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. 2021 Sep 8;23(9):1391-1399.
doi: 10.1093/europace/euab090.

Pulsed field ablation selectively spares the oesophagus during pulmonary vein isolation for atrial fibrillation

Hubert Cochet  1   2 , Yosuke Nakatani  3 , Soumaya Sridi-Cheniti  2 , Ghassen Cheniti  3 , F Daniel Ramirez  3 , Takashi Nakashima  3 , Charles Eggert  4 , Christopher Schneider  4 , Raju Viswanathan  4 , Nicolas Derval  1   3 , Josselin Duchateau  1   3 , Thomas Pambrun  1   3 , Remi Chauvel  1   3 , Vivek Y Reddy  5 , Michel Montaudon  1   2 , François Laurent  1   2 , Frederic Sacher  1   3 , Mélèze Hocini  1   3 , Michel Haïssaguerre  1   3 , Pierre Jais  1   3
Affiliations

Pulsed field ablation selectively spares the oesophagus during pulmonary vein isolation for atrial fibrillation

Hubert Cochet et al. Europace. .

Abstract

Aims: Extra-atrial injury can cause complications after catheter ablation for atrial fibrillation (AF). Pulsed field ablation (PFA) has generated preclinical data suggesting that it selectively targets the myocardium. We sought to characterize extra-atrial injuries after pulmonary vein isolation (PVI) between PFA and thermal ablation methods.

Methods and results: Cardiac magnetic resonance (CMR) imaging was performed before, acutely (<3 h) and 3 months post-ablation in 41 paroxysmal AF patients undergoing PVI with PFA (N = 18, Farapulse) or thermal methods (N = 23, 16 radiofrequency, 7 cryoballoon). Oesophageal and aortic injuries were assessed by using late gadolinium-enhanced (LGE) imaging. Phrenic nerve injuries were assessed from diaphragmatic motion on intra-procedural fluoroscopy. Baseline CMR showed no abnormality on the oesophagus or aorta. During ablation procedures, no patient showed phrenic palsy. Acutely, thermal methods induced high rates of oesophageal lesions (43%), all observed in patients showing direct contact between the oesophagus and the ablation sites. In contrast, oesophageal lesions were observed in no patient ablated with PFA (0%, P < 0.001 vs. thermal methods), despite similar rates of direct contact between the oesophagus and the ablation sites (P = 0.41). Acute lesions were detected on CMR on the descending aorta in 10/23 (43%) after thermal ablation, and in 6/18 (33%) after PFA (P = 0.52). CMR at 3 months showed a complete resolution of oesophageal and aortic LGE in all patients. No patient showed clinical complications.

Conclusion: PFA does not induce any signs of oesophageal injury on CMR after PVI. Due to its tissue selectivity, PFA may improve safety for catheter ablation of AF.

Keywords: Atrial fibrillation; Cardiac magnetic resonance; Catheter ablation; Oesophagus; Pulsed field ablation.

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Figures

None
Graphical abstract
Figure 1
Figure 1
Examples of acute oesophageal injuries on CMR following thermal ablation. LGE CMR images acquired less than 3 h post-ablation are shown in four patients treated with RF (A, C) or cryoballoon (B, D). In each, the oesophagus is shown in a sagittal oblique view parallel to the oesophagus (left image), and in a transaxial view (right image). The dotted yellow lines indicate oesophagus location. All patients show intense and transmural oesophageal LGE in direct contact with atrial areas targeted by ablation, also exhibiting LGE. CMR, cardiac magnetic resonance; LGE, late gadolinium enhancement; RF, radiofrequency.
Figure 2
Figure 2
Absence of acute oesophageal injury on CMR after PVI using PFA. LGE CMR images acquired less than 3 h post-ablation are shown in four patients treated with PFA (A–D). In each, the oesophagus is shown in a sagittal oblique view parallel to the oesophagus (left image), and in a trans axial view (right image). The dotted yellow lines indicate oesophagus location. No oesophageal LGE is seen in any of the patients despite direct contact with LA wall regions targeted by ablation, and showing intense LGE. CMR, cardiac magnetic resonance; LGE, late gadolinium enhancement; PFA, pulsed field ablation; PVI, pulmonary vein isolation.
Figure 3
Figure 3
Examples of acute aortic injuries on CMR following thermal ablation or PFA. Sagittal oblique images parallel to the descending aorta are shown in three patients treated with PFA (A–C), and three patients treated with thermal methods (D: RF, E and F: cryoballoon). In each, baseline imaging is shown in the left column, and acute imaging acquired less than 3 h post-ablation is shown in the right column. All patients show LGE on the anterior wall of the descending aorta (yellow arrows), in direct contact with atrial areas targeted by ablation, also exhibiting LGE. Ao, aorta; CMR, cardiac magnetic resonance; LGE, late gadolinium enhancement; PFA, pulsed field ablation; RF, radiofrequency.
Figure 4
Figure 4
Acute extra-atrial damage on CMR after PVI with thermal vs. pulsed field ablation. (A) oesophageal injuries and (B) aortic injuries. CMR, cardiac magnetic resonance; LA, left atrium; PVI, pulmonary vein isolation.
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