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. 2024 May;10(5):885-896.
doi: 10.1016/j.jacep.2023.12.015. Epub 2024 Feb 21.

Nitroglycerin to Ameliorate Coronary Artery Spasm During Focal Pulsed-Field Ablation for Atrial Fibrillation

Yury Malyshev  1 , Petr Neuzil  2 , Jan Petru  2 , Moritoshi Funasako  2 , Pavel Hala  2 , Karel Kopriva  2 , Christopher Schneider  3 , Anitha Achyutha  3 , Annelies Vanderper  3 , Daniel Musikantow  1 , Mohit Turagam  1 , Srinivas R Dukkipati  1 , Vivek Y Reddy  4
Affiliations
Free article

Nitroglycerin to Ameliorate Coronary Artery Spasm During Focal Pulsed-Field Ablation for Atrial Fibrillation

Yury Malyshev et al. JACC Clin Electrophysiol. 2024 May.
Free article

Abstract

Background: In treating atrial fibrillation, pulsed-field ablation (PFA) has comparable efficacy to conventional thermal ablation, but with important safety advantages: no esophageal injury or pulmonary vein stenosis, and rare phrenic nerve injury. However, when PFA is delivered in proximity to coronary arteries using a pentaspline catheter, which generates a broad electrical field, severe vasospasm can be provoked.

Objectives: The authors sought to study the vasospastic potential of a focal PFA catheter with a narrower electrical field and develop a preventive strategy with nitroglycerin.

Methods: During atrial fibrillation ablation, a focal PFA catheter was used for cavotricuspid isthmus ablation. Angiography of the right coronary artery (some with fractional flow reserve measurement) was performed before, during, and after PFA. Beyond no nitroglycerin (n = 5), and a few testing strategies (n = 8), 2 primary nitroglycerin administration strategies were studied: 1) multiple boluses (3-2 mg every 2 min) into the right atrium (n = 10), and 2) a bolus (3 mg) into the right atrium with continuous peripheral intravenous infusion (1 mg/min; n = 10).

Results: Without nitroglycerin, cavotricuspid isthmus ablation provoked moderate-severe vasospasm in 4 of 5 (80%) patients (fractional flow reserve 0.71 ± 0.08). With repetitive nitroglycerin boluses, severe spasm did not occur, and mild-moderate vasospasm occurred in only 2 of 10 (20%). Using the bolus + infusion strategy, severe and mild-moderate spasm occurred in 1 and 3 of 10 patients (aggregate 40%). No patient had ST-segment changes.

Conclusions: Ablation of the cavotricuspid isthmus using a focal PFA catheter routinely provokes right coronary vasospasm. Pretreatment with high doses of parenteral nitroglycerin prevents severe spasm.

Keywords: atrial fibrillation; catheter ablation; cavotricuspid isthmus; cavotricuspid isthmus ablation; nitroglycerin; pulsed field ablation; spasm; vasospasm.

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Conflict of interest statement

Funding Support and Author Disclosures This study was supported by Boston Scientific Inc. Dr Neuzil has received grant support and consulting from Farapulse-Boston Scientific, as well as grant support from Adagio and Kardium; and grant support and consulting from Abbott, Biosense Webster, BTL, Cardiofocus, and Medtronic. Mr Schneider, Ms Achyutha, and Ms Vanderper are employees of Boston Scientific. Dr Dukkipati has equity in Farapulse-Boston Scientific, and unrelated to this manuscript, equity in Manual Surgical Sciences, and serves as a consultant to Biosense Webster. Dr Reddy has received consulting fees (and equity—now divested) from Farapulse Inc and is a consultant for Boston Scientific Inc; serves as a consultant for and has equity in Ablacon, Acutus Medical, Affera-Medtronic, Anumana, Apama Medical-Boston Scientific, APN Health, Aquaheart, Atacor, Autonomix, Axon Therapies, Backbeat, BioSig, CardiaCare, Cardiofocus, CardioNXT / AFTx, Circa Scientific, CoRISMA, Corvia Medical, Dinova-Hangzhou DiNovA EP Technology, East End Medical, EPD-Philips, EP Frontiers, Epix Therapeutics-Medtronic, EpiEP, Eximo, Field Medical, Focused Therapeutics, HRT, Intershunt, Javelin, Kardium, Keystone Heart, Laminar, LuxMed, Medlumics, Middlepeak, Neutrace, Nuvera-Biosense Webster, Oracle Health, Restore Medical, Sirona Medical, SoundCath, Valcare; unrelated to this work; has served as a consultant for Abbott, Adagio Medical, AtriAN, Biosense-Webster, BioTel Heart, Biotronik, Cairdac, Cardionomic, CoreMap, Fire1, Gore & Associates, Impulse Dynamics, Medtronic, Novartis, Novo Nordisk, Philips, Pulse Biosciences; and has equity in DRS Vascular, Manual Surgical Sciences, Newpace, Nyra Medical, Surecor, and Vizaramed. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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