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Current Problems in Cardiology Jun 2024There has been a significant increase in the prevalence of atrial fibrillation (AF) over the past 30 years. Pulmonary vein isolation (PVI) is an effective treatment for... (Review)
Review
There has been a significant increase in the prevalence of atrial fibrillation (AF) over the past 30 years. Pulmonary vein isolation (PVI) is an effective treatment for AF, but research investigations have shown that AF recurrence still occurs in a significant number of patients after ablation. Heart rhythm outcomes following catheter ablation are correlated with numerous clinical factors, and researchers developed predictive models by integrating risk factors to predict the risk of recurrence of atrial fibrillation. The purpose of this article is to outline the risk scores for predicting cardiac rhythm outcomes after PVI and to discuss the modifiable factors that increase the risk of recurrence of AF, with the hope of further improving catheter ablation efficacy through preoperative identification of high-risk populations and postoperative management of modifiable risk factors.
Topics: Atrial Fibrillation; Humans; Catheter Ablation; Risk Factors; Pulmonary Veins; Recurrence; Risk Assessment; Treatment Outcome; Patient Care Team
PubMed: 38518845
DOI: 10.1016/j.cpcardiol.2024.102514 -
Pulmonary Vein Isolation in Persistent Atrial Fibrillation: Not Necessarily Durable, Nor Sufficient.JACC. Clinical Electrophysiology Jun 2024
Topics: Atrial Fibrillation; Humans; Pulmonary Veins; Catheter Ablation; Treatment Outcome; Male; Middle Aged
PubMed: 38925720
DOI: 10.1016/j.jacep.2024.05.013 -
Europace : European Pacing,... Dec 2023Pulsed field ablation (PFA) has emerged as a novel, non-thermal energy source to selectively ablate cardiac tissue. We describe a multicentre experience on pulmonary...
AIMS
Pulsed field ablation (PFA) has emerged as a novel, non-thermal energy source to selectively ablate cardiac tissue. We describe a multicentre experience on pulmonary vein isolation (PVI) via the pentaspline Farapulse™ PFA system vs. thermal-based technologies in a propensity score-matched population of paroxysmal atrial fibrillation (PAF) patients.
METHODS AND RESULTS
Propensity score matching was adopted to compare PVI-only ablation outcomes via the Farawave™ system (Group PFA), cryoballoon (Group CRYO), or focal radiofrequency (Group RF) (PFA:CRYO:RF ratio = 1:2:2). Among 1572 (mean age: 62.4 ± 11.3 years; 42.5% females) PAF patients undergoing first time PVI with either PFA (n = 174), CRYO (n = 655), or RF (n = 743), propensity score matching yielded 174 PFA, 348 CRYO, and 348 RF patients. First-pass isolation was achieved in 98.8% of pulmonary veins (PVs) with PFA, 81.5% with CRYO, and 73.1% with RF (P < 0.001). Procedural and dwell times were significantly shorter with PFA, whereas the availability of a 3D mapping system led to a significant reduction in X-ray exposure with RF. Overall complication rates were 3.4% (n = 6) with PFA, 8.6% (n = 30) with CRYO, and 5.5% (n = 19) with RF (P = 0.052). The 1-year Kaplan-Meier estimated freedom from any atrial tachyarrhythmia was 79.3% with PFA, 74.7% with CRYO, and 72.4% with RF (log-rank P-value: 0.24). Among 145 repeat ablation procedures, PV reconnection rate was 19.1% after PFA, 27.5% after CRYO, and 34.8% after RF (P = 0.01).
CONCLUSION
Pulsed field ablation contributed to significantly shorter procedural times. Follow-up data showed a similar arrhythmia freedom, although a higher rate of PV reconnection was documented in post-CRYO and post-RF redo procedures.
Topics: Female; Humans; Middle Aged; Aged; Male; Atrial Fibrillation; Cryosurgery; Propensity Score; Treatment Outcome; Heart Atria; Pulmonary Veins; Catheter Ablation; Recurrence
PubMed: 38245007
DOI: 10.1093/europace/euae016 -
JACC. Clinical Electrophysiology Nov 2023Pulmonary vein isolation (PVI) is less effective in patients with persistent atrial fibrillation (PsAF). Adjunctive ablation targeting low voltage areas (LVAs) may... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Pulmonary vein isolation (PVI) is less effective in patients with persistent atrial fibrillation (PsAF). Adjunctive ablation targeting low voltage areas (LVAs) may improve arrhythmia outcomes.
OBJECTIVES
This study aims to compare the outcomes of adding posterior wall isolation (PWI) to PVI, vs PVI alone in PsAF patients with posterior wall LVAs.
METHODS
The CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation) study was a multicenter, randomized trial involving PsAF patients randomized 1:1 to either PVI alone or PVI with PWI. Voltage mapping performed during pacing pre-ablation was reviewed offline, with LVA defined as bipolar voltage of <0.5 mV. The primary endpoint was freedom from any documented atrial arrhythmia of >30 seconds off antiarrhythmic medication at 12 months after a single ablation procedure in patients with posterior LVA.
RESULTS
A total of 210 patients (average 64.6 ± 9.2 years,73.3% males, median atrial fibrillation duration 4.5 months [IQR: 2 to 8 months]) underwent multipolar left atrial mapping during coronary sinus pacing with posterior LVA present in 69 (32.9%). Patients with posterior LVA were more likely to have LVA in other atrial regions (91.7% vs 57.1%; P < 0.01), larger left atrial diameter (4.8 cm vs 4.4 cm; P < 0.01), and significantly increased risk of atrial arrhythmia recurrence at 12 months (LVA: 56.5% vs no LVA: 41.4%; HR: 1.51; 95% CI: 1.01-2.27; P = 0.04) compared to no posterior LVA. However, the addition of PWI to PVI did not significantly improve freedom from atrial arrhythmia recurrence over PVI alone (PVI with PWI: 44.8% vs PVI: 41.9%; HR: 0.95; 95% CI: 0.51-1.79; P = 0.95).
CONCLUSIONS
In patients with PsAF undergoing catheter ablation, posterior LVA was associated with a significant increase in atrial arrhythmia recurrence. However, the addition of PWI in those with posterior LVA did not reduce atrial arrhythmia recurrence over PVI alone.
Topics: Male; Humans; Female; Atrial Fibrillation; Treatment Outcome; Heart Atria; Pulmonary Veins; Atrial Appendage; Catheter Ablation
PubMed: 37715741
DOI: 10.1016/j.jacep.2023.08.002 -
Europace : European Pacing,... Feb 2024When it occurs, pulmonary vein (PV) stenosis after atrial fibrillation (AF) ablation is associated with significant morbidity. Even mild-to-moderate PV narrowing may... (Randomized Controlled Trial)
Randomized Controlled Trial
AIMS
When it occurs, pulmonary vein (PV) stenosis after atrial fibrillation (AF) ablation is associated with significant morbidity. Even mild-to-moderate PV narrowing may have long-term implications. Unlike thermal ablation energies, such as radiofrequency (RF) or cryothermy, pulsed field ablation (PFA) is a non-thermal modality associated with less fibrotic proliferation. Herein, we compared the effects of PFA vs. thermal ablation on PV narrowing after AF ablation.
METHODS AND RESULTS
ADVENT was a multi-centre, randomized, single-blind study comparing PFA (pentaspline catheter) with thermal ablation-force-sensing RF or cryoballoon (CB)-to treat drug-refractory paroxysmal AF. Pulmonary vein diameter and aggregate cross-sectional area were obtained by baseline and 3-month imaging. The pre-specified, formally tested, secondary safety endpoint compared a measure of PV narrowing between PFA vs. thermal groups, with superiority defined by posterior probability > 0.975. Among subjects randomized to PFA (n = 305) or thermal ablation (n = 302), 259 PFA and 255 thermal ablation (137 RF and 118 CB) subjects had complete baseline and 3-month PV imaging. No subject had significant (≥70%) PV stenosis. Change in aggregate PV cross-sectional area was less with PFA (-0.9%) than thermal ablation (-12%, posterior probability > 0.999)-primarily driven by the RF sub-cohort (-19.5%) vs. CB sub-cohort (-3.3%). Almost half of all PFA PV diameters did not decrease, but the majority (80%) of RF PVs decreased, regardless of PV anatomic location.
CONCLUSION
In this first randomized comparison of PFA vs. thermal ablation, PFA resulted in less PV narrowing-thereby underscoring the qualitatively differential and favourable impact of PFA on PV tissue.
Topics: Humans; Pulmonary Veins; Constriction, Pathologic; Single-Blind Method; Treatment Outcome; Atrial Fibrillation; Catheter Ablation; Stenosis, Pulmonary Vein
PubMed: 38305503
DOI: 10.1093/europace/euae038 -
Sultan Qaboos University Medical Journal Dec 2023This review provides an update on the morphology of the sinus venosus defect. It was earlier believed that a 'common wall' separated the right pulmonary veins from the... (Review)
Review
This review provides an update on the morphology of the sinus venosus defect. It was earlier believed that a 'common wall' separated the right pulmonary veins from the superior caval vein. In the sinus venosus defects, this wall was absent. Current evidence shows that the superior rim of the oval fossa, rather than forming a second septum or representing a common wall, is an infolding between the walls of the caval veins and the right pulmonary veins. The sinus venosus defect is caused by the anomalous connection of one or more pulmonary veins to a systemic vein. However, the pulmonary vein(s) retain their left atrial connections, leading to a veno-venous bridge that allows interatrial shunting outside the oval fossa. True atrial septal defects are located within the oval fossa or in the anteo-inferior buttress, while sinus venosus defects, ostium defects and coronary sinus defects are morphologically distinct from them.
Topics: Humans; Vena Cava, Superior; Heart Septal Defects, Atrial; Pulmonary Veins; Heart Atria
PubMed: 38161764
DOI: 10.18295/squmj.12.2023.075 -
Journal of Interventional Cardiac... Dec 2023
Topics: Humans; Pulmonary Veins; Atrial Fibrillation; Treatment Outcome; Cryosurgery; Catheter Ablation
PubMed: 37338612
DOI: 10.1007/s10840-023-01592-y -
Europace : European Pacing,... Dec 2023Pulsed field ablation (PFA) is emerging as a non-thermal, tissue-specific technique for pulmonary vein isolation (PVI) in atrial fibrillation therapy. This pre-clinical...
AIMS
Pulsed field ablation (PFA) is emerging as a non-thermal, tissue-specific technique for pulmonary vein isolation (PVI) in atrial fibrillation therapy. This pre-clinical study aims to investigate the feasibility and safety of PVI using a novel PFA system including a nanosecond-scale PFA generator, a novel lotos PFA catheter, and a customized 12 Fr steerable sheath.
METHODS AND RESULTS
A total of 11 Yorkshire swine were included in this study, with 4 in the acute cohort and 7 in the chronic cohort. Under general anaesthesia, transseptal puncture and pulmonary vein (PV) angiography was initially performed. The PFA catheter was navigated to position at the right and left PV antrum after the electroanatomic reconstruction of the left atrium. Biphasic PFA applications were performed on PVs in both the spindle-shaped and the lotos-shaped poses. Pulmonary vein isolation and PFA-associated safety were assessed 30 min after ablation in both cohorts and 30 days later in the chronic cohort. Detailed necropsy and histopathology were performed. Additional intracardiac echocardiography and coronary angiogram were evaluated for safety. All target PVs (n = 20) were successfully isolated on the first attempt. No spasm of coronary artery or microbubble was seen during the procedure. Eleven of 12 PVs (91.6%) remained in isolation at the 30-day invasive study. No evidence of PV stenosis was observed in any targets. However, transient diaphragm capture occurred in 17.6%. Histopathological examinations showed no evidence of collateral injury.
CONCLUSION
This study provides scientific evidence demonstrating the safety and efficacy of the novel PFA catheter and system for single-shot PVI, which shows great potential.
Topics: Humans; Swine; Animals; Pulmonary Veins; Feasibility Studies; Atrial Fibrillation; Catheter Ablation; Catheters; Treatment Outcome
PubMed: 38109928
DOI: 10.1093/europace/euad362 -
Journal of Vascular Surgery. Venous and... Mar 2024
Topics: Humans; Arteriovenous Fistula; Pulmonary Veins; Pulmonary Artery
PubMed: 37972756
DOI: 10.1016/j.jvsv.2023.101717 -
Circulation Journal : Official Journal... Nov 2023Pulsed field ablation (PFA) is a non-thermal energy source with promising safety and efficacy advantages. We aimed to develop a convenient, safe, effective and fast...
BACKGROUND
Pulsed field ablation (PFA) is a non-thermal energy source with promising safety and efficacy advantages. We aimed to develop a convenient, safe, effective and fast method of pulmonary vein isolation (PVI) utilizing a penta-spline PFA catheter via a single femoral vein and a venous closure system.Methods and Results: Consecutive patients (n=50; mean age: 63.6±10.7 years, 38% female) presenting with AF (paroxysmal AF: 56%) underwent first-time PVI via PFA. A single ultrasound-guided femoral vein puncture and a single transseptal puncture were used. After PVI using the penta-spline PFA catheter, extra pulse trains were added to the posterior wall for wide antral circumferential ablation. A venous closure system was used and a Donati suture was performed. The pressure bandage was removed after 1 h. A total of 196 PVs were identified and isolated with PFA only. The mean procedural time was 27.4±6.6 min, and the mean dwelling time was 14.4±5.5 min. Time to ambulation was 3.3±3.1 h. No severe complications occurred. During a mean follow-up of 6.5±2.1 months, 41/50 patients (82%) remained in sinus rhythm.
CONCLUSIONS
The combination of a single venous puncture, single transseptal puncture approach using PFA and vascular closure device resulted in a 100% rate of acute PVI and an extraordinarily fast procedure and time to ambulation. The rate of periprocedural complications was low.
Topics: Humans; Female; Middle Aged; Aged; Male; Pulmonary Veins; Treatment Outcome; Catheter Ablation; Atrial Fibrillation; Catheters
PubMed: 37532529
DOI: 10.1253/circj.CJ-23-0389