Focal pulsed field ablation and ultrahigh-density mapping — versatile tools for all atrial arrhythmias? Initial procedural experiences

Abstract

Background Focal pulsed field ablation (FPFA) is a novel and promising method of cardiac ablation. The aim of this study was to report the feasibility, short-term safety, and procedural findings for a broad spectrum of ablated atrial arrhythmias. Methods Patients (n = 51) scheduled for ablation of atrial arrhythmias were prospectively included and underwent FPFA using the Galvanize CENTAURI generator with energy delivery through commercially available ablation catheters with ultrahigh-density (UHDx) 3D electroanatomic voltage/local activation time map evaluations. Workflow, procedural data, and peri-procedural technical errors and complications are described. Results Planned ablation strategy was achieved with FPFA-only in 48/51 (94%) of the cases. Ablation strategy was first-time pulmonary vein isolation (PVI) in 17/51 (36%), repeat ablation in 18/51 (38%), PVI + in 13/51 (28%), and cavotricuspid isthmus block (CTI)-only in 3/51 (6%). The mean procedure time was 104 ± 31 min (first-time PVI), 114 ± 26 min (repeat procedure), 152 ± 36 min (PVI +), and 62 ± 17 min (CTI). Mean UHDx mapping time to assess lesion formation and block after ablation was 7 ± 4 min with 5485 ± 4809 points. First pass acute (linear) isolation with bidirectional block for anatomical lesion sets was 120/124 (97%) for all PVs, 17/17 (100%) for (any) isthmus, and 14/17 (82%) for left atrium posterior wall (LAPW). We observed several time-consuming integration errors with the used ablation system (mean 3.4 ± 3.7 errors/procedure), one transient inferior ST elevation when ablating CTI resolved by intravenous nitroglycerine and one transient AV block requiring temporary pacing for > 24 h. Conclusions FPFA was a highly versatile method to treat atrial arrhythmias with high first-pass efficiency. UHDx revealed acute homogenous low-voltage lesions in ablated areas. More data is needed to establish lesion durability and limitations of FPFA.

Focal Pulsed Field Ablation for Atrial Arrhythmias: Efficacy and Safety under Deep Sedation

“…This study evaluated the feasibility, safety, and effectiveness of atrial arrhythmia ablation under deep sedation. Patient characteristics were typical of atrial fibrillation cases [15], similar to other focal pulsed field trials using the CENTAURI system [10,16]. In our study, a significant 80% had previous ablations, and 50% presented with atypical flutter or atrial fibrillation at the onset of the procedure.…”

“…Future studies with extended follow-up will need to verify if this holds true for ablation lesions beyond the PVI. The average procedure time was 122.5 ± 42.85 min, similar to another focal PFA study [10], with slightly extended fluoroscopy time due to complex repeat procedures with additional lesions.…”

“…This system consists of a generator that can be coupled with various ablation catheters and mapping systems. While successful ablation of both atrial [10] and ventricular arrhythmias [11] has been demonstrated using this system, numerous questions remain regarding its optimal use, appropriate sedation strategies, and the determination of reliable ablation endpoints.…”

Focal point-by-point pulsed field ablation for the treatment of atrial arrhythmias in patients with challenging anatomy where radiofrequency ablation cannot be applied: A case series

“…In our case series, we used a conventional 4-mm-tip ablation catheter, through which we delivered F-PFA energy using the focal PFA generator (CENTAURI; Galvanize EP, San Carlos, CA). Initial experience with this system is promising, 15 with steep learning curves and good AF rhythm outcomes. F-PFA ablation allows the creation of lesion sets tailored to the challenging anatomies in our case series, which positions F-PFA as a useful and important tool to manage patients who may not be treatable with thermal radiofrequency ablation and cryoablation strategies.…”

Characterization of durability and reconnection patterns at time of repeat ablation after single-shot pulsed field pulmonary vein isolation

“…ATs were mapped accordingly using local activation time maps and coherence conduction vectors to establish critical isthmuses and circuits with supplementary entrainment mapping if needed, as per clinical standard, and described earlier [ 10 , 16 , 17 ]. Ad-hoc ablation based on the above findings was performed with RFA through steerable sheaths with irrigated SmartTouch surround flow catheters (Biosense Webster) adhering best possible to the CLOSE protocol in terms of interlesion distance and ablation index [ 18 ] or by focal PFA utilizing the Galvanize EP (Galvanize EP) system through SmartTouch catheters (Biosense Webster) as described previously [ 19 ]. Choice of focal PFA, instead of RFA, was based on the availability of general anesthesia.…”