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. 2023 Feb 8;25(1):65-73.
doi: 10.1093/europace/euac111.

Characterization of circumferential antral pulmonary vein isolation areas resulting from pulsed-field catheter ablation

Marius Bohnen  1 , Reinhold Weber  1 , Jan Minners  1 , Amir Jadidi  1 , Martin Eichenlaub  1 , Franz-Josef Neumann  1 , Thomas Arentz  1 , Heiko Lehrmann  1
Affiliations

Characterization of circumferential antral pulmonary vein isolation areas resulting from pulsed-field catheter ablation

Marius Bohnen et al. Europace. .

Abstract

Aims: The cornerstone of pulmonary vein (PV) isolation (PVI) is a wide-area circumferential ablation (WACA) resulting in an antral PVI area. Pulsed-field ablation (PFA) is a new nonthermal 'single-shot' PVI technique resulting in well-characterized posterior isolation areas. However, information on circumferential PVI area is lacking. Thus, we sought to characterize the circumferential antral PVI areas after PFA-PVI.

Methods and results: Atrial fibrillation (AF) patients underwent fluoroscopy-guided PVI with a pentaspline PFA catheter. Ultra-high-density voltage maps using a 20-polar circular mapping catheter were created before and immediately after PVI to identify and quantify (i) insufficient isolation areas per antral PV segment (10-segment model) and (ii) enlarged left atrial (LA) isolation areas (beyond the antral PV segments) per LA region (8-region model). The PFA-PVI with pre- (5469 ± 1822 points) and post-mapping (6809 ± 2769 points) was performed in 40 consecutive patients [age 62 ± 6 years, 25/40 (62.5%) paroxysmal AF]. Insufficient isolation areas were located most frequently in the anterior antral PV segments of the left PVs (62.5-77.5% of patients) with the largest extent (median ≥0.4 cm2) located in the same segments (segments 2/5/8). Enlarged LA isolation areas were located most frequently and most extensively on the posterior wall and roof region (89.5-100% of patients; median 1.1-2.7 cm2 per region).

Conclusion: Fluoroscopy-guided PFA-PVI frequently results in insufficient isolation areas in the left anterior antral PV segments and enlarged LA isolation areas on the posterior wall/roof, which both may be extensive. To optimize the procedure, full integration of PFA catheter visualization into three-dimensional-mapping systems is needed.

Keywords: Antral; Catheter ablation; Circumferential; Isolation area; Pulmonary vein isolation; Pulsed-field ablation.

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Conflict of interest statement

Conflict of interest: M.B. reports educational grant support from Boston Scientific (Fellowship ‘Herzrhythmus’). F.J.N. reports lecture fees paid to his institution from Amgen, Bayer Healthcare, Boehringer Ingelheim, Boston Scientific, Daiichi Sankyo, Edwards Lifesciences, Ferrer, Pfizer, Novartis; consultancy fees paid to his institution from Boehringer Ingelheim, Novartis, and grant support from Bayer Healthcare, Boston Scientific, Biotronik, Edwards Lifesciences, GlaxoSmithKline, Medtronic, Pfizer, Abbot Vascular. All the remaining authors have declared no conflicts of interest.

Figures

Figure 1
Figure 1
Frequency of insufficient isolation area per antral pulmonary vein segments (n = 40). Data are displayed as percentage. LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; PV, pulmonary veins; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.
Figure 2
Figure 2
Examples of resulting isolation areas. (A, B) Insufficient isolation of the left anterior antral pulmonary vein segments. (C) Sufficient isolation of the left anterior antral pulmonary vein segments. (D) Enlarged isolation of the posterior wall. (E) Sufficient circumferential antral pulmonary vein isolation areas with acceptable degree of enlarged ablation. LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; PV, pulmonary veins; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.
Figure 3
Figure 3
Extent of insufficient isolation area per antral left and right pulmonary vein segments (n = 40). Data are displayed as median (interquartile range). Bold P values highlight statistical significance. *Indicates comparison between PV segment 1 and 10. LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; PV, pulmonary veins; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein; S, segment.
Figure 4
Figure 4
Extent of enlarged isolation area per left atrium region (n = 38). Data are displayed as median (interquartile range). Bold P values highlight statistical significance. LA, left atrium.
See this image and copyright information in PMC

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