Ostial dimensional changes after pulmonary vein isolation: Pulsed field ablation vs radiofrequency ablation

Abstract

BACKGROUND Pulmonary vein (PV) stenosis is an important potential complication of PV isolation using thermal modalities such as radiofrequency ablation (RFA). Pulsed field ablation (PFA) is an alternative energy that causes nonthermal myocardial cell death.OBJECTIVE The purpose of this study was to compare the effect of PFA vs RFA on the incidence and severity of PV narrowing or stenosis.METHODS Data were analyzed from 4 paroxysmal atrial fibrillation ablation trials using either PFA or RFA; because of absent CT scans or poor computed tomography scan quality, 73 of 153 patients (47.7%) were excluded. Baseline and 3-month cardiac computed tomography scans were reconstructed into 3-dimensional images, and the long and short axes of the PV ostia were quantitatively and qualitatively assessed in a randomized blinded manner by 2 physicians.RESULTS A total of 299 PVs from 80 patients after either PFA (n 5 37) or RFA (n 5 43) were enrolled. PV ostial diameters decreased significantly less with PFA than with RFA (% change; long axis: 0.9% 6 8.5% vs 211.9% 6 16.3%; P , .001 and short axis: 3.4% 6 12.7% vs 212.9% 6 18.5%; P , .001). After a combined quantitative/qualitative analysis, mild (30%-49%), moderate (50%-69%), or severe (70%-100%) PV narrowing was observed, respectively, in 9.0% (15 of 166), 1.8% (3 of 166), and 1.2% (2 of 166) of PVs in the RFA cohort but in none of the PVs after PFA (P , .001). Overall, PV narrowing/stenosis was present in 0% and 0% vs 12.0% and 32.5% of PVs and patients who underwent PFA and RFA, respectively.CONCLUSION This study indicates that unlike after RFA, the incidence and severity of PV narrowing/stenosis after PV isolation is virtually eliminated with PFA.

Does pulsed field ablation regress over time? A quantitative temporal analysis of pulmonary vein isolation

“…Pulsed field ablation (PFA) is a nonthermal energy modality that is unique in having tissue-selective ablative properties. [1][2][3][4][5][6][7] Using a custom PFA generator able to deliver a custom hierarchical pulse sequence, a dedicated PFA catheter was shown to be safe and effective in electrically isolating porcine thoracic vessels-pulmonary veins (PVs) and superior vena cava. Histological analysis demonstrated similar transmurality to radiofrequency ablation, but without the attendant collateral injury.…”

Ablation Modalities for Therapeutic Intervention in Arrhythmia-Related Cardiovascular Disease: Focus on Electroporation

“…It was evident that no PV stenosis arose due to IRE-exposed subjects at 3-month follow-up, while those who underwent RF ablation exhibited stenosis immediately that persisted for the follow-up survival period [ 89 ]. In recent years, the effects of IRE and RF were investigated in humans and research showed that the incidence of stenosis and narrowing of PV diameter following PFA was virtually eliminated (0%), while patients who received RF energy saw a 12.0% reduction in diameter and 32.5% incidence of stenosis at 3-month follow-up [ 90 ].…”

“…Thus, the absolute requirement for synchronization is unclear. The use of IRE requires meticulous monitoring of blood pressure and electrolytes, as instances of induced mild hypertension and epileptic-like seizures have been reported with the use of high voltages and general anaesthesia during IRE procedures [ 81 , 90 , 101 ]. Cases of such intraoperative complications could jeopardize patient safety, therefore a clear understanding and rapid, appropriate management by the clinician is paramount.…”

“…Cases of such intraoperative complications could jeopardize patient safety, therefore a clear understanding and rapid, appropriate management by the clinician is paramount. Nevertheless, it has been concluded that an application of irreversible PEFs directly to cardiac tissue both endocardially and epicardially in preclinical studies is safe when timed with the R-wave during sinus rhythm, and in early clinical studies regardless of timing [ 51 , 66 , 80 , 81 , 82 , 90 , 100 , 101 ]. However, as PEF is a novel technique, safety boundaries and significant safety data remain scarce for human application and further investigation is required.…”

Letter from the Editor in Chief

“…Numerous preclinical studies have demonstrated its ability to spare the esophagus and phrenic nerve during ablation, 1 and first-in-human research showed that it has no effect on the diameter of the pulmonary veins following ablation. 2 Its short-term efficacy has also been demonstrated with a high rate of acute pulmonary vein isolation, which was also proven to be durable based on remapping studies. 3 Moreover, PFA appears to be an efficient modality, with very short procedure times.…”