Irreversible electroporation for the treatment of cardiac arrhythmias

Abstract

Cardiac ablation is an established treatment modality for the management of patients with cardiac arrhythmias. Current approaches to cardiac ablation employ thermal based energy to achieve lesions (damage) within the heart. There are many shortcomings and limitations of thermal based approaches. Electroporation (DC energy) is a non-thermal alternative approach to ablation that has shown significant promise in animal studies. Areas covered: An extensive review of the literature on the application of electroporation for ablation (both cardiac and collateral cardiac tissue) was undertaken. This review explores irreversible electroporation as a cardiac ablation modality. Specifically, it focuses and explains the biophysics of electroporation, the limitations of current thermal based approaches and examines the current data published on electroporation cardiac ablation. Expert commentary: Electroporation is a fast-growing novel ablation modality that has many advantages over current thermal based approaches. Current research in animal models shows its can be safely and efficaciously applied to the heart. Although further research is required, electroporation represents an appealing option for the ablation cardiac arrhythmias.

AC Pulsed Field Ablation Is Feasible and Safe in Atrial and Ventricular Settings: A Proof-of-Concept Chronic Animal Study

“…It exploits the localized application of short -nano/microseconds -high-voltage electric fields to induce irreversible electroporation, a prolonged state or pore-induced permeability that triggers non-necrotic deaths (Davalos et al, 2005), in the proximal tissue (Wittkampf et al, 2018;Wojtaszczyk et al, 2018;Sugrue et al, 2019) with high selectivity (Miklavčič, 2018) and without strict need of contact (Ramirez et al, 2020). These characteristics make the method an excellent candidate to avoid thermal collateral damages observed with radiofrequency and cryo-balloon ablation, among which phrenic/vagal nerve injury/palsy, atrio-esophageal fistula, pulmonary vein stenosis and thrombus formation (Sugrue et al, 2018;Wojtaszczyk et al, 2018).…”

Safety and chronic lesion characterization of pulsed field ablation in a Porcine model

“…Another theory is that endocardial tissue in closest contact with the electrodes is exposed to the very highest field strengths, while the tissues beyond the epicardium are exposed to a rapid drop‐off in electric field strength. The drop‐off in field strength further reduces the chances of collateral tissue damage 24,27,43,44 . Further modeling and preclinical studies performed systematically with the same PFA system are warranted to better understand field strength drop‐off, IRE thresholds and the impact on safety.…”

“…Based on cell membrane irreversible electroporation (IRE), pulsed field ablation (PFA) has been identified as a potential alternative to existing ablation technologies 16–23 . PFA delivery is not reliant on uniform electrode‐tissue contact for lesion creation, and can ablate myocardial cells without collateral tissue damage which may enhance the safety profile of this energy source 24–27 . Currently, no preclinical study has evaluated the potential for adverse effects from repeated overlapping energy deliveries on the same targeted local myocardium, nor provided a detailed analysis of the non‐thermal aspect of PFA based on electrode temperature recordings.…”

Highlights from Heart Rhythm 2018: Innovative Techniques

“…[7][8][9][10] It represents an alluring method for cardiac ablation, as it is considered nonthermal and can be tissuespecific and performed quickly. Although there has been significant work completed in animal models [11][12][13][14][15][16][17][18] showing reasonable efficacy and safety with IRE ablation, this is the first inhuman data.…”