Optimizing Durability in Radiofrequency Ablation of Atrial Fibrillation

Abstract

Radiofrequency ablation (RFA) remains a highly effective therapy in the management of paroxysmal atrial fibrillation (PAF) and is an important therapeutic option in the management of persistent atrial fibrillation (PeAF) when clinically indicated. Lesion size is influenced by many parameters, which include those related to energy application (RFA power, temperature, and time), delivery mechanism (electrode size, orientation, and contact force), and the environment (blood flow and local tissue contact, stability, and local impedance). Successful durable RFA is dependent on achieving lesions that are reliably transmural and contiguous, whilst also avoiding injury to the surrounding structures. This review focuses on the variables that can be adjusted in connection with RFA to achieve long-lasting lesions that enable patients to derive the maximum sustained benefit from pulmonary vein isolation and additional lesion sets if utilized.

Understanding Lesion Creation Biophysics and Improved Lesion Assessment during Radiofrequency Catheter Ablation. The Perfect Combination to Achieve Durable Lesions in Atrial Fibrillation Ablation

“…Advancements in CF, power, energy delivery parameters, catheter stability information (Fig. 2 .8), and the understanding of lesion biophysics have led to the development of ablation indexes (AIs) that can objectively assess lesion creation and durability during RFA [ 56 , 57 ]. Commercially available AIs, such as the Lesion Index (Abbott, Green Oaks, IL, USA) and the CARTO VISITAG™ Module (Biosense Webster, Irvine, CA, USA), integrate stability, CF, time, and power to aid in optimizing lesion formation.…”

“…However, its implementation is currently limited to right-sided procedures, and more data are needed to establish its use in LA ablation or in the left ventricle [ 70 , 71 ]. Challenges include the correlation between T-2 edemas and long-lasting lesions and the time required for LGE to be fully established, in addition to the EP laboratory device and equipment compatibility limitation, which remains a major area of concern [ 57 , 71 ]. Additionally, studies have revealed that utilizing an MRI-guided, fibrosis-targeted ablation with PVI did not significantly improve ablation outcomes.…”

“…Nicotinamide adenine dinucleotide (NADH), used in fluorometric imaging to assess catheter contact and predict lesion effectiveness, has shown promise in animals, although data from clinical studies are still pending [ 57 , 76 ].…”

Comparison of radiofrequency ablation and antiarrhythmic drug for the treatment of atrial fibrillation: A protocol for systematic review and meta-analysis

“…A beneficial effect of radiofrequency ablation (RFA) on quality of life has been suggested by several studies, [11,12] but it is unclear whether the effect of RFA on quality of life is sustained, because long-term follow-up data have been limited. The optimal therapeutic approach for AF is still debated and no randomized controlled trials (RCTs) have been sufficiently powered to address these issues.…”