 for maximum AI (sensitivity, 0.89; specificity, 0.56) and 301 for mean AI (sensitivity, 0.97; specificity, 0.44). In a time-to-event analysis, maximum AI was significantly associated with survival free from AT recurrence (p = 0.001), whereas mean AI was not (p = 0.08). In summary, maximum AI is the best procedural parameter associated with the outcomes of CA for focal AT, and may help standardize the procedural approach. Full article

(This article belongs to the Special Issue Recent Advances in Catheter Ablation of Arrhythmias)

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