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Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II

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

Deadline for manuscript submissions: closed (30 July 2024) | Viewed by 14717

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Prof. Dr. Sebastien Knecht

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AZ Sint Jan Ziekenhuis, Brugge, Belgium
Interests: atrial fibrillation; catheter ablation; technology; pulmonary vein isolation
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Dear Colleagues,

Atrial Fibrillation (AF) is the most common cardiac arrhythmia and is responsible for increased stroke risk, heart failure and all-cause mortality. The role of the pulmonary veins in triggering AF is well known; however the mechanisms of AF persistence are still discussed. Catheter ablation of AF has emerged as the most efficacious treatment to maintain sinus rhythm and has to be considered in symptomatic patients, certainly after AF recurrence despite antiarrhythmic medication. Results of catheter ablation have dramatically improved in the last few years, in line with technological evolution and better understanding and judgement of the lesions performed during the procedure. This is particularly the case for Pulmonary Vein Isolation, which remains the gold standard for any AF procedure and which has been shown to be much more efficient and durable than before. This also seems to be the case for ablation outside PV isolation, which is sometimes necessary to potentially improve the outcome of some patients presenting with persistent AF or left sided flutters.

This special issue will discuss the different aspects of AF management, from comprehension of AF mechanisms to expectations from AF ablation.

Prof. Dr. Sebastien Knecht
Guest Editor

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Keywords

atrial Fibrillation
pulmonary Vein Isolation
atrial tachycardia technology
atrial flutter
symptoms of atrial fibrillation

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Published Papers (8 papers)

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Research

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13 pages, 4149 KiB

Open AccessArticle

Safety of the Radiofrequency Balloon for Pulmonary Vein Isolation: A Focus on Lesion Metric Analysis of Posterior Electrodes

by Alexandre Almorad, Alvise Del Monte, Yannick Teumer, Milad El Haddad, Luigi Pannone, Domenico Giovanni Della Rocca, Charles Audiat, María Cespón-Fernández, Sahar Mouram, Robbert Ramak, Ingrid Overeinder, Gezim Bala, Antonio Sorgente, Erwin Ströker, Juan Sieira, Pedro Brugada, Mark La Meir, Carlo de Asmundis and Gian-Battista Chierchia

J. Clin. Med. 2023, 12(19), 6256; https://doi.org/10.3390/jcm12196256 - 28 Sep 2023

Cited by 1 | Viewed by 1133

Abstract

Previous clinical studies on pulmonary vein isolation (PVI) with radiofrequency balloons (RFB) reported safe and effective procedures for a 20 s RF delivery via posterior electrodes. Recent recommendations from the manufacturer suggest reducing the application time to 15 s on the posterior wall (PW) when facing the esophagus region. Here, we retrospectively assess whether 15 s of RF delivery time on posterior electrodes is safe while still ensuring lesion metrics of sufficient quality. This retrospective study included 133 patients with paroxysmal and persistent atrial fibrillation who underwent PVI using an RFB (Heliostar, Biosense Webster, Inc., Irvine, CA, USA) at two European centers. The ablation protocol was set for an RF duration of 20 s/60 s for the posterior/anterior electrodes. A multielectrode temperature probe was systematically used. In the case of an esophageal temperature rise (ETR) above 42 °C (ETR+), an endoscopic evaluation was performed. All posterior electrode lesion metric dynamics (temperature (T) and impedance (Z)) were collected from the RFB generator and analyzed offline. In total, 2435 posterior electrode applications were analyzed. With an RF delivery of 19.8 (19.7–19.8) s, the median impedance drop was 18.4 (12.2–25.2) Ω, while the temperature rise was 11.1 (7.1–14.9) °C. Accordingly, impedance (84.6 (79.3–90.2) Ω) and temperature plateaus (38 (35.3–41.1) °C) were reached at 13.9 (10.6–16) s and 16.4 (12.6–18.5) s, respectively. Overall, 99.6% and 95.8% of electrodes reached 90% (16.6 Ω) and 95% (17.5 Ω) of their impedance drops within 15 s of RF delivery, while 97.2% and 92.8% achieved 90% (34.2 °C) and 95% (36.1 °C) of their temperature rise to reach the plateaus within 15 s of RF delivery. An ETR >42 °C occurred in 37 (30.1%) patients after 17.7 ± 2.3 s of RF delivery. In the ETR+ group, the impedance drop and temperature rise on the posterior electrodes were higher compared to patients where ETR was <42 °C. Two asymptomatic thermal esophageal injuries were observed. In conclusion, 15 s of RF delivery on the posterior electrodes provides a good balance between safety, with no esophageal temperature rise, and efficacy with high-profile lesion metrics. Full article

(This article belongs to the Special Issue Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II)

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11 pages, 2717 KiB

Open AccessFeature PaperArticle

Subclinical Dysfunction of Left Atrial Compliance after Cryoballoon versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation

by Ewa Pilichowska-Paszkiet, Agnieszka Sikorska, Ilona Kowalik, Krzysztof Smarż, Małgorzata Sikora-Frąc, Jakub Baran, Roman Piotrowski, Tomasz Kryński, Piotr Kułakowski and Beata Zaborska

J. Clin. Med. 2023, 12(15), 4974; https://doi.org/10.3390/jcm12154974 - 28 Jul 2023

Cited by 1 | Viewed by 1192

Abstract

It has been suggested that cryoballoon (CB) ablation for paroxysmal atrial fibrillation (PAF) may lead to more extensive left atrial (LA) injury than radiofrequency (RF) ablation; however, results are conflicting. We sought to address this issue using modern echocardiographic techniques estimating the LA function after successful CB and RF ablation for PAF. A total of 90 patients (66% males, mean age 57 ± 10 years) successfully treated (no AF recurrences confirmed in serial 4–7 day ECG Holter monitoring) with RF (51%) or CB (49%) ablation for PAF were retrospectively studied. Echocardiography with speckle tracking (STE) was performed before and 12 months after the procedure. The peak longitudinal LA strain (LAS) and strain rate (LASR) during the reservoir (r), conduit (cd), and contraction (ct) phases were measured in sinus rhythm. Analysis of covariance was applied to compare changes in the echocardiographic parameters over time with the baseline measurements as covariance and the type of ablation as the factor. The parallelism of the slopes of the covariance was tested. The LA diameter decreased (38.3 ± 4.1 mm vs. 36.8 ± 3.6 mm, p < 0.001) in the whole study group at 12 months after ablation. The LASRr and LASRcd increased (1.1 ± 0.3 s⁻¹ vs. 1.3 ± 0.3 s⁻¹, p < 0.001 and 1.1 ± 0.3 s⁻¹ vs. 1.2 ± 0.3 s⁻¹, p < 0.001, respectively) whereas other LA strain parameters remained unchanged in the whole study group at 12 months after ablation. In the analysis of LA function at 12 months after the procedure regarding the mode of ablation, the worsening of parameters reflecting LA compliance was observed in patients with better pre-served baseline values in the CB ablation subgroup. For baseline LAScd >28%, the difference ΔCB − ΔRF was −7.6 (11.7; −3.4), p < 0.001, and for baseline LAScd >16%, ΔCB − ΔRF was −1.8 (−3.2; −0.4), p = 0.014. The traditional Doppler-derived parameter e′ showed the same trend—for baseline e′ ≥12 cm/s, ΔCB − ΔRF was −1.7 (−2.8; −0.6), p = 0.003. We conclude that worsening of parameters reflecting LA compliance was observed 12 months after CB ablation compared to RF ablation for PAF in patients who underwent a successful procedure and had better-preserved baseline LA function. This might suggest subclinical dysfunction of LA after the CB ablation procedure. The clinical significance of these findings warrants further investigations. Full article

(This article belongs to the Special Issue Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II)

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15 pages, 1610 KiB

Open AccessArticle

CLOSE-Guided Pulmonary Vein Isolation to Treat Persistent Atrial Fibrillation: 1-Year Outcome

by Philippe Taghji, Jean-Claude Deharo, Sana Amraoui and Sok-Sithikun Bun

J. Clin. Med. 2023, 12(14), 4698; https://doi.org/10.3390/jcm12144698 - 15 Jul 2023

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Abstract

Background: CLOSE-guided pulmonary vein isolation (PVI) is based on contiguous and optimized (Ablation Index-guided) radiofrequency lesions. The efficacy of CLOSE-guided PVI in persistent atrial fibrillation (AF) treatment has been poorly evaluated. Methods: In two centers, 50 patients eligible for persistent AF ablation underwent CLOSE-guided PVI (Ablation Index ≥ 450 at the anterior wall, ≥300 at posterior wall, intertag distance ≤ 6 mm). If PVI failed to restore sinus rhythm (SR), electrical cardioversion (ECV) was performed. Atrial substrate modification (ASM) was performed only if PVI and ECV failed to restore SR. Recurrence was defined as any recorded episode of AF, atrial tachycardia (AT) or atrial flutter (AFL) > 30 s on Holter electrocardiographs at 3, 6 and 12 months. Results: From the 50 patients (64 ± 10 years, 14% long-standing persistent AF), SR was restored by ECV in 34 patients (68%) 56 ± 38 days prior to ablation. On the day of ablation, 42 patients (84%) were on class I-III anti-arrhythmic drug therapy (ADT) and the rhythm was AF in 23/50 patients. PVI was achieved in all patients; after PVI, ECV was required in 21 patients and ASM in 1 patient. The mean procedure time, radiofrequency time and fluoroscopy time were 141 ± 33 min, 23 ± 7 min and 7 ± 6 min, respectively. At 12 months, single-procedure freedom from AF/AT/AFL was 80%, with 19 patients (38%) receiving class I-III ADT. Conclusions: In a population of patients with persistent AF monitored with intermittent cardiac rhythm recordings, CLOSE-guided PVI resulted in high single-procedure arrhythmia-free survival at 1 year. Future large-scale studies involving continuous cardiac monitoring are necessary. Full article

(This article belongs to the Special Issue Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II)

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11 pages, 1095 KiB

Open AccessArticle

Cardioselective versus Non-Cardioselective Beta-Blockers and Outcomes in Patients with Atrial Fibrillation and Chronic Obstructive Pulmonary Disease

by Dimitra Vlachopoulou, Charalampos Balomenakis, Anastasios Kartas, Athanasios Samaras, Andreas S. Papazoglou, Dimitrios V. Moysidis, Konstantinos Barmpagiannos, Melina Kyriakou, Anastasios Papanastasiou, Amalia Baroutidou, Ioannis Vouloagkas, Apostolos Tzikas and George Giannakoulas

J. Clin. Med. 2023, 12(9), 3063; https://doi.org/10.3390/jcm12093063 - 23 Apr 2023

Cited by 1 | Viewed by 1757

Abstract

Background: Atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) have been independently associated with increased mortality; however, there is no evidence regarding beta-blocker cardioselectivity and long-term outcomes in patients with AF and concurrent COPD. Methods: This post hoc analysis of the MISOAC-AF randomized trial (NCT02941978) included patients hospitalized with comorbid AF. At discharge, all patients were classified according to the presence of COPD; patients with COPD on beta-blockers were classified according to beta-blocker cardioselectivity. Adjusted hazard ratios (aHRs) were calculated by using multivariable Cox regression models. The primary outcome was all-cause mortality, and the secondary outcomes were cardiovascular mortality and hospitalizations. Results: Of 1103 patients with AF, 145 (13%) had comorbid COPD. Comorbid COPD was associated with an increased risk of all-cause (aHR, 1.33; 95% confidence interval (CI), 1.02 to 1.73) and cardiovascular mortality (aHR 1.47; 95% CI, 1.10 to 1.99), but not with increased risk of hospitalizations (aHR 1.10; 95% CI, 0.82 to 1.48). The use of cardioselective versus non-cardioselective beta-blockers was associated with similar all-cause mortality (aHR 1.10; 95% CI, 0.63 to 1.94), cardiovascular mortality (aHR 1.33; 95% CI, 0.71 to 2.51), and hospitalizations (aHR 1.65; 95% CI 0.80 to 3.38). Conclusions: In recently hospitalized patients with AF, the presence of COPD was independently associated with increased risk of all-cause and cardiovascular mortality. No difference between cardioselective and non-cardioselective beta-blockers, regarding clinical outcomes, was identified. Full article

(This article belongs to the Special Issue Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II)

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Review

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12 pages, 1217 KiB

Open AccessReview

Vein of Marshall Ethanol Infusion for AF Ablation; A Review

by Louisa O’Neill, Benjamin De Becker, Maarten De Smet, Clara Francois, Rene Tavernier, Mattias Duytschaever, Jean-Benoit Le Polain De Waroux and Sebastien Knecht

J. Clin. Med. 2024, 13(8), 2438; https://doi.org/10.3390/jcm13082438 - 22 Apr 2024

Cited by 1 | Viewed by 2505

Abstract

The outcomes of persistent atrial fibrillation (AF) ablation are modest with various adjunctive strategies beyond pulmonary vein isolation (PVI) yielding largely disappointing results in randomised controlled trials. Linear ablation is a commonly employed adjunct strategy but is limited by difficulty in achieving durable bidirectional block, particularly at the mitral isthmus. Epicardial connections play a role in AF initiation and perpetuation. The ligament of Marshall has been implicated as a source of AF triggers and is known to harbour sympathetic and parasympathetic nerve fibres that contribute to AF perpetuation. Ethanol infusion into the Vein of Marshall, a remnant of the superior vena cava and key component of the ligament of Marshall, may eliminate these AF triggers and can facilitate the ease of obtaining durable mitral isthmus block. While early trials have demonstrated the potential of Vein of Marshall ‘ethanolisation’ to reduce arrhythmia recurrence after persistent AF ablation, further randomised trials are needed to fully determine the potential long-term outcome benefits afforded by this technique. Full article

(This article belongs to the Special Issue Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II)

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18 pages, 1738 KiB

Open AccessReview

Hybrid Endo-Epicardial Therapies for Advanced Atrial Fibrillation

by Christopher X. Wong, Eric F. Buch, Ramin Beygui and Randall J. Lee

J. Clin. Med. 2024, 13(3), 679; https://doi.org/10.3390/jcm13030679 - 24 Jan 2024

Viewed by 1721

Abstract

Atrial fibrillation (AF) is a growing health problem that increases morbidity and mortality, and in most patients progresses to more advanced diseases over time. Recent research has examined the underlying mechanisms, risk factors, and progression of AF, leading to updated AF disease classification schemes. Although endocardial catheter ablation is effective for early-stage paroxysmal AF, it consistently achieves suboptimal outcomes in patients with advanced AF. Identification of the factors that lead to the increased risk of treatment failure in advanced AF has spurred the development and adoption of hybrid ablation therapies and collaborative heart care teams that result in higher long-term arrhythmia-free survival. Patients with non-paroxysmal AF, atrial remodeling, comorbidities, or AF otherwise deemed difficult to treat may find hybrid treatment to be the most effective option. Future research of hybrid therapies in advanced AF patient populations, including those with dual diagnoses, may provide further evidence establishing the safety and efficacy of hybrid endo-epicardial ablation as a first line treatment. Full article

(This article belongs to the Special Issue Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II)

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13 pages, 288 KiB

Open AccessFeature PaperReview

Atrial Fibrillation Ablation: Current Practice and Future Perspectives

by Laura Rottner and Andreas Metzner

J. Clin. Med. 2023, 12(24), 7556; https://doi.org/10.3390/jcm12247556 - 7 Dec 2023

Cited by 2 | Viewed by 2401

Abstract

Catheter ablation to perform pulmonary vein isolation (PVI) is established as a mainstay in rhythm control of atrial fibrillation (AF). The aim of this review is to provide an overview of current practice and future perspectives in AF ablation. The main clinical benefit of AF ablation is the reduction of arrhythmia-related symptoms and improvement of quality of life. Catheter ablation of AF is recommended, in general, as a second-line therapy for patients with symptomatic paroxysmal or persistent AF, who have failed or are intolerant to pharmacological therapy. In selected patients with heart failure and reduced left-ventricular fraction, catheter ablation was proven to reduce all-cause mortality. Also, optimal management of comorbidities can reduce AF recurrence after AF ablation; therefore, multimodal risk assessment and therapy are mandatory. To date, the primary ablation tool in widespread use is still single-tip catheter radiofrequency (RF) based ablation. Additionally, balloon-based pulmonary vein isolation (PVI) has gained prominence, especially due to its user-friendly nature and established safety and efficacy profile. So far, the cryoballoon (CB) is the most studied single-shot device. CB-based PVI is characterized by high efficiency, convincing success rates, and a beneficial safety profile. Recently, CB-PVI as a first-line therapy for AF was shown to be superior to pharmacological treatment in terms of efficacy and was shown to reduce progression from paroxysmal to persistent AF. In this context, CB-based PVI gains more and more importance as a first-line treatment choice. Non-thermal energy sources, namely pulsed-field ablation (PFA), have garnered attention due to their cardioselectivity. Although initially applied via a basket-like ablation tool, recent developments allow for point-by-point ablation, particularly with the advent of a novel lattice tip catheter. Full article

(This article belongs to the Special Issue Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II)

Other

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14 pages, 1814 KiB

Open AccessSystematic Review

Three Ablation Techniques for Atrial Fibrillation during Concomitant Cardiac Surgery: A Systematic Review and Network Meta-Analysis

by Dudy Arman Hanafy, Wahyu Prima Erdianto, Theresia Feline Husen, Ilona Nathania, Ananda Pipphali Vidya, Ruth Angelica, Widya Trianita Suwatri, Pasati Lintangella, Priscillia Prasetyo and Sugisman

J. Clin. Med. 2023, 12(17), 5716; https://doi.org/10.3390/jcm12175716 - 1 Sep 2023

Viewed by 1666

Abstract

Atrial fibrillation (AF) ablation is a frequent procedure used in concomitant cardiac surgery. However, uncertainty still exists concerning the optimal extent of lesion sets. Hence, the objective of this study was to assess the results of various ablation techniques, aiming to offer a reference for clinical decision making. This review is listed in the prospective register of systematic reviews (PROSPERO) under ID CRD42023412785. A comprehensive search was conducted across eight databases (Scopus, Google Scholar, EBSCOHost, PubMed, Medline, Wiley, ProQuest, and Embase) up to 18 April 2023. Studies were critically appraised using the Cochrane Risk of Bias 2.0 for randomized control trials (RCTs) and the Newcastle Ottawa Scale adapted by the Agency for Healthcare Research and Quality (AHRQ) for cohort studies. Forest plots of pooled effect estimates and surface under the cumulative ranking (SUCRA) were used for the analysis. Our analysis included 39 studies and a total of 7207 patients. Both bi-atrial ablation (BAA) and left atrial ablation (LAA) showed similar efficacy in restoring sinus rhythm (SR; BAA (77.9%) > LAA (76.2%) > pulmonary vein isolation (PVI; 66.5%); LAA: OR = 1.08 (CI 0.94–1.23); PVI: OR = 1.36 (CI 1.08–1.70)). However, BAA had higher pacemaker implantation (LAA: OR = 0.51 (CI 0.37–0.71); PVI: OR = 0.52 (CI 0.31–0.86)) and reoperation rates (LAA: OR = 0.71 (CI 0.28–1.45); PVI: OR = 0.31 (CI 0.1–0.64)). PVI had the lowest efficacy in restoring SR and a similar complication rate to LAA, but had the shortest procedure time (Cross-clamp (Xc): PVI (93.38) > LAA (37.36) > BAA (13.89)); Cardiopulmonary bypass (CPB): PVI (93.93) > LAA (56.04) > BAA (0.03)). We suggest that LAA is the best surgical technique for AF ablation due to its comparable effectiveness in restoring SR, its lower rate of pacemaker requirement, and its lower reoperation rate compared to BAA. Furthermore, LAA ranks as the second-fastest procedure after PVI, with a similar CPB time. Full article

(This article belongs to the Special Issue Current Practice and Future Perspectives in Ablation of Atrial Fibrillation—Volume II)

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