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Clinical Trial
. 2021 Nov 8;23(11):1757-1766.
doi: 10.1093/europace/euab150.

How does the level of pulmonary venous isolation compare between pulsed field ablation and thermal energy ablation (radiofrequency, cryo, or laser)?

Iwanari Kawamura  1 , Petr Neuzil  2 , Poojita Shivamurthy  1 , Kenji Kuroki  1 , Jeff Lam  1 , Daniel Musikantow  1 , Edward Chu  1 , Mohit K Turagam  1 , Kentro Minami  2 , Moritoshi Funasako  2 , Jan Petru  2 , Subbarao Choudry  1 , Marc A Miller  1 , Marie-Noelle Langan  1 , William Whang  1 , Srinivas R Dukkipati  1 , Jacob S Koruth  1 , Vivek Y Reddy  1   2
Affiliations
Clinical Trial

How does the level of pulmonary venous isolation compare between pulsed field ablation and thermal energy ablation (radiofrequency, cryo, or laser)?

Iwanari Kawamura et al. Europace. .

Abstract

Aims: We studied the extent/area of electrical pulmonary vein isolation (PVI) after either pulsed field ablation (PFA) using a pentaspline catheter or thermal ablation technologies.

Methods and results: In a clinical trial (NCT03714178), paroxysmal atrial fibrillation (PAF) patients underwent PVI with a multi-electrode pentaspline PFA catheter using a biphasic waveform, and after 75 days, detailed voltage maps were created during protocol-specified remapping studies. Comparative voltage mapping data were retrospectively collected from consecutive PAF patients who (i) underwent PVI using thermal energy, (ii) underwent reablation for recurrence, and (iii) had durably isolated PVs. The left and right PV antral isolation areas and non-ablated posterior wall were quantified. There were 20 patients with durable PVI in the PFA cohort, and 39 in the thermal ablation cohort [29 radiofrequency ablation (RFA), 6 cryoballoon, and 4 visually guided laser balloon]. Pulsed field ablation patients were younger with shorter follow-up. Left atrial diameter and ventricular systolic function were preserved in both cohorts. There was no significant difference between the PFA and thermal ablation cohorts in either the left- and right-sided PV isolation areas, or the non-ablated posterior wall area. The right superior PV isolation area was smaller with PFA than RFA, but this disappeared after propensity score matching. Notch-like normal voltage areas were seen at the posterior aspect of the carina in the balloon sub-cohort, but not the PFA or RFA cohorts.

Conclusion: Catheter-based PVI with the pentaspline PFA catheter creates chronic PV antral isolation areas as encompassing as thermal energy ablation.

Keywords: Atrial fibrillation; Electroporation; Level of isolation; Pulmonary vein isolation; Pulsed field ablation.

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Figures

Figure 1
Figure 1
Catheter ablation technologies. PFA: The multispline PFA catheter is positioned at the ostia of each vein to deliver a therapeutic waveform. RFA: Point-by-point ablation lesions are delivered to achieve circumferential PVI. VGLB: Under endoscopic visual guidance, ablation lesions are delivered in a circumferential, contiguous, and overlapping manner around the vein. Cryoballoon: With the balloon apposed against the ostia of each vein, cryoapplications are delivered. PFA, pulsed field ablation; RFA, radiofrequency ablation; VGLB, visually guided laser balloon.
Figure 2
Figure 2
Patient selection flow chart. AF, atrial fibrillation; PAF, paroxysmal atrial fibrillation; PFA, pulsed field ablation; PV, pulmonary vein; RFA, radiofrequency ablation; VGLB, visually guided laser balloon.
Figure 3
Figure 3
Pulsed field ablation (PFA) vs. thermal energy ablation. The isolated area of each PV antrum and non-ablated posterior LA area were not significantly different between the cohorts. LIPV, left inferior pulmonary vein; LPV, left pulmonary vein; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RPV, right pulmonary vein; RSPV, right superior pulmonary vein.
Figure 4
Figure 4
Representative voltage maps. (A) Pulsed field ablation, (B) radiofrequency ablation, (C) cryoballoon ablation, and (D) visually guided laser balloon. In the balloon sub-cohorts, there were notch-like areas of normal voltage at the carinal areas (white arrows).
Figure 5
Figure 5
Pulsed field ablation (PFA) vs. radiofrequency ablation (RFA) vs. balloon ablation. The total ablation area and non-ablated area on the posterior LA wall were similar among the cohorts. The isolation area of the RSPV in the PFA cohort was smaller than that of RFA cohort, but similar to the balloon ablation cohort. LIPV, left inferior pulmonary vein; LPV, left pulmonary vein; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RPV, right pulmonary vein; RSPV, right superior pulmonary vein. *P<0.05
Figure 6
Figure 6
Pulsed field ablation (PFA) vs. radiofrequency ablation (RFA) after propensity matching. After the propensity scores matching, there was no significant difference in the RSPV isolation areas between the cohorts. Patients in the PFA cohort had a larger isolation area in at the left inferior PV than patients in the RFA cohort. LIPV, left inferior pulmonary vein; LPV, left pulmonary vein; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RPV, right pulmonary vein; RSPV, right superior pulmonary vein.
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