High‐power short‐duration ablation: Turn up the heat to cool down the esophagus

Winkle, Roger A.

doi:10.1111/jce.14108

Cited by 7 publications

(8 citation statements)

References 8 publications

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“…Collateral damage of adjacent tissue is a limitation of thermal energy sources for catheter ablation of arrhythmias, leading to rare (<0.05%) life‐threatening complications such as atrioesophageal fistula 19 . New ablation strategies, such as high‐power short‐duration (HPSD) RF ablation cause more local resistive heating and local atrial tissue destruction without conductive heating of more distant tissue that might cause less distant collateral damage 20 . Studies show markedly low esophageal injury after HPSD ablation 21–23 …”

Section: Discussionmentioning

confidence: 99%

Pulsed‐field ablation combined with ultrahigh‐density mapping in patients undergoing catheter ablation for atrial fibrillation: Practical and electrophysiological considerations

Gunawardene

Schaeffer

Jularic

et al. 2022

Cardiovasc electrophysiol

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Background: Pulsed-field ablation (PFA) yields a novel ablation technology for atrial fibrillation (AF). PFA lesions promise to be highly durable, however clinical data on lesion characteristics are still limited.Objective: This study sought to investigate PFA lesion creation with ultrahighdensity (UHDx) mapping.Methods: Consecutive AF patients underwent PFA-based pulmonary vein isolation (PVI) using a multispline catheter (Farwave, Farapulse Inc.). Additional ablation, including left atrial posterior wall isolation (LAPWI) and mitral isthmus ablation (MI) were performed in a subset of persistent AF patients. The extent of PFA-lesions and decrease of LA-voltage were assessed with pre-and post PFA UHDx-mapping (Orion™ catheter and Rhythmia™ 3D-mapping system, Boston Scientific).Results: In 20 patients, acute PVI was achieved in 80/80 PVs, LAPW isolation in 9/9 patients, MI ablation in 2/2 (procedure time: 123 ± 21.6 min, fluoroscopy time: 19.2 ± 5.5 min). UHDx-mapping subsequent to PVI revealed early PV-reconnection in five case (5/80, 6.25%). Gaps were located at the anterior-superior PV ostia and were successfully targeted with additional PFA. Repeat UHDx mapping after PFA revealed a significant decrease of voltage along the PV ostia (1.67 ± 1.36 mV vs. 0.053 ± 0.038 mV, p < .0001) with almost no complex electrogram-fractionation at the lesion border zones. PFA-catheter visualization within the mapping system was feasible in 17/19 (84.9%) patients and adequate in 92.9% of ablation sites. Conclusion:For the first time illustrated by UHDx mapping, PFA creates wide antral circumferential lesions and homogenous LAPW isolation with depression of tissue voltage to a minimum. Although with a low incidence, early PV reconnection can still occur also in the setting of PFA.

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Section: Discussionmentioning

confidence: 99%

Pulsed‐field ablation combined with ultrahigh‐density mapping in patients undergoing catheter ablation for atrial fibrillation: Practical and electrophysiological considerations

Gunawardene

Schaeffer

Jularic

et al. 2022

Cardiovasc electrophysiol

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“…High power (45–50 W) short duration (5–10 s) ablation (in power‐controlled mode), which produces wider and shallower lesions compared to conventional radiofrequency application approaches, appears to have an overall excellent safety profile 50 . Given the LAPW is a thin walled structure, high power short duration ablation may be particularly well suited for effecting shallow but transmural lesions that reduce the risk for esophageal damage 51 …”

Section: Emerging Approaches To Energy Deliver To Improve Safety and Efficacy Of Pwimentioning

confidence: 99%

The role of posterior wall isolation in catheter ablation of persistent atrial fibrillation

Clarke

Piccini

Friedman

2021

Cardiovasc electrophysiol

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The left atrial posterior wall has many embryologic, anatomic, and electrophysiologic characteristics, that are important for the initiation and maintenance of persistent atrial fibrillation. The left atrial posterior wall is a potential target for ablation in patients with persistent atrial fibrillation, a population in whom pulmonary vein isolation alone has resulted in unsatisfactory recurrence rates. Published clinical studies report conflicting results on the safety and efficacy of posterior wall isolation. Emerging technologies including optimized use of radiofrequency ablation, pulse field ablation, and combined endocardial/epicardial ablation may optimize approaches to posterior wall isolation and reduce the risk of injury to nearby structures such as the esophagus. Critical evaluation of future and ongoing clinical studies of posterior wall isolation requires careful scrutiny of many characteristics, including intraprocedural definition of posterior wall isolation, concomitant extrapulmonary vein ablation, and study endpoints.

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“…Atrial arrhythmia recurred less frequently in the HPSD group, probably because HPSD ablation produces more resistive heating, leading to durable lesions (6). In animal studies, lesion sets formed with 50 W-60 W ablations for 5 seconds at 10 g CF were transmural (38).…”

Section: Recurrence Of Atrial Arrhythmiamentioning

confidence: 96%

“…Conversely, high-power short-duration (HPSD) ablation produces a much larger area of resistive heating to create the transmural lesion and a smaller area of conductive heating to alleviate complications associated with posterior wall isolation (PWI) (6). Initial results from HPSD ablation include shorter procedure and ablation times and equivalent safety and efficacy compared with conventional ablation, which has popularized the HPSD approach (7).…”

Section: Introductionmentioning

confidence: 99%

Meta-analysis comparing outcomes of high-power short-duration and low-power long-duration radiofrequency ablation for atrial fibrillation

Khanra¹,

Hamid²,

Deshpande³

et al. 2022

The Anatolian Journal of Cardiology

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Objective: High power short duration (HPSD) ablation strategy is proposed to be more effective than low power long duration (LPLD) for radiofrequency ablation of atrial fibrillation. Although small trials abound, data from a large cohort are lacking. This meta-analysis compares all the existing studies comparing these two approaches to evaluate perceived advantages of one over the other. Methods: A systematic search of PubMed, EMBASE, and Cochrane databases identified studies comparing HPSD to LPLD ablation. All the analyses used the random-effects model. Results: Ablation settings varied widely across 20 studies comprising 2,136 patients who underwent HPSD and 1,753 patients who underwent LPLD. The pooled incidence of atrial arrhythmia recurrence after HPSD ablation was 20% [95% confidence interval (CI): 0.16-0.25; I 2 =88%]. Atrial arrhythmia recurrences were significantly less frequent with HPSD ablation (incidence risk ratio=0.66; 95% CI: 0.49-0.88; I 2 =72%; p=0.004). Procedural, fluoroscopy, and ablation times were significantly shorter with HPSD ablation. First-pass pulmonary vein isolations (PVIs) were significantly more [odds ratio (OR)=2.94; 95% CI: 1.50-5.77; I 2 =89%; p=0.002), and acute pulmonary vein reconnections (PVRs) were significantly lesser (OR=0.41; 95% CI: 0.28-0.62; I 2 =62%; p<0.001) in the HPSD group. Although radiofrequency energy was significantly higher, esophageal thermal injuries (ETI) were lower with HPSD ablation. Acute complications, including steam-pops, were rare and statistically similar in both the groups. Conclusion: HPSD ablation enables faster first-pass PVI with fewer PVRs, similar ETI rates, rare collateral damage, and lower recurrence of atrial arrhythmia in the long term than LPLD. Randomized controlled studies with a larger cohort are indicated both to confirm the benefit of HPSD ablation and standardize the ablation protocol.

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High‐power short‐duration ablation: Turn up the heat to cool down the esophagus

Cited by 7 publications

References 8 publications

Pulsed‐field ablation combined with ultrahigh‐density mapping in patients undergoing catheter ablation for atrial fibrillation: Practical and electrophysiological considerations

Pulsed‐field ablation combined with ultrahigh‐density mapping in patients undergoing catheter ablation for atrial fibrillation: Practical and electrophysiological considerations

The role of posterior wall isolation in catheter ablation of persistent atrial fibrillation

Meta-analysis comparing outcomes of high-power short-duration and low-power long-duration radiofrequency ablation for atrial fibrillation

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