Bronchial Safety After Pulsed Field Ablation for Paroxysmal Atrial Fibrillation

Abstract

Background: Thermal left atrial ablation can cause bronchial damage. Pulsed-field ablation (PFA) is a novel, nonthermal ablation modality for paroxysmal atrial fibrillation. We report on bronchial effects after pulmonary vein isolation using PFA for paroxysmal atrial fibrillation. Methods: A computed tomography scan showing the respiratory tract adjacent to the left atrial was obtained. Oral anticoagulation was interrupted on procedure day. Peri-procedurally, patients received heparin with an activated clotting time goal of >350 seconds. All pulmonary veins were individually isolated with a 13F steerable sheath and a pentaspline PFA catheter using either a straight-tip or J-tip guide wire. The J-tip guide wire patients were added to test the hypothesis that the straight-tip guidewire was associated with bleeding complications. One day afterward, bronchoscopy was performed. Serial hemoglobin levels were measured during 30-day follow-up. Results: In 2 series of 30 patients, PFA was performed, with all pulmonary veins acutely isolated. Clinical course was uneventful, no patient had chest discomfort, coughing, or hemoptysis. All patients underwent uncomplicated bronchoscopy, without thermal lesions or ulcers. In 12 out of 30 (40%) straight-tip guide wire patients, small amounts of old blood without active bleeding were seen in multiple segments. All hemoglobin levels remained clinically stable. At 30-day follow-up, all patients were asymptomatic. Conclusions: Pulmonary vein isolation using PFA for paroxysmal atrial fibrillation does not cause thermal lesions in the bronchial system. Use of a straight-tip, extrastiff guide wire for the over-the-wire PFA catheter can lead to asymptomatic bleeding in the bronchial system without clinical relevance at 30-day follow-up, opposite to use of a J-tip guide wire.

Comparison of pulsed‐field ablation versus very high power short duration‐ablation for pulmonary vein isolation

“…Two tamponades occurred in the PFA group while using the extra stiff guidewire, also reported in the MANIFEST‐PF registry 15 . The possible complications using the extra stiff guidewire have been discussed previously, resulting in abandoning the use of this certain guidewire in PFA procedures 29 …”

“…15 The possible complications using the extra stiff guidewire have been discussed previously, resulting in abandoning the use of this certain guidewire in PFA procedures. 29 After switching to a J-tip guidewire, no further wire-nor devicerelated pericardial tamponades occurred.…”

Safety and Efficacy With Pulsed Field Ablation: Having the Cake and Eating It Too

“…The prospect of improved safety with PFA as part of the invasive management of atrial fibrillation is encouraging, and hype for this new technology is certainly warranted. The work by Füting et al 3 adds to this optimism, and the authors should be congratulated for their efforts. Operators adopting PFA should, however, realize that any tissue is potentially vulnerable under the correct conditions, and, especially early in its introduction, a risk of collateral injury should still be respected in a way similar to how we have learned to respect the current standards of radiofrequency and cryoballoon ablation.…”

“…This proximity and the potential wider field effects of PFA perhaps specifically require pulmonary safety data. Füting et al 3 report a 7% incidence of a brief cough after PFA, and it is likely that this finding motivated the investigators to further evaluate with bronchoscopy and vary their procedural technique.…”

“…The assumption that PFA will decrease complication rates is largely based on preclinical observations, requiring ongoing early patient experience proof. In this issue of Circulation: Arrhythmia and Electrophysiology , Füting et al 3 report their single-center experience of 60 patients who underwent PFA ablation for atrial fibrillation and subsequent bronchoscopy to evaluate for evidence of early macroscopic bronchial injury.…”