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European Heart Journal Open May 2024Pulmonary vein isolation (PVI) represents the gold standard in the treatment of atrial fibrillation (AF) and the use of single-shot techniques, such as cryoballoon...
AIMS
Pulmonary vein isolation (PVI) represents the gold standard in the treatment of atrial fibrillation (AF) and the use of single-shot techniques, such as cryoballoon ablation (CBA) and pulsed field ablation (PFA) using a pentaspline catheter, has gained prominence. Recent studies hypothesize that PFA might be superior to CBA, although procedural efficacy and safety data are inconsistent. A meta-analysis was conducted to compare both energy sources for the treatment of AF.
METHODS AND RESULTS
A structured systematic database search and meta-analysis were performed on studies investigating outcomes, periprocedural complications, and/or procedural parameters of AF patients treated by either CBA or PFA. Eleven studies reporting data from 3805 patients were included. Pulmonary vein isolation by PFA was associated with a significantly lower recurrence of atrial fibrillation/atrial tachycardia [odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.54-0.98, I = 20%] and fewer periprocedural complications (OR = 0.62, 95% CI = 0.40-0.96, I = 6%) compared to CBA. The lower complication rate following PFA was mainly driven by fewer phrenic nerve injuries (OR = 0.19, 95% CI = 0.08-0.43, I = 0%). However, there were more cases of cardiac tamponades after PFA (OR = 2.56, 95% CI = 1.01-6.49, I = 0%). Additionally, using PFA for PVI was associated with shorter total procedure times [mean difference (MD) = -9.68, 95% CI = -14.92 to -4.43 min, I = 92%] and lower radiation exposure (MD = -148.07, 95% CI = -276.50 to -19.64 µGy·mI = 7%).
CONCLUSION
Our results suggest that PFA for PVI, compared to CBA, enables shorter procedure times with lower arrhythmia recurrence and a reduced risk of periprocedural complications. Randomized controlled trials need to confirm our findings.
PubMed: 38933428
DOI: 10.1093/ehjopen/oeae044 -
ESC Heart Failure Jun 2024
PubMed: 38923812
DOI: 10.1002/ehf2.14919 -
Journal of Cardiovascular Development... Jun 2024In recent years, the prevalence of and mortality associated with cardiovascular diseases have been rising in most countries and regions. AF is the most common arrhythmic... (Review)
Review
In recent years, the prevalence of and mortality associated with cardiovascular diseases have been rising in most countries and regions. AF is the most common arrhythmic condition, and there are several treatment options for AF. Pulmonary vein isolation is an effective treatment for AF and is the cornerstone of current ablation techniques, which have one major limitation: even when diagnosed and treated at a facility that specializes in ablation, patients have a greater chance of recurrence. Therefore, there is a need to develop better ablation techniques for the treatment of AF. This article first compares the current cryoablation (CBA) and radiofrequency ablation (RFA) techniques for the treatment of AF and discusses the utility and advantages of the development of pulsed-field ablation (PFA) technology. The current research on PFA is summarized from three perspectives, namely, simulation experiments, animal experiments, and clinical studies. The results of different stages of experiments are summarized, especially during animal studies, where pulmonary vein isolation was carried out effectively without causing injury to the phrenic nerve, esophagus, and pulmonary veins, with higher safety and shorter incision times. This paper focuses on a review of various a priori and clinical studies of this new technique for the treatment of AF.
PubMed: 38921675
DOI: 10.3390/jcdd11060175 -
BMC Cardiovascular Disorders Jun 2024Catheter ablation and antiarrhythmic drug therapy are utilized for rhythm control in atrial fibrillation (AF), but their comparative effectiveness, especially with... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Catheter ablation and antiarrhythmic drug therapy are utilized for rhythm control in atrial fibrillation (AF), but their comparative effectiveness, especially with contemporary treatment modalities, remains undefined. We conducted a systematic review and meta-analysis contrasting current ablation techniques against antiarrhythmic medications for AF.
METHODS
We searched PubMed, SCOPUS, Cochrane CENTRAL, and Web of Science until November 2023 for randomized trials comparing AF catheter ablation with antiarrhythmics, against antiarrhythmic drug therapy alone, reporting outcomes for > 6 months. Four investigators extracted data and appraised risk of bias (ROB) with ROB 2 tool. Meta-analyses estimated pooled efficacy and safety outcomes using R software.
RESULTS
Twelve trials (n = 3977) met the inclusion criteria. Catheter ablation was associated with lower AF recurrence (relative risk (RR) = 0.44, 95%CI (0.33, 0.59), P ˂ 0.0001) and hospitalizations (RR = 0.44, 95%CI (0.23, 0.82), P = 0.009) than antiarrhythmic medications. Catheter ablation also improved the physical quality of life component score (assessed by a 36-item Short Form survey) by 7.61 points (95%CI -0.70-15.92, P = 0.07); but, due to high heterogeneity, it was not statistically significant. Ablation was significantly associated with higher procedural-related complications [RR = 15.70, 95%CI (4.53, 54.38), P < 0.0001] and cardiac tamponade [RR = 9.22, 95%CI (2.16, 39.40), P = 0.0027]. All-cause mortality was similar between the two groups.
CONCLUSIONS
For symptomatic AF, upfront catheter ablation reduces arrhythmia and hospitalizations better than continued medical therapy alone, albeit with moderately more adverse events. Careful patient selection and risk-benefit assessment are warranted regarding the timing of ablation.
Topics: Humans; Atrial Fibrillation; Catheter Ablation; Anti-Arrhythmia Agents; Treatment Outcome; Recurrence; Risk Factors; Middle Aged; Female; Male; Heart Rate; Aged; Quality of Life; Time Factors; Risk Assessment; Randomized Controlled Trials as Topic
PubMed: 38918704
DOI: 10.1186/s12872-024-03983-z -
Europace : European Pacing,... Jun 2024Technological advancements have contributed to the enhanced precision and lesion flexibility in pulsed-field ablation (PFA) by integrating a three-dimensional mapping...
AIMS
Technological advancements have contributed to the enhanced precision and lesion flexibility in pulsed-field ablation (PFA) by integrating a three-dimensional mapping system combined with a point-by-point ablation strategy. Data regarding the feasibility of this technology remain limited to some clinical trials. This study aims to elucidate initial real-world data on catheter ablation utilizing a lattice-tip focal PFA/radiofrequency ablation (RFA) catheter in patients with persistent atrial fibrillation (AF).
METHODS AND RESULTS
Consecutive patients who underwent catheter ablation for persistent AF via the lattice-tip PFA/RFA catheter were enrolled. We evaluated acute procedural data including periprocedural data as well as the clinical follow-up within a 90-day blanking period. In total, 28 patients with persistent AF underwent AF ablation either under general anaesthesia (n = 6) or deep sedation (n = 22). In all patients, pulmonary vein isolation was successfully achieved. Additional linear ablations were conducted in 21 patients (78%) with a combination of successful anterior line (n = 13, 46%) and roof line (n = 19, 68%). The median procedural and fluoroscopic times were 97 (interquartile range, IQR: 80-114) min and 8.5 (IQR: 7.2-9.5) min, respectively. A total of 27 patients (96%) were interviewed during the follow-up within the blanking period, and early recurrent AF was documented in four patients (15%) including one case of recurrent AF during the hospital stay. Neither major nor minor procedural complication occurred.
CONCLUSION
In terms of real-world data, our data confirmed AF ablation feasibility utilizing the lattice-tip focal PFA/RFA catheter in patients with persistent AF.
Topics: Humans; Atrial Fibrillation; Male; Catheter Ablation; Female; Middle Aged; Treatment Outcome; Aged; Pulmonary Veins; Equipment Design; Cardiac Catheters; Recurrence; Time Factors
PubMed: 38916275
DOI: 10.1093/europace/euae129 -
European Heart Journal. Case Reports Jun 2024Fluoroscopy-guided catheter ablation has become the gold standard for treatment of cardiac arrhythmias. High resolution electro-anatomical mapping systems have become...
BACKGROUND
Fluoroscopy-guided catheter ablation has become the gold standard for treatment of cardiac arrhythmias. High resolution electro-anatomical mapping systems have become fundamental to perform these procedures. Recently, interventional cardiac magnetic resonance (iCMR) has been proposed as an alternative for fluoroscopy to guide atrial flutter ablations. The clinical experience with iCMR and dedicated three-dimensional mapping systems is growing. NorthStar is currently the first available vendor-neutral mapping system.
CASE SUMMARY
We performed a real-time CMR-guided cavotricuspid isthmus (CTI) catheter ablation (CA) on a 69-year-old man using a novel mapping system (NorthStar Mapping System, Imricor Medical Systems, MN, USA). Starting from the CMR imaging, a pre-rendered segmentation model was loaded on NorthStar and used to guide the catheters, display voltage and activation maps, show mapping and ablation points. NorthStar can also take full control of the CMR scanner (i.e. start/stop sequences for anatomical information, tissue characterization, and catheter visualization) and communicate with the recorder/stimulator system (Advantage-MR EP, Imricor Medical Systems, MN, USA). With comparable procedural time to standard fluoroscopy-guided CA, CTI bidirectional block was achieved, without any complication.
DISCUSSION
Using the NorthStar Mapping System, we managed to achieve a successful CMR-guided CTI ablation without any complication. Its further use should be explored, especially in more complex arrhythmias where a substrate-guided ablation is critical, as it could significantly improve results in terms of arrhythmia recurrence.
PubMed: 38915740
DOI: 10.1093/ehjcr/ytae271 -
Self-sealing atrio-oesophageal fistula as a complication of pulmonary vein isolation: a case report.European Heart Journal. Case Reports Jun 2024Atrio-oesophageal fistulas (AEFs) are an uncommon complication of pulmonary vein ablation, and its diagnosis is challenging. Multidisciplinary interventions and...
BACKGROUND
Atrio-oesophageal fistulas (AEFs) are an uncommon complication of pulmonary vein ablation, and its diagnosis is challenging. Multidisciplinary interventions and diagnostic imaging are usually required and may play a role in the initial assessment.
CASE SUMMARY
A 69-year-old female with atrial fibrillation who had undergone recent pulmonary vein ablation consulted with unspecific symptoms and sudden hemiparesis. Brain imaging showed pneumocephalus and acute infarcts. Chest computed tomography (CT) was highly suspicious for AEF. Surgical exploration revealed a swollen mediastinum attached to the right inferior pulmonary vein.
DISCUSSION
Non-specific symptoms after pulmonary vein ablation should prompt the suspicion of complications. In the presence of fever or neurological deficit, AEF must be suspected and assessed with a contrast-enhanced chest CT, which has become the gold standard. In brain imaging, pneumocephalus and multiple punctate acute infarcts might also indicate the presence of this complication.
PubMed: 38915738
DOI: 10.1093/ehjcr/ytae283 -
Biomolecules & Biomedicine Jun 2024Soluble suppression of tumorigenicity-2 (sST-2), a marker of myocardial fibrosis and remodeling, has been related to the development of atrial fibrillation (AF). The aim... (Meta-Analysis)
Meta-Analysis
Soluble suppression of tumorigenicity-2 (sST-2), a marker of myocardial fibrosis and remodeling, has been related to the development of atrial fibrillation (AF). The aim of this meta-analysis was to evaluate the relationship between baseline serum sST-2 levels and the risk of AF recurrence after ablation. Relevant observational studies were retrieved from PubMed, Web of Science, Embase, Wanfang and China National Knowledge Infrastructure (CNKI). A random-effects model was used to combine the data, accounting for between-study heterogeneity. Fourteen prospective cohorts were included. Pooled results showed higher sST-2 levels before ablation in patients with AF recurrence compared to those without AF recurrence (standardized mean difference = 1.15, 95% confidence interval [CI] = 0.67 to 1.63, P < 0.001; I2 = 92%). Meta-regression analysis suggested that the proportion of patients with paroxysmal AF (PaAF) was positively related to the difference in serum sST-2 levels between patients with and without AF recurrence (coefficient = 0.033, P < 0.001). Subgroup analysis showed a more remarkable difference in serum sST-2 levels between patients with and without AF recurrence in studies where PaAF was ≥ 60% compared to those where it was < 60% (P = 0.007). Further analyses showed that high sST-2 levels before ablation were associated with an increased risk of AF recurrence (odds ratio [OR] per 1 ng/mL increment of sST-2 =1.05, OR for high versus low sST-2 = 1.73, both P values < 0.05). In conclusion, high sST-2 baseline levels may be associated with an increased risk of AF recurrence after catheter ablation.
PubMed: 38912883
DOI: 10.17305/bb.2024.10653 -
Frontiers in Cardiovascular Medicine 2024Cardio-oncology is a new field of interest in cardiology focusing on the detection and treatment of cardiovascular diseases, such as arrhythmias, myocarditis, and heart...
Cardio-oncology is a new field of interest in cardiology focusing on the detection and treatment of cardiovascular diseases, such as arrhythmias, myocarditis, and heart failure, as side-effects of chemotherapy and radiotherapy. The association between chemotherapeutic agents and arrhythmias has previously been established. Atrial tachyarrhythmias, particularly atrial fibrillation, are most common, but ventricular arrhythmias, including those related to treatment-induced QT prolongation, and bradyarrhythmias can also occur. However, the association between chemotherapeutic agents and atrioventricular re-entrant tachycardia (AVRT)/atrioventricular node re-entrant tachycardia (AVNRT) remains poorly understood. Here, we report a patient with new-onset AVRT/AVNRT and lung cancer who underwent chemotherapy. We considered that chemotherapy or cancer itself may have been a trigger for the initiation of paroxysmal AVRT/AVNRT, and that radiofrequency catheter ablation was effective in treating this type of tachycardia. Here, possible mechanisms and potential genes (mostly ion channels) involved in AVRT/AVNRT are summarized and the mechanisms underlying the possible regulatory patterns of cancer cells and chemotherapy on ion channels are reviewed. Finally, we considered that ion channel abnormalities may link cancer or chemotherapy to the onset of AVRT/AVNRT. The aim of the present study was to highlight the association between chemotherapeutic agents and AVRT/AVNRT and to provide new insights for future research. Understanding the intermediate mechanisms between chemotherapeutic agents and AVRT/AVNRT may be beneficial in preventing chemotherapy-evoked AVRT/AVNRT (and/or other arrhythmias) in future.
PubMed: 38911514
DOI: 10.3389/fcvm.2024.1367893 -
Frontiers in Physiology 2024Pulsed Field Ablation (PFA) is a novel non-thermal method for cardiac ablation, relying on irreversible electroporation induced by high-energy pulsed electric fields...
INTRODUCTION
Pulsed Field Ablation (PFA) is a novel non-thermal method for cardiac ablation, relying on irreversible electroporation induced by high-energy pulsed electric fields (PEFs) to create localized lesions in the heart atria. A significant challenge in optimizing PFA treatments is determining the lethal electric field threshold (EFT), which governs ablation volume and varies with PEF waveform parameters. However, the proprietary nature of device developer's waveform characteristics and the lack of standardized nonclinical testing methods have left optimal EFTs for cardiac ablation uncertain.
METHODS
To address this gap, we introduced a laboratory protocol employing human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) in monolayer format to evaluate the impact of a range of clinically relevant biphasic pulse parameters on lethal EFT and adiabatic heating (AH). Cell death areas were assessed using fluorescent dyes and confocal microscopy, while lethal EFTs were quantified through comparison with electric field numerical simulations.
RESULTS AND CONCLUSION
Our study confirmed a strong correlation between cell death in hiPSC-CMs and the number and duration of pulses in each train, with pulse repetition frequency exerting a comparatively weaker influence. Fitting of these results through machine learning algorithms were used to develop an open-source online calculator. By estimating lethal EFT and associated temperature increases for diverse pulse parameter combinations, this tool, once validated, has the potential to significantly reduce reliance on animal models during early-stage device de-risking and performance assessment. This tool also offers a promising avenue for advancing PFA technology for cardiac ablation medical devices to enhance patient outcomes.
PubMed: 38911328
DOI: 10.3389/fphys.2024.1395923