Pulsed field ablation in patients with complex consecutive atrial tachycardia in conjunction with ultra‐high density mapping: Proof of concept

Abstract

Introduction Catheter‐ablation (CA) of consecutive left atrial tachycardias (LAT) can be challenging. Pulsed field ablation (PFA) yields a novel nonthermal CA technology for treatment of atrial fibrillation (AF). There is no data regarding PFA of LAT. This study sought to investigate PFA of consecutive LAT following prior CA of AF. Methods Consecutive patients with LAT underwent ultrahigh‐density (UHDx) mapping. Subsequent to identification of the AT mechanism, PFA was performed at the assumed critical sites for LAT maintenance. Continuous ablation lines were performed if required and evaluated with pre‐ and post‐PFA HDx‐mapping. Results Fifteen patients (age 70 ± 10, male 73%) who underwent 3.6 ± 2 prior AF‐CA procedures were included. The total mean procedure and fluoroscopy times were 141 ± 43 and 18 ± 10 min, respectively. All 19 of 19 (100%) LAT were successfully ablated with PFA. Two AT located at the right atria required RF‐ablation. LAT were identified as localized reentry (n = 1) and macro‐reentry LAT (n = 18) and targeted with PFA. All LAT terminated with PFA either to sinus rhythm (9/15) or a secondary AT (6/15 and subsequently to SR); 63% (12/19) terminated with the first PFA‐application. All lines (13 roof, 11 anterior, 1 mitral) were blocked. LA‐posterior‐wall isolation (LAPWI) was successfully achieved when performed (10/10). AF/AT free survival was 80% (12/15) after 153 [88–207] days of follow‐up. No procedure‐related complications occurred. Conclusion PFA of consecutive LAT is feasible and safe. Successful creation of ablation lines and LAPWI can be achieved in a short time. PFA may offer the opportunity for effective ablation of atrial arrhythmias beyond AF.

Pulsed Field Ablation for Atrial Fibrillation

“…14 This finding was confirmed in other studies and a more detailed analysis showed that the PV size may play a significant role, with larger PVs showing more reconnections and the superior PVs being commonly larger in diameter than their inferior counterparts. 28,29 Since both the 31-mm and 35-mm FARAWAVE catheters usually cover the whole PV-ostium, the reasons for more reconnections of larger-diameter PVs are not obvious and need further research. The density of the electric field at different distances from the catheter might play a role.…”

Pearls and Pitfalls of Pulsed Field Ablation

“…Its current field of application is mostly AF ablation, e.g., PVI, 15) but other ablation approaches in the atria or ventricles have been investigated in animal models 16) 17) 18) 19) and as an off-label use in humans. 20) 21) 22) The technique utilizes high amplitude pulsed electrical fields that are exposed to sensitive myocardial cells, which leads to subsequent cell death through the mechanism of irreversible electroporation (IRE). Electroporation acts by increasing the permeability of the cell membrane after exposure to electric fields.…”

Left atrial field isolation with pulsed field ablation: a new option for challenging left atrial tachycardias?

“…In this issue of the journal, Gunawardene and co-workers present their early experience with PFA for the treatment of patients with post-AF ablation atrial tachycardia (AT) (4). Their analysis includes 15 patients with a history of multiple AF/AT ablation procedures.…”