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Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

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Dr. Wilber Su,
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AF Symposium & other medical conferences articles

2020 AF Symposium Live Case: Ultra-Low Temperature Cryoablation

AF Symposium 2020

Live Case: Ultra-Low Temperature Cryoablation

Background: The Adagio Medical iCLAS catheter is a Cryo catheter that uses ultra-low temperatures and is unlike anything currently on the market. To learn more about the iCLAS catheter, see my earlier report from the 2018 AF Symposium: Innovative iCLAS Cyro Catheter by Adagio Medical.
Note: The Adagio Medical iCLAS is not yet FDA approved. The U.S. IDE study trial is active and enrolling. The clinical trial started in December 2019. https://clinicaltrials.gov/ct2/show/NCT04061603.

Live Ablation Via Streaming Video

Tom DePottee, MD

Live from Belgium, Dr. Tom De Potter and his colleagues from OLV Hospital performed an ablation using Adagio Medical’s ultra-low temperature cryoablation catheter.

When the Symposium audience joined the live ablation via streaming video, Dr. De Potter and his colleagues had already performed a single transseptal puncture and were working in the left atrium.

Several catheter configurations possible with the Adagio Medical system.

To produce temperatures as low as (minus) –196° Celsius, Adagio Medical uses what they call Near Critical Nitrogen (NCN) which is far lower than current CryoBalloon technologies.

Producing Continuous Linear Ablations

Adagio catheters produce continuous linear ablations and can also be configured to do focal (single point) catheter lesions. Dr. De Potter also showed how the same Adagio Medical catheter can also do cryo mapping.

As we watched, Dr. De Potter encircled the Left Superior Pulmonary Vein (PV) with a double loop catheter. Then applied the cryo energy and froze the ostium area to isolate the PV. The catheter stylus included a loop of the freezing section and a loop with electrodes which recorded/mapped the A-Fib signals.

Freezing Isolated the Vein

We could see the ice formation on the catheter itself and how the freezing isolated the vein.

Adagio catheter encircles PV and freezes to isolate the PV area.

It only took 30 seconds to isolate that vein, but Dr. De Potter continued the freeze for one minute. Then performed what he called a bonus freeze.

On the catheter monitor, we could see how that vein had PV potentials which were then isolated.

Then Dr. De Potter moved to the Right Pulmonary Veins. The phrenic nerve usually runs close to the ostia of the right PVs. He said they perform phrenic nerve pacing to prevent damage to the phrenic nerve. We saw how they performed phrenic nerve capture.

Monitoring the Phrenic Nerve

If they do find they might be damaging the phrenic nerve, they don’t ablate there or insert a different catheter stylus configuration which doesn’t affect that area.

They didn’t achieve isolation of the Right Interior PV, so they did a second ablation while slightly changing the stylus loop position. Dr. De Potter said that he usually achieves isolation with one pass, except for, as in this case, with the Right Interior PV which is more challenging.

Protecting the esophagus with the Adagio Medical Warming Balloon (right of heart)

CryoAblation is Reversible. Dr. De Potter showed how they first used low energy cryo in a 30 second ablation to see if the phrenic nerve was affected (if affected, the tissue can be de-frosted and returned to normal or reversed.) Then they applied the full cryo energy at the ultra-low temperature which is permanent. The speed of decrease in cooling is very fast at 300°C/sec.

Protecting the Esophagus

To protect the esophagus, Dr. De Potter showed how they insert a warming balloon with constantly circulating warm saline into the esophagus which prevents excessive cooling and damage to the esophagus.

He stated that the next generation of the warming balloon will also have temperature sensing. They can then have a much better idea of what the freezing will do to the esophagus, how much temperature affects will be seen in the esophagus.

Ablating the Posterior Wall 

Dr. De Potter also showed the Adagio Medical system ablating the posterior wall. “It’s very simple. We will make overlapping rings.”

We saw him make those overlapping ring ablations in three passes which blocked conduction over the posterior wall. But with a larger atria, he may use 6 applications. He mentioned that at this stage he hasn’t achieved consistent success making a Mitral Isthmus line.

The Key Benefit of Ultra-Low Temperature Cryoablation

According to Dr. De Potter:

“The key benefit of this technology is a different energy source in contrast to the CryoBalloon which uses a theoretical minimum of –80°C.

This system (Adagio Medical) uses liquid nitrogen which has a theoretical minimum of –196°C. When you consider that this –80°C is at the center of the balloon and not necessarily at the tissue, we think we have a far better margin for efficient energy delivery while providing for patient safety.”

Editor’s Comments:

When I visited the Adagio booth at the Symposium exhibit hall, I was fascinated to see how easily the catheter can be manipulated into many different configurations depending on the lesions which need to be made.
Using its full length, the catheter can produce ultra-low temperatures along its whole span (110mm). Its 20 electrodes can also produce cryo-mapping of the atria.
Why is the iCLAS Cryo catheter special and innovative? The iCLAS catheter produces ablation lesions like current CryoBalloon catheters but at lower temperatures (colder). One would expect that such ultra-low Cryo lesions would be deeper, more transmural, and more lasting.
In addition, the ability to produce unlimited shapes gives the iCLAS catheter a unique ability to position Cryo lesions in a variety of locations in the heart.

The Adagio Medical iCLAS cyro system will make ablations much simpler and easier for EPs. It may eventually supersede normal CryoBalloon ablation (which is already a very effective ablation strategy).

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2020 AF Symposium: 5 Abstracts on Pulsed Field Ablation

The 2020 AF Symposium abstracts are one-page descriptions of A-Fib research, both published or unpublished. The abstracts are supplemental to the Symposium live presentations, panels discussions and spotlight sessions. This year the printed digest contained 55 abstracts. I choose only a few to summarize.

My Summaries of Select PFA Abstracts

Pulsed Field Ablation (PFA) was the single most important topic at this year’s Symposium. I summarized five of the PFA abstracts of most interest to A-Fib patients.

Lesion Durability and Safety Outcomes of Pulsed Field Ablation
The durability of PFA lesions is the focus of Dr. Vivek Reddy’s abstract. His research study followed 113 patients who each received a PFA ablation.

Pulsed Field Ablation with CTI Lesions Terminates Flutter in a Small Study
The use of Pulsed Field Ablation (PFA) may significantly improve CTI ablation lesions to block the Flutter signal. (CTI: Cavo-Tricuspid Isthmus)

Durability of Pulsed Field Ablation Isolation Over Time: Preliminary Study
Pulsed Field Ablation (PFA) is a new treatment. This study asked the question of whether PFA electrical isolation (lesions) regresses over time.

Pulsed Field Ablation vs RF Ablation: A Study in Swine 
PFA is “tissue-specific”. This study tested if surrounding non-heart tissue (the esophagus) would be affected. PFA ablation was compared to RF ablation. Swine (pigs) were used so tissue could be dissected and examined.

Using MRI to Check Pulsed Field Ablations (PFA)
Normally, during a RF or cryo ablation, doctors move the esophagus as far away as possible from where they are ablating. In this study they took no such precautions.

My Summary Reports

For more from the 2020 AF Symposium, go to My Summary Reports Written for A-Fib Patients. Remember, all my reports are written in plain language for A-Fib patients and their families.

2020 AF Symposium Abstract: Pulsed Field Ablation Follow-Up Study

2020 AF Symposium Abstract

Pulsed Field Ablation Follow-Up Study

Dr. Vivek Reddy, Mt Siani Hospital

Dr Vivek Reddy, Mt Sinai Hospital

Background: At the 2020 AF Symposium, Dr. Vivek Reddy demonstrated an ablation using Pulsed Field Ablation (PFA). Radically improving ablation treatment, PFA is:
• Tissue selective; affects heart tissue only and not other structures or organs.
• Very fast and precise; long-lasting lesions can be delivered in seconds.
• No direct contact needed only proximity, i.e., millimeters from the targeted tissue.
• Safer than current ablation energy sources, primarily because of its tissue selectivity.
• Offers two catheter shapes designed to fit into various areas of the heart.

But Does Pulsed Field Ablation Endure Long-Term?

The durability of PFA lesions is the focus of Dr. Vivek Reddy’s abstract, Lesion Durability and Safety Outcomes of Pulsed Field Ablation. His research study followed 113 patients who each received a PFA ablation.

Study Description: Patients were enrolled in 3 multi-center clinical trials which used a biphasic PFA waveform with a basket/flower catheter configuration.

Dwell time’ is the time transpiring from introduction of the ablation catheter into the body to the catheter’s removal.

Five EPs were chosen to do the PFA ablations. The 88 most recent patients were ablated. They were not under general anesthesia. PFA procedures required around 33 minutes of Left Atrium (LA) dwell time.

Follow-up Testing and Results: At 75-90 days, patients were invasively re-mapped.

Then, after 1 year, the Pulmonary Vein (PV) lesions were re-assessed and safety re-examined.

All PVs remained isolated. The primary safety event rate was 1.8% (1 pericardial tamponade, 1 groin hematoma).

The esophagus was carefully evaluated. There was no evidence of thermal esophageal lesions.

Cerebral MRI revealed no post-procedure swelling (ischemia). There was no PV stenosis. There were no latent safety issues. Invasive re-map procedures showed that lesion durability of the Pulmonary Veins reached 98%.

Study Conclusion

The researchers concluded that Pulsed Field Ablation (PFA) demonstrated:

• An excellent safety profile, no unexpected safety issues over a full year of follow-up.
• A very high rate of long-term Pulmonary Vein isolation (durable lesions).

So Does Pulsed Field Ablation Endure Long-Term? Yes!

Editor’s Comments

A year’s follow-up demonstrated that Pulsed Field Ablation (PFA) is a significant improvement over current ablation treatments. And these extraordinary results were obtained by 5 operators, which means that PFA is not dependent of the skill of a particular electrophysiologist.
I predict that Pulsed Field Ablation (PFA) will supersede all current ablation strategies. It’s almost too good to be true.

Unfortunately, it will probably take 3-5 years for PFA to be available for most A-Fib patients.

Reference for this report
Reddy, V. et al. Lesion Durability and Safety Outcomes of Pulsed Field Ablation in > 100 Paroxysmal Atrial Fibrillation Patients. AF Symposium 2020 brochure, Abstract AFS2020-19, p. 44. Ichan School of Medicine at Mount Sinai.

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2020 AF Symposium Abstract: Using MRI to Check Pulsed Field Ablations (PFA)

2020 AF Symposium Abstract

Using MRI to Check Pulsed Field Ablations (PFA)

by Steve S. Ryan

Background: Pulsed Field Ablation (PFA) is a new treatment for Atrial Fibrillation with some unique features. First, the ablations are tissue-specific, only affecting heart tissue and not the surrounding organs. Second, instead of direct contact to make lesions, as with RF ablation, all that’s necessary is proximity to the targeted tissue to make the ablation.

Pierre Jaïs, MD, The Bordeaux Group

In a remarkable statement that would strike terror in the heart of most Electrophysiologists (EPs), the French Bordeaux group stated about Pulsed Field Ablations:

Measures to alter lesion placement based on proximity of the esophagus and phrenic nerve were not taken.”

Normally, during a RF or cryo ablation, doctors move the esophagus as far away as possible from where they are ablating. In this study they took no such precautions.

Pulsed Field Ablation (PFA) study

Farapulse catheter – Five Petal Flower configuration

At this year’s AF Symposium, the French Bordeaux group presented an abstract of their study using Pulsed Field Ablation (PFA) with MRI.

Study Technique: With the Pulsed Field Ablation (PFA) waveform generator, they used a 5-spline 12F catheter to isolate the Pulmonary Veins (PVs). Then, they used MRI to check the PFA lesions to assess any extra-cardiac damage.

Study Results

NO DAMAGE TO THE ESOPHAGUS

Position of Esophagus behind the heart

In 17 patients, the esophagus was located directly behind and adjacent to PFA lesions at a distance of 0.5 to 2 mm. Post PFA ablation and using MRI imaging, they found no esophageal lesions.

They also found no discontinuities (gaps) in any isolated PV.

(With other energy ablation sources such as RF, the esophagus would be scarred, have ulcer-like damage, and fistula.)

NO PHRENIC NERVE DAMAGE

Phrenic nerve near heart

When they ablated the right PVs, they knew that they were right next to or close to the phrenic nerve.

Upon examination, PFA lesions were found in the area of the phrenic nerve but no damage was seen (despite the fact that there was consistent phrenic nerve capture during PFA delivery).

LESS THAN 60 SECONDS PER PATIENT

And even more remarkably, the total energy delivery time per patient was less than 60 seconds. This is much less time than with other types of ablation.

Editor’s Comments:
I expect Pulsed Field Ablation (PFA) will revolutionize catheter ablation for A-Fib. This is incredibly good news for patients and will make the EP’s job much easier requiring less time in the EP lab.

Better for Patients

Atrial-Esophageal Fistula No Longer a Threat: These are remarkable results! When using Pulsed Field Ablation (PFA), EPs don’t have to worry about damaging the esophagus, even though the PFA catheter may be very close to the esophagus. The dreaded complication Atrial-Esophageal Fistula will become a thing of the past! The same holds for Phrenic Nerve damage.
PFA is Tissue Selective: Instead of direct tissue contact as with RF ablation, all that’s necessary with PFA is to position the catheter in proximity to the targeted tissue. Because PFA is tissue selective, it’s easier and faster to make lesions without gaps.

Better for EPs

PFA Allows More A-Fib Patients to be Treated: Because PFA takes so little time, patients won’t have to wait for months to schedule an ablation. EPs will be better able to handle today’s epidemic of A-Fib cases. (One wonders how many PFA ablations a skilled EP will be able to do during a day?)
Better for Health of EPs: PFA may add years to an EP’s career and health. EPs no longer will have to wear those heavy lead shields for long periods of time to prevent fluoroscopy radiation damage.

But Not Ready Yet

It will probably take 3-5 years for PFA to be available for most A-Fib patients.

Reference for this report
Jais, P. et al. Lesion Visualization of Pulsed Field Ablation by MRI in an Expanded Series of PAF Patients. IHU Liryc, University de Bordeaux. AF Symposium 2020 brochure, Abstract AFS2020-37, p. 62.

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2020 AF Symposium: Pulsed Field Ablation vs RF Ablation: a Study in Swine

2020 AF Symposium Abstract

Pulsed Field Ablation vs RF Ablation: a Study in Swine

by Steve S. Ryan

Background: Pulsed Field Ablation (PFA) is a new treatment for Atrial Fibrillation, but it will probably take 3-5 years to be available for most A-Fib patients.

At this year’s AF Symposium, Dr. Jacob Koruth and others from Mount Sinai Medical Center in New York City presented an abstract and poster session of an ingenious study. They conducted research on pigs to compare Pulsed Field Ablation (PFA) with Radio-Frequency (RF) ablation.

Jacob Koruth, MD

Potential Atrial Esophageal Fistula

Normally when doctors perform a catheter ablation which affects the posterior wall of the left atrium, they do everything they can to make sure they don’t also damage the esophagus which often lies just behind the posterior wall.

In a worst case scenario, damage to the esophagus can produce an atrial esophageal fistula (a hole from the esophagus into the left atrium) which can be fatal. To learn more, see 2018 AF Symposium Live Case: The DV8 Esophageal Retractor.  

Moving the Esophagus to Purposefully Cause Fistula!

RF ablation vs PFA and risk of esophagus damage at A-Fib.com

RF ablation vs PFA and risk of esophagus damage

Dr. Koruth and his colleagues wanted to observe was the risk of esophagus damage during a Pulsed Field Ablation (PFA) versus RF ablation. Because PFA is “tissue-specific”, they wanted to test if surrounding non-heart tissue (the esophagus) would be affected.

The subjects in this study were swine (pigs) that could be examined (dissected) afterwards.

During a normal ablation, doctors move the esophagus as far away as possible from where they are ablating.

In this study, Dr. Koruth and his team used the balloon esophageal deviation device (Manual Surgical Sciences Inc.) in all swine to purposefully move the esophagus as close as possible to the posterior left atrium wall.

They then ablated one group of swine using PFA and the other group with RF energy.

Results: Dissection of the Surrounding Non-Heart Tissue

After 25 days, dissection of the pigs revealed the following results.

The pigs who had the Pulsed Field Ablation suffered no esophageal injury damage. Whereas all the RF ablated swine suffered major esophageal injury (including one fistula).

All RF ablated pigs had major ulcerations. In comparison, none of the PFA pigs had any esophageal lesions.

Photos of Dissection: If you want to see the dissection photos comparing the tissue from the PFA vs RF ablation pigs, click on the tab below.

Dissection photos of PFA and RF ablations on swine

Views of esophageal changes at sacrifice 25 days post ablation. A: After pulsed field ablation (PFA), representative images demonstrating the normal luminal (interior) and adventitial (outer) surface of the esophagus. B: After RF ablation, a perforating ulcer and fistula is seen on the luminal (interior) part of the esophagus.

Close-up views of tissue dissected after RF ablation. A: Shows ulceration (top arrow) and perforation (center arrow) from RF ablation. B and C show partially healed ulcerations/lesions from RF ablation.

Editor’s Comments:

These Pulsed Field Ablation results are possible because PFA is “tissue-specific” and doesn’t affect surrounding non-heart tissue (such as the esophagus). It’s an incredible improvement in the treatment of A-Fib.

Pulsed Field Ablation (PFA) will eliminate the most dreaded complication of catheter ablation―Atrial Esophageal Fistula (heat damage to the esophageal from the catheter). Though a very rare complication (around 1 in 2000 cases), it’s unique in that it can kill you or result in major health problems in those who survive.

With PFA, patients and their EPs performing catheter ablations will no longer have to worry about creating these lethal Fistulas. This may be the most significant feature of PFA for Atrial Fibrillation.

It would be hard to imagine a more convincing demonstration! Kudos to Dr. Koruth and his colleagues for this study.

Reference for this article
Koruth, Jacob et al. Pulsed Field Ablation vs Radiofrequency Ablation: Esophageal Effects in a Novel Preclinical Model, Abstract AFS2020-51 p51. AF Symposium 2020 digest publication.

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AF Symposium 2020: For A-Fib Patients Under Age 40: Genetic Testing Before Your Catheter Ablation?

AF Symposium 2020

For A-Fib Patients Under Age 40: Genetic Testing Before Your Catheter Ablation?

by Steve S. Ryan

Patrick Ellinor, MD

Patrick Ellinor, MD

Background: We have previously reported on the extraordinary work of Dr. Patrick Ellinor of Massachusetts General Hospital and his colleagues world-wide in examining the genetics and genome sequencing of A-Fib, and the genetic susceptibility to A-Fib. This group has been doing genetic testing of A-Fib for over 25 years at over 60 sites throughout the world. (See AF Symposium 2017 World-Wide Studies on Genetic A-Fib)
Gene vs Genome: A gene is a part of a DNA molecule; The genome is the total DNA in a cell.

Over the years, researchers have identified 100 distinct genetic loci for A-Fib. (A locus is a specific, fixed position on a chromosome where a particular gene or genetic marker is located.)

Finding the Genome for A-Fib

In a presentation entitled “AF Under Age 40―Genetic Testing Before Ablation?”, Dr. Ellinor of Massachusetts General Hospital described what is perhaps the culmination of years of work―the discovery that the muscle protein titin-gene (TTN mutation) is the main gene linked to genetic A-Fib.

This is major news! All these efforts by Dr. Ellinor and his many colleagues throughout the world have finally paid off.

Loss-of-function mutation: A mutation that results in reduced or abolished protein function.

The Titin gene is critical for normal heart function. It’s the largest gene in the human genome. About one out of 250 people carries a Loss-Of-Function (LOF) mutation in one of their TTN genes.

In a recent study which examined genome-wide associations in 1,546 people with A-Fib and 41,593 controls, 14% of people who have this mutation have A-Fib. No other gene locus even comes close (see blue arrow in chart below). These TTN mutations have been associated with early-onset A-Fib.

Caption: High-confidence loss-of-function (LOF) variants in TTN among atrial fibrillation (AF) cases and controls cases in UK Biobank. Source: Choi, S. H.

Patients with TTN Mutation Much More Likely to Develop A-Fib

Dr. Ellinor described “finger printing” of a few hundred thousand genetic variants scattered throughout the genome. These capture about 90% of the differences between any one of us.

Having the TTN mutation gives you a six-fold increased chance of developing A-Fib.

His studies compare associated regions and look for spikes such as the TTN mutation. People with the TTN mutation have a six-fold increase in the likelihood of developing A-Fib.

There is also a much smaller TTN association with heart failure and cardiomyopathy. They have done cardiac MRIs on many patients with the TTN mutation.

What Do We Do with This TTN Data?

Dr. Hugh Calkins from Johns Hopkins asked the question on everyone’s mind.

“Now that we have this TTN data, what do we do with it?”

Dr. Ellinor described very preliminary research where they divide patients into low, medium and high risk, then document how the patients do after their catheter ablation.

One might speculate that catheter ablation results with high risk patients wouldn’t be as successful. But right now, this is speculation.

Patients Need to Know If They Have the TTN Gene Mutation

So, will doctors tell their patient if they are at high risk of developing A-Fib? Most patients would want to know.

Popular genetic testing companies include Ancestry and 23andMe.

Dr. Ellinor advises his patients that genetic testing companies offer testing for the TTN mutation as part of an “arrhythmia test” panel for around $100.

Perhaps, patients already diagnosed with early-onset A-Fib would benefit from knowing if they have the TTN mutation.

For patients with the TTN mutation: Your doctor could perform a cardiac MRI and more closely examine and monitor your results. In addition, your children could be tested for the TTN mutation.

The Bottom Line for Patients: Dr. Ellinor recommends genetic testing early and offered to anyone 40 years old or younger with A-Fib.

Editor’s Comments:

Finding the TTN gene/genome responsible for so much A-Fib is a hugely important discovery!
And equally important is finding out that so many people have the TTN LOF mutation. The TTN mutation may cause or make it more likely that someone will develop A-Fib. This is invaluable information both for patients and for the doctors treating them.
But how this TTN information can or will be used in treating patients is a whole new, barely explored world.
A great deal of work lies ahead to better understand the precise mechanisms by which genomic variation causes Atrial Fibrillation.

Participate in A-Fib Genetic Studies

If you and at least 3 other members of your family have A-Fib, you can become involved in this potentially very important research. Contact the studies at Mass. General Hospital or Vanderbilt University.

Patrick T. Ellinor, MD, PhD, Director, Cardiac Arrhythmia Service
Marisa Shea, RN,  Research Nurse
Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
617-724-7780, Email: mshea1(at)partners.org

Vanderbilt University also welcomes families with A-Fib for their genetic studies. Contact the Vanderbilt Atrial Fibrillation Registry (they also have an AF Ablation Registry)

Diane Crawford, RN
Vanderbilt University Medical Center, 1266 MRB IV, Nashville, TN 37232-0575
(615) 322-0067, Email: Diane.n.crawford(at)vanderbilt.edu

References for this article
Choi, S. H. et al. Monogenic and Polygenic Contributions to Atrial Fibrillation Risk, Results From a National Biobank. Circulation Research. 2020 Jan 17;126[2]: 200-9. https://www.ahajournals.org/doi/pdf/10.1161/CIRCRESAHA.119.315686

Choi, S. H. et al. Association Between Titin Loss-of-Function Variants and Early-Onset Atrial Fibrillation. Jama Network, December 11, 2018. https://jamanetwork.com/journals/jama/fullarticle/2718069?resultClick=1

2020 AF Symposium Abstract: PFA+CTI Lesions Terminates Flutter in a Small Study

2020 AF Symposium Abstract

Pulsed Field Ablation With CTI Lesions Terminates Flutter in a Small Study

Illustration of right atrium, cavotricuspid isthmus (CTI) and tricuspid valve annulus.

Definition: Cavotricuspid isthmus (CTI) is part of the right atrium located between the inferior vena cava (IVC) ostium and the tricuspid valve.

Typical Atrial Flutter comes from the right atrium and is usually terminated by what is called a Cavo-Tricuspid Isthmus (CTI) lesion ablation line which blocks the Flutter. But for a CTI lesion to work, the Electrophysiologist (EP) using RF has to make small continuous lesions which require intense concentration to be gap free.

Even though a CTI lesion is one of the safest ablation procedures, there are some risks. Damage can be to the right coronary artery or to the AV Node and His bundle signal pathways.

PFA Makes Flutter Ablation Easier and More Effective

Ante Anic, MD, U. Hospital Center, Croatia

An abstract distributed at the 2020 AF Symposium by Dr. Ante Anic showed how the use of Pulsed Field Ablation (PFA) may significantly improve CTI ablation lesions.

Pulsed Field Ablation is fast, contact forgiving, and only affects cardiac muscle cells (cardiomyocyte).

In a small PFA study (3 patients), a continuous, non-conducting line of CTI lesions was made with a deployable 4-spline, multi-electrode basket-shaped tip catheter.

Study Results: Right atrium Typical Flutter was successfully blocked with bidirectional block (BDB) confirmed. Moreover, these CTI lesions required little time to make (3, 4, & 6 minutes).

Unlike with standard radio-frequency (RF), the Pulsed Field Ablation catheter required few ablation sites (4, 3, and 6 respectively). In effect, making a CTI ablation line with PFA was much easier and required much less precision and concentration.

After a 15 minute waiting period, bidirectional block (BDB) was confirmed in all three patients to make sure there were no Flutter signals. They also used adenosine in one patient to try to stimulate that patient back into Flutter with no success.

Overall, they found that the PFA lesions were persistent and completely blocked the Flutter.

Editor’s Comments:
Pulsed Field Ablation (PFA) has different catheter shapes which enable the operator (EP) to easily work in all areas of the heart.

PFA catheter shapes: (L) Basket catheter (R) Flower Petal catheter.

In this limited study, a Cavo-Tricuspid Isthmus (CTI) lesion was used to eliminate typical Atrial Flutter. The electrophysiologist (EP) used a basket configuration to make linear, focal lesions. PFA seems well suited to any heart configuration an EP may encounter.
Furthermore, EPs don’t have to worry about precisely positioning the PFA catheter for direct contact. Proximity is all that’s needed. PFA is fast and tissue specific. It won’t damage surrounding nerves and organs.
Though a small study, this abstract from Croatia opens up new frontiers for the use of PFA.

I see Pulsed Field Ablation (PFA) as a radically superior treatment for right atrium typical Flutter.

Reference for this article
Antic, A. et al. Acute Experience with Pulsed Field Ablation for Typical Flutter. University Hospital Center Split, Croatia. AF Symposium 2020 brochure, AFS 2020-26, p. 51.

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2020 AF Symposium Abstract: Durability of Pulsed Field Ablation Isolation Over Time: Preliminary Study

2020 AF Symposium Abstract

Durability of Pulsed Field Ablation Isolation Over Time: Preliminary Study

To better understand this report you should read it in conjunction with my report of Dr. Reddy’s pre-recorded video entitled, Pulsed Field Ablation (PFA) for AF.

This abstract, distributed at the AF Symposium, details a small preliminary study by researchers at Mount Sinai Hospital in New York. They investigated whether Pulsed Field Ablation (PFA) lesions last over time.

We know that Pulsed Field Ablation (PFA) makes safe and durable lesions around the Pulmonary Veins and it produces a zone of irreversible electroporation and cell death. We also know that surrounding this ablated area is a zone of reversible electroporation and cell injury that normalizes over time and turns back into normal tissue.

This study asked whether the level of electrical isolation after PFA regressed over time.

Comparing PFA Ablated Areas with Non-PFA Ablated Tissue

In this clinical trial, detailed voltage maps were created immediately after PFA and again after 3 months. They basically compared the areas of left- and right-sided PV antrum isolation with the non-ablated posterior wall area and, more importantly, with the borders between these two areas.

Results and Conclusion

After 3 months, the ablated areas remained isolated and the non-ablated areas stayed non-ablated. The distances between the borders remained the same.

The authors concluded that PFA isolation persists without regression.

Editor’s Comments:
Since Pulsed Field Ablation (PFA) is such a new treatment, the question of whether PFA electrical isolation regresses over time needed to be asked.

This small preliminary study confirms what we would expect. PFA isolation makes safe and durable lesions that lasts over time.

References for this article
Kawamura, I. et al. Do Pulsed Field Ablation Lesions Regress Over Time?―A Quantitative Analysis of the PVI Level of Isolation in the Acute and Chronic Settings. Ichan School of Medicine at Mount Sinai. AF Symposium 2020 brochure, Abstract AFS2020-54, p. 78.

Graphic source: Maor, Elad et al. Pulsed electric fields for cardiac ablation and beyond: A state-of-the-art review. Heart Rhythm, Volume 16, Issue 7, 1112 – 1120.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

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AF Symposium 2020: Live Case of Difficult A-Fib Ablation of Atypical Flutter

2020 AF Symposium

Live Case of Difficult A-Fib Ablation of Atypical Flutter

by Steve S. Ryan

Atypical Flutter circuits can be the most difficult to map and ablate. This live case of Atypical Flutter was a very difficult and challenging ablation. It was certainly among the toughest situations electrophysiologists (EPs) will encounter.

This live catheter ablation from Boston was presented via streaming video. We observed Atypical Flutter during this live ablation.

A-Fib Patient History

Kevin Heist MD

Kevin Heist MD

Dr. Kevin Heist from Massachusetts General Hospital described the patient as a 73-year-old man who had A-Fib and Flutter for 13 years. The antiarrhythmic drugs, dofetilide (Tikosyn) and flecainide, were unsuccessful.

In 2007 he had a successful right atrium Flutter ablation at an outside facility (not Mass. General).

In 2009, while on warfarin, he suffered a spontaneous subdural hemorrhage (bleeding between the brain and the skull) while at work. Fortunately, he lived through it.

In 2013 he had his Left Atrial Appendage closed off by a Lariat device, though they found he still had a small stump of the LAA (which is common after lariat closure).

In 2018 he had a catheter ablation for persistent A-Fib. His Pulmonary Veins (PVs) and his posterior left atrial wall were ablated which terminated his A-Fib, but left him in Mitral Annular Flutter. They ablated extensively particularly in the Coronary Sinus. Finally, they were able to convert him from Flutter to normal sinus rhythm (NSR) by making a Mitral Isthmus ablation line.

2018 Mapping Data was Re-Processed and Updated

The Carto-3 mapping system from Biosense Webster with Smart Touch catheter

Dr. Heist showed the patient’s 2018 mapping. Then he used the new Biosense Webster Carto-3 mapping system with a Smart Touch SF catheter. It can accommodate more points than the traditional system, “it creates a best fit for arrhythmia mechanism.”

He showed the 2018 vectors around the Mitral Annulus which were re-processed through the current Carto mapping system. This electroanatomical system created vectors which showed both directionality and the speed of travel.

Targeted Ablation of Scarring and Reconnection

When Dr. Heist and his team started their initial voltage and activation mapping, they found that a portion of the left vein and the posterior left atrial wall had reconnected, and there was activation of the atypical flutter around the mitral annulus.

They found a portion of the left vein and the posterior left atrial wall had reconnected
In addition, they found passive activation of the left pulmonary vein from that flutter as it traveled across the mitral isthmus line into the left veins posteriorly. They directed their ablation to that point.

With voltage mapping they found quite a bit of scar in the rightward of the posterior wall and quite a bit of scar in the Mitral Isthmus region, but a small channel for activation of the pulmonary vein.

Dr. Heist said: “These advanced mapping systems give you a pretty clear ideas of breakthrough areas. So, we targeted our ablation to isolate the left vein and the posterior wall.” This Flutter seemed to be traveling around the Mitral Annulus and through the Coronary Sinus.

“These advanced mapping systems give you a pretty clear ideas of breakthrough areas.” – Dr. Kevin Heist 

At this point in the procedure, Dr. Heist described his plan to continue to move on to more ablation and if necessary, to Coronary Sinus ablation as was done in 2018 to achieve Mitral Isthmus block.

“We have moved to higher energy and shorter duration lesions and are using 50 Watts for 10-15 seconds commonly to perform typical pulmonary vein isolation. But here we may need deeper lesions than for the rest of the left atrium. We will use 40 Watts with a force of 10 or 15 grams. We’ve been using the lesion index and trying to reach lesion indexes in the range of 500.” (The ablation index is a marker or measure of ablation quality that incorporates power, contact force, and time in a weighted formula.)

Why No Use of Pacing?

Dr. Heist didn’t want to use pacing (entrainment) because he didn’t want to prematurely terminate the Flutter signal. Around this time, they saw some esophageal warming and had to limit their ablations.

Atrial Flutter Termination!

We watched as they actually terminated the Atypical Flutter!

Success! The patient’s atypical Atrial Flutter was terminated.

Nonetheless, Dr. Heist said they would continue the ablation in the Coronary Sinus and the Mitral Isthmus line. They might also ablate circumferentially around the Coronary Sinus to make sure there are no potentials present.

As the ablation team continued to ablate in the Coronary Sinus, they answered questions from the Symposium attendees. They then had to end the live case presentation because of time constraints.

Editor’s Comments:
This ablation procedure for Atypical Flutter has got to be one of the most difficult ablation cases I’ve ever seen performed live! Dr. Heist did everything possible to check for hidden or latent arrhythmia signal sources (a characteristic of a “master” EP).
In an email to the me after the AF Symposium, Dr. Heist shared:

• At the end of the procedure, all pulmonary veins and the left atrial posterior wall were isolated.

• The mitral isthmus through which the atypical flutter had passed was completely blocked (and remained blocked when the IV drug adenosine was given).

• No arrhythmia (flutter or fibrillation) could be induced by aggressive rapid pacing. That’s the best possible result for a patient! 

One can’t help but admire Dr. Heist’s and his colleagues’ tenacity in searching for and ablating this patient’s elusive atypical Flutter.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

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2020 AF Symposium: Pulsed Field Ablation—A Game Changer for A-Fib

This year’s AF Symposium was abuzz about an emerging technology, Pulsed Field Ablation (PFA). It could change everything in the field of catheter ablation for Atrial Fibrillation.

Pulsed Field Ablation and how it works was presented by Dr. Vivek Reddy of Mount Sinai Medical Center, NY, NY. He also narrated a video showing an actual Pulsed Field Ablation procedure.

What is Pulsed Field Ablation? Pulsed Field Ablation (PFA) from Farapulse, Inc. is a non-thermal energy system that uses a series of ultra-short electrical pulses to ablate heart tissue. This series of pulses, or the “waveform”, makes a long-lasting lesion in a manner of seconds compared with hours for radiofrequency.

More importantly, PFA works on the selected cell types while leaving others alone (like the esophagus).

Proximity Not Actual Contact: Unlike standard ablation energy sources such as RF (heat) and Cryo (freezing), the PFA catheter does not require actual physical contact but only needs proximity to the tissue to be ablated. And it doesn’t cause scarring or char formation. …click for full report on PFA.

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