Impact of weight adjusted high frequency low tidal volume ventilation and atrial pacing in lesion metrics in high-power short-duration ablation: Results of a pilot study.

INTRODUCTION: Lesion size index (LSI) was introduced with the use of Tacticath™ and as a surrogate of lesion quality. The metric used to achieve the predetermined values involves combined information of contact force (CF), power and radiofrequency time. Rapid atrial pacing (RAP) and high-frequency low-tidal volume ventilation (HFLTV) independently or in combination improve catheter stability and CF and quality of lesions. Data of the impact of body weight adjusted HFLTV ventilation strategy associated with RAP in the lesion metrics still lacking. The study aimed to compare the results of high-power short-duration (HPSD) atrial fibrillation ablation using simultaneous weight adjusted HFLTV and RAP and standard ventilation (SV) protocol. METHODS: Prospective, nonrandomized study with 136 patients undergoing de novo ablation divided into two groups; 70 in RAP (100 ppm) + HFLTV with 4 mL/kg of tidal volume and 25 breaths/min (group A) and 66 patients with SV in intrinsic sinus rhythm (group B). Ablation using 50 W, CF of 5-10 g/10-20 g and 40 mL/minute flow rate on the posterior and anterior left atrial wall, respectively. RESULTS: No procedure-related complications. Group A: Mean LSI points 70 ± 16.5, mean total lower LSI 3.4 ± 0.5, mean total higher LSI 8.2 ± 0.4 and mean total LSI 5.6 ± 0.6. Anterior and posterior wall mean total LSI was 6.0 ± 0.4 and 4.2 ± 0.3, respectively. Mean local impedance drop (LID) points were 118.8 ± 28.4, mean LID index (%) 12.9 ± 1.5, and mean LID < 12% points 55.9 ± 23.8. Anterior and posterior wall mean total LID index were 13.6 ± 2.0 and 11.9 ± 1.7, respectively. Recurrence in 11 (15.7%) patients. Group B: Mean LSI points 56 ± 2.7, mean total lower LSI 2.9 ± 0.7, mean total higher LSI 6.9 ± 0.9, and mean total LSI 4.8 ± 0.8. Anterior and posterior wall mean total LSI was 5.1 ± 0.3 and 3.5 ± 0.5, respectively. Mean LID points were 111.4 ± 21.5, mean LID index (%) 11.4 ± 1.2, and mean LID < 12% points 54.9 ± 25.2. Anterior and posterior wall mean total LID index were 11.8 ± 1.9 and 10.3 ± 1.7, respectively. Recurrence in 14 (21.2%) patients. Mean follow up was 15.2 ± 4.4 months. CONCLUSION: Weight adjusted HFLTV ventilation with RAP HPSD ablation produced lower recurrence rate and better LSI and LID parameters in comparison to SV and intrinsic sinus rhythm.

Incidental parasympathetic cardiac denervation during atrial fibrillation ablation using high power short duration: a marker of long-term success.

BACKGROUND: There are multiple factors in both technique and substrate that lead to recurrence of atrial fibrillation after ablation. We sought to examine whether the degree of heart rate increase (HRI) caused by concurrent high-power-short-duration (HPSD) incidental parasympathetic denervation during AF ablation predicts long term success. Between December 2018 and December 2021, prospectively enrolled 214 patients who presented in sinus rhythm at AF ablation. Used 50 W of power and contact force (CF) of 5-15 g and 10-20 g at a flow rate of 40 mL/min on the anterior and posterior left atrial walls, respectively. RESULTS: Males were 143 (66.8%) and paroxysmal was 124 (57.9%) patients. Mean age 61.1 ± 12.3 years and follow-up time was 32.8 ± 13.2 months. Arrhythmia occurred after 90 days in 39 (18.2%) patients, 19 (48.7%) from the paroxysmal and 20 (51.3%) from the persistent AF patients. Recurrence group showed a lower HRI from a mean of 57 ± 7.7 to 64.4 ± 10.4 bpm (12.3%) while in success group HRI was from 53.8 ± 9.7 to 66.8 ± 11.6 bpm [(24.2%) p = 0.04]. We divided HRI in 3 percentiles of ≤ 8%, > 8 ≤ 37% and > 37%. A predictor of recurrence was identified in those in the first (< 8%, p = 0.006) and a predictor of success in the later (> 37%, p = 0.01) HRI percentile. CONCLUSION: Atrial fibrillation ablation with HPSD incidental cardiac parasympathetic denervation identified that patients with lower heart rate increase are prone to recurrence while those with higher heart rate increase had higher maintenance of sinus rhythm at a long-term follow-up.

Comparison between weight-adjusted, high-frequency, low-tidal-volume ventilation and atrial pacing with normal ventilation in high-power, short-duration atrial fibrillation ablation: Results of a pilot study.

Background: Better contact force (CF) and catheter stability (CS) during atrial fibrillation (AF) ablation are associated with higher success rate. Changes in CF and CS are observed during respiratory movements and cardiac contraction. Previous studies have suggested that rapid atrial pacing (RAP) and high-frequency, low-tidal-volume ventilation (HFLTV) independently or in combination improve CS and CF and quality of lesions. Data from a body weight-adjusted HFLTV strategy associated with RAP in AF high-power, short-duration (HPSD) ablation are still lacking. Objective: This study aimed to compare the results of HPSD AF ablation using simultaneous weight-adjusted HFLTV and RAP and standard ventilation (SV) protocol. Methods: This was a prospective, nonrandomized study with 136 patients undergoing de novo ablation were divided into 2 groups: 70 in RAP (100 ppm) + HFLTV with 4 mL/kg of tidal volume and 25 breaths/min (group A) and 66 patients with SV in intrinsic sinus rhythm (group B). The ablation used 50 W, CF of 5 to 10 g and 10 to 20 g, and 40 mL/min flow rate on the posterior and anterior left atrial walls, respectively. Results: There were no procedure-related complications. In group A, left atrial and total ablation times were 53.5 ± 8.3 minutes and 67.4 ± 10.1 minutes, respectively. Radiofrequency time was 19.7 ± 5.7 minutes, radioscopy time was 3.4 ± 1.8 minutes, 62 (88.6%) patients had first-pass isolation, 23 (33.3%) patients had elevation of luminal esophageal temperature, and 7 (10%) patients had recurrence. In group B, left atrial time was 56.7 ± 10.8 minutes, total ablation time was 72.4 ± 11.5 minutes, radiofrequency time was 22.4 ± 6.2 minutes, radioscopy time was 3.6 ± 3 minutes, 58 (87.9%) patients had first-pass isolation, and 20 (30.3%) patients had luminal esophageal temperature elevation. Conclusion: Weight-adjusted HFLTV with RAP in comparison with SV and intrinsic sinus rhythm in HPSD ablation is safe with no CO2 retention. The approach produced significantly reduced radiofrequency, left atrial, and total ablation times and better CF and local impedance drop indexes.

Is Age Associated with Complications of Atrial Fibrillation Catheter Ablation?

Abstract Background Atrial fibrillation (AF) is the most frequent arrhythmia, and its prevalence increases with age. The management of AF in the elderly is challenging, as it is normally associated with comorbidities and frailty. AF catheter ablation (CA) is a safe and superior alternative to antiarrhythmic drugs (AADs) for the maintenance of sinus rhythm. Objectives To evaluate the rate of complications associated with CA for AF across different age groups. Methods A retrospective analysis of 219 patients who underwent CA for AF between 2016 and 2020 were divided into 3 age groups: less than 60 years, 60 to 70 years, and > 70 years. All the included patients underwent radiofrequency ablation using an electroanatomic mapping system. Categorical variables were evaluated with chi-square and Fisher's test, and continuous variables were evaluated by Kruskal-Wallis and post-hoc Tamhane's T2. P values less than 0.05 were considered significant. Results We found an overall total complication rate of 4.6%. The total complication rate was 3.3% in patients < 60 years of age, 5.7% in patients between 60 and 70 years, and 5.2% in patients > 70 years (p = 0.742). No deaths occurred. Conclusion There was no significant difference in the AF CA-related complications when comparing the patients by age group.

Comparison of outcomes with low-power long duration versus high-power short duration of ablation: the role of the acute change in sinus rhythm after the ablation as a predictor of long-term success.

Different results are described after atrial fibrillation ablation and multiple predictors of recurrence are well established. Evaluate and analyze if heart rate increase (HRI) during a first atrial fibrillation (AF) ablation with low-power long-duration (LPLD) and subsequently with high-power short-duration (HPSD) can impact. Retrospectively analyzed 340 consecutive patients (pts) undergoing first AF ablation. There were 158 pts in LPLD group: 113 (71.5%) paroxysmal AF with ablation with a power of 30/20 w, on anterior and posterior left atrial (LA) wall, respectively, and contact force of 10-30g for 30 s. There were 182 pts in HPSD group: 106 (58.2%) paroxysmal AF, who underwent ablation with 45/50 w, contact force of 8-15g/10-20g and 35 mL/min flow rate on anterior and posterior left atrial wall, respectively. Median follow-up was 32 ± 16 months. Success was observed in 94 (59.5%) patients in LPLD and 152 (83.5%) in HPSD, in LPLD group we documented a median HRI of 4.3 bpm (8%), compared to preablation heart rate, while a higher HRI in HPSD group of HRI 13.5 bpm (27.2%) was noted. Heart rate increase was associated with a higher success rate in both ablation techniques and independently showed an important impact on the success rate after AF ablation. HPSD compared to LPLD showed a higher proportion of HRI and also demonstrated a superiority in maintaining sinus rhythm at a long-term follow-up.

Initial Experience with Fractionation Mapping in the Identification of Vagal Ganglionated Plexus During Cardioneuroablation

This is a series case report of five symptomatic patients presented with diagnosis of sinus bradycardia, first and second degrees atrioventricular (AV) blocks, that were referred to pacemaker implantation. During the screening, a functional cause for the bradycardia and AV blocks were documented by treadmill stress test, 24-hour Holter monitoring and atropine test. After the confirmation of the diagnosis, patients were submitted to cardioneuroablation on an anatomical basis supported by a tridimensional electroanatomical fractionation mapping software. The technique and the acute and short-term results of the cardioneuroablation are described.

Successful Left Atrial Appendage Closure with Watchman Device Implantation in Two Patients with Inferior Vena Cava Filters

Percutaneous procedures through femoral access in patients with inferior vena cava (IVC) filter may be at risk of complications. We evaluated the feasibility and safety of left atrial appendage closure (LAAC) through femoral access in patients previously implanted with IVC filter. We described the WatchmanTM device implantation in two patients with formal contraindication for oral anticoagulation. First patient had a GreenfieldTM filter and the second one an OpteaseTM filter, and in this patient an attempt to withdrawal the filter immediately before the LAAC procedure failed. A femoral approach was performed in both patients using a 14 Fr sheath. Before crossing IVC filters, venographies did not detect any thrombus. All steps of IVC filter crossing were performed under fluoroscopic guidance. No immediate or intrahospital complications related to the procedure occurred. Herein, we presented two cases of successful LAAC closure with Watchman device in patients with two different kinds of IVC filters.

Reduced esophageal heating in high-power short-duration atrial fibrillation ablation in the contact force catheter era.

BACKGROUND:  Atrial fibrillation (AF) ablation is alternative treatment to medical therapy. Most feared complication is atrioesophageal fistula METHODS: Observational, retrospective analysis of consecutive 355 patients undergoing first AF ablation. Low-power long-duration (LPLD) group contained 158 patients, with 121 (76.58%) having paroxysmal AF who underwent ablation with power 20/30W (anterior and posterior left atrial wall), 17 mL/min flow, and a contact force of 10-30 g for 30 s. High-power short-duration group (HPSD) contained 197 patients, with 113 (57.36%) having paroxysmal AF who underwent ablation at 45/50W of power with a contact force of 8-15 g/10-20 g and a 35 mL/min flow rate for 6-8 s on the anterior and the posterior left atrial wall, respectively. Both groups had pulmonary veins isolated and atrial flutter was ablated when needed. For patients not in sinus rhythm, cardioversion was performed before ablation RESULTS: There were no complications. LPLD group: Left atrial time 118.74 min, total 145.32 min, radiofrequency time 4317.99s, X-ray 13.42 min, and elevation of luminal esophageal temperature (LET) in 132 (84.53%) patients. HPSD group: Left atrial time 72.16 min, total 93.76 min, radiofrequency time 1511.29s, X-ray 7.6 min, and LET elevation in only 75 (38.07%) patients. A markedly higher rate of first-pass isolation was observed in HPSD compared to LPLD, 77.16% versus 13.29%, respectively. Recurrence occurred in 64 (40.50%) and 32 (16.24%) in 28.45 and 22.35 months in LPLD and HPSD patients, respectively. In LPLD, 10 patients were submitted to endoscopy, and one (10%) had mild erythema and in HPSD, 13 performed the endoscopy, with two (15.38%) patients showing mild erythema CONCLUSION: HPSD technique compared to the LPLD technique showed significant reduced radiofrequency and fluoroscopy times, higher rate of first-pass isolation, lower recurrence rate, and esophageal temperature elevation and may also have a protective effect avoiding incidental esophageal injury due to these findings.

Changes and impacts in early recurrences after atrial fibrillation ablation in contact force era: comparison of high-power short-duration with conventional technique-FIRST experience data.

BACKGROUND OR PURPOSE: Different atrial tachyarrhythmias (AT) may be seen during follow-up after atrial fibrillation ablation. Evaluate and analyze characteristics and management of AT following first atrial fibrillation (AF) ablation with high-power short-duration (HPSD) comparing to low-power long-duration (LPLD) and its impact on late outcome. METHODS: Observational, retrospective study, 144 patients submitted to HPSD and LPLD ablation. HPSD with 71 and LPLD with 73 patients and no major clinical differences between the two groups. RESULTS: AT occurred in 60 patients (41.67%) in entire follow-up. HPSD 22 patients had AT: 13 during blanking period (BP) and 9 after that. LPLD: 38 patients with AT, 14 during BP and 24 after that. During BP, HPSD showed high rate of atrial flutter/tachycardia in 9 (69.23) of 13 and LPLD 4 (28.57%) of 14 patients. At 12 months' follow-up, 62 (87.32%) of 71 HPSD patients were in sinus rhythm comparing to 49 (67.12%) of 73 patients in LPLD. CONCLUSIONS: HPSD ablation produced higher rates of early than late recurrence comparing to LPLD. Regular tachyarrhythmias were most common arrhythmia during BP with HPSD ablation and AF in LPLD. HPSD compared to LPLD showed a superiority in maintaining sinus rhythm at 12 months.

Long-Term Follow-Up of Cardioneuroablation to Treat Second-Degree Block After Slow Pathway Ablation.

We present the long-term follow-up of a 31-year-old woman who underwent cardioneuroablation (for atrioventricular (AV) block. Slow pathway ablation was performed in September 2017 with normal follow-up until April 2018, when the patient started noticing symptoms of palpitations at rest, and the electrocardiogram showed a Mobitz I AV block. A cardiac stress test and 24-h Holter monitoring demonstrated first- and second-degree block and normal AV conduction during times of higher heart rate. (Level of Difficulty: Advanced.).

Comparison of high-power short-duration (HPSD) ablation of atrial fibrillation using a contact force-sensing catheter and conventional technique: Initial results.

INTRODUCTION: Atrial fibrillation (AFib) ablation is alternative treatment to drugs. Literature suggests that use of contact force (CF) catheter with higher power for short periods is effective and safe. METHODS/RESULTS: Retrospectively analyzed 76 patients undergoing the first ablation. Third five patients-group A: 27 (77%) paroxysmal AFib (PAFib) and 8 (23%) persistent AFib (PersAFib) who underwent ablation at the power of 30 W-17 mL/minute flow with a CF of 10-30 g for 30 seconds. Fourty one patients-group B: 28 (68.3%) PAFib and 13 (31.70%) PersAFib underwent ablation using 45 W on posterior wall with CF of 8/15 g, as well as 50-W anterior wall with CF of 10/20 g-35 mL/minute flow for 6 seconds. Pulmonary vein isolation in both groups and ablated. For patients not in the sinus, we performed cardioversion before ablation. No complications. Group A: Left atrial time 110 ± 29 minutes, total 148 ± 33.6 minutes, radiofrequency time (RF) 4558 ± 1998 seconds, X-ray 8.5 ± 3.5 minutes, and elevation of esophageal temperature (ET) in 26 (74.3%). group B: Left atrial time 70.7 ± 18.5 minutes ( P < .00001), total 106 ± 23 minutes ( P < .00001), RF 1909 ± 675.8 seconds ( P < .00001), X-ray 8.8 ± 6.6 minutes ( P = .221) and elevation of ET in 21 (51.20% - P = .0578). In 6 and 12 months follow-up, we had 9 (25.71%) and 11 (31.42%) recurrences in group A and 5 (12.19%) and 7 (17.07%) in group B ( P = .231 at 6 and P = .14 at 12 months), respectively. CONCLUSIONS: HPSD was safe, useful, and efficient compared with CT, and reduced procedural time and total RF time. HPSD may reduce esophageal injury because of lower heating rate and it may reduce the recurrence of atrial tachyarrythmias.

Características e resultados do teste de inclinação na população sintomática: [revisão] / Characteristcs and results of tilt table testing in symptomatic population: [review] / Características y resultados de la prueba de inclinación en la población sintomática: [revisión]

Síncope é um sintoma de prevalência significativa na população geral e possui prognóstico variável de acordo com sua etiologia. O teste de inclinação ou Tilt-teste é um exame útil na investigação dos pacientes com Síncope, Hipotensão Postural e Disautonomia e trata-se de um exame já rotineiro em nosso meio. Objetivo: Analisar o índice de positividade do exame, além dos seus tipos de respostas mais comuns, e a necessidade do uso da sensibilização com dinitrato de isossorbida no auxílio do diagnóstico. Material e métodos: Entre o período de março de 2005 a junho de 2009, foram avaliados 348 pacientes submetidos ao Tilt-teste, dentre os quais, 244(70,1%) pacientes eram do sexo feminino com idade média de 36 anos. Resultados: O Tilt-teste foi negativo em 163(46,8%) pacientes. Nos exames positivos, o tipo mais comum de resposta foi a vasodepressora em 113(32,47%) pacientes, seguido pela resposta mista em 56(16,1%) pacientes e cardioninibiotória em 14(4%) pacientes. Dois pacientes apresentaram quadros de Disautonomia e Síndrome da Taquicardia Postural Ortostática (POTS). O tempo médio para positivação dos exames foi de 28 minutos após início da ortostase, sendo que, em 166(89,72%) pacientes, foi necessário uso de sensibilização com dinitrato de isossorbida por via sublingual. Conclusão: Na população estudada, observamos que o Tilt-teste foi positivo em 53,2% dos casos. Dentre esses pacientes, a forma mais comum de resposta da síncope neurocardiogênica foi a vasodepressora em 113 pacientes, sendo que o uso da sensibilização foi necessário em quase 90% dos pacientes na positivação dos exames.

Syncope is a symptom of significant prevalence in the general population and has changeable prognostic in accordance with its etiology. The inclination test or Tilt table test is a useful examination in the investigation of patients with syncope, postural hypotension and disautonomy and it is a routine examination already in our way. Objective: To analyze the positive rate of the exam, in addition to its most common types of response and the need of sensitization with isosorbide dinitrate to aid the diagnosis. Material and methods: 348 patients submitted to Tilt table test were evaluated between March of 2005 and June of 2009, 244 (70.1%) females at the mean age of 36 years. Results: The Tilt table test was negative in 163 (46.8%) patients. In the positive exams the most common type of response was the vasodepressor in 113 (32.47%) patients, followed by the mixed response in 56 (16.1%) patients and cardioinhibitory in 14 (4%) patients. Two patients had history of disautonomy and Postural Ortostatic Tachycardia Syndrome (POTS). The average time for positivation of the examinations was of 28 minutes after the beginning of the ortostasis, in 166 (89.72%) patients the use of sensitization with isosorbide dinitrate via sublingual was necessary. Conclusion: In the studied population weobserve that the Tilt table test was positive in 53,2% of the cases. Among these patients the most common response of neurocardiogenic syncope was the vasodepressor in 113 patients and the use of the sensitization was necessary in almost 90% of the patients in the positivation of the examinations.

Síncope es un síntoma de prevalencia significativa en la población general y tiene pronóstico variable de acuerdo con su etiología. La prueba de inclinación o Tilt-test es un examen útilen la investigación de los pacientes con Síncope, Hipotensión Postural y Disautonomia y ya se trata de un examen de rutina en nuestro medio. Objetivo: Analizar el índice de positividad del examen, además de sus tipos de respuestas más comunes, y la necesidad del uso de la sensibilización con dinitrato de isosorbida para ayudar el diagnóstico. Material y métodos: Entre el período de marzo de 2005 y junio de 2009, se evaluaron a 348 pacientes sometidos al Tilt-test, entre los cuales, 244 (70,1%) pacientes eran del sexo femenino con edad media de 36 años. Resultados: El Tilt-test fue negativo en 163 (46,8%) pacientes. En los exámenes positivos, el tipo más común de respuesta fue la vasodepresora en 113 (32,47%) pacientes, seguido de la respuesta mixta en 56 (16,1%) pacientes y cardioinhibitoria en 14 (4%) pacientes. Dos pacientes presentaron cuadros de Disautonomia y Síndrome de Taquicardia Postural Ortostática (POTS). El tiempo medio para positivación de losexámenes foi de 28 minutos tras el inicio de la ortostasis, siendo que, en 166 (89,72%) pacientes, fuenecesario el uso de sensibilización con dinitrato de isosorbida por vía sublingual. Conclusión: En la población estudiada, observamos que el Tilt-test fue positivo en el 53,2% de los casos. Entre dichos pacientes, la forma más común de respuesta del síncope neurocardiogénico fue la vasodepresora en 113 pacientes, siendo que el uso de la sensibilización fue necesario en casi el 90% de los pacientes en la positivación de los exámenes.