Pulsed Electrical Field Ablation for Atrial Fibrillation
Is it feasible and safe to perform pulmonary vein (PV) isolation with pulsed field ablation (PFA)?
A novel over-the-wire multielectrode catheter (flower-shaped) was advanced to the region of the PV antrum in 15 patients with paroxysmal atrial fibrillation, and a circular catheter was placed over the epicardial aspect of the posterior left atrium in seven patients undergoing cardiac surgery. The procedure was performed under general anesthesia. PFA was performed in these regions during simultaneous atrial and ventricular pacing to synchronize the pulses to myocardial refractoriness. A pre- and post-endocardial voltage map was performed in each patient.
The PVs were isolated (confirmed by a multielectrode catheter) in all 15 patients undergoing endocardial PFA, using about three lesions per PV (total energy duration <60 seconds/patient), with the mean procedure and fluoroscopic time of about 67 and 12 minutes, respectively. A “box” lesion created during the surgical procedure was successful in 6/7 patients. The post-procedure voltage map showed elimination/reduction of myocardial voltage in the ablated region. There were no obvious complications such as catheter entrapment, thromboembolism, or phrenic or esophageal injury. Data regarding clinical efficacy were not available.
The authors concluded that the initial experience using catheter-based pulsed electrical field ablation of the PVs was safe, expedient, and acutely successful.
Pulsed electrical field ablation results in irreversible electroporation of myocardial cells. PFA has several potential advantages over radiofrequency (heat)/cryothermy–based ablation systems: it relies on proximity of the energy source to the target as opposed to intimate contact; it is more efficient than point-by-point radiofrequency ablation techniques, and likely cryoballoon-based procedures; it is less likely to result in collateral damage to the phrenic nerve, esophagus, and coronary arteries based on myocardial tissue selectivity; and minimal heat generation during PFA should result in lower incidence of overheating phenomena such as charring/thromboembolism and steam pops/perforation. The electrophysiology community eagerly awaits the long-term clinical data in a larger sample size to determine the durability and clinical efficacy of pulsed electrical field–guided PV isolation for atrial fibrillation.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias
Keywords: Anesthesia, General, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, Catheter Ablation, Electrophysiology, Electroporation, Endocardium, Esophagus, Pulmonary Veins, Thromboembolism
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