Initial experience of transoesophageal echocardiography-guided percutaneous pulsed field ablation of atrial fibrillation

Abstract

Objective: Pulsed-field ablation (PFA) is a new technology of catheter ablation for atrial fibrillation (AF). This research is to investigate the feasibility of a new strategy (transoesophageal echocardiography-guided pulsed field ablation, TEEP) to guide PFA for AF with no contrast and zero fluoroscopy.

Methods: Patients with AF underwent TEEP under general anaesthesia with the guidance of three-dimensional (3D) transoesophageal echocardiography (TEE) throughout the procedure. After a successful transseptal puncture, the PFA catheter (CardiPulse) was delivered to the different pulmonary veins sequentially for standard PFA, and the pulmonary vein electrical isolation (PVI) was observed in real-time. After the ablation, left atrial bipolar voltage mapping under sinus rhythm was performed to verify the PVI.

Results: 10 patients with AF were enrolled, including 6 patients with paroxysmal AF and 4 patients with persistent AF. The mean operative time was 99±14 min, the mean time of the left atrial manoeuvre was 66±23 min, and the mean PFA ablation time was 105±8 s. First-pass PVI of all veins was achieved in all patients, thus no additional PFA applications were needed after the initial set. No contrast was needed and no X-ray was exposed. No complications were observed.

Conclusions: We report the preliminary application of 3D TEE-guided PFA for AF in the world. Its immediate safety and efficacy are promising. Compared with traditional PFA procedures, TEEP has many advantages, including accuracy of the transeptal puncture, direct visualisation of contact between the catheter and myocardial tissue, no contrast and zero fluoroscopy.

Keywords: Atrial Fibrillation; Catheter Ablation; Echocardiography; Electrocardiography.

Figure 1. Preablation and postablation PV potential. After one pulsed field application (PFA), the disappearance of PV potentials (B) compared with preablation (A). PV, pulmonary venous.

Figure 2. Postablation LA voltage maps. (A) Anteroposterior 3D electroanatomical views of the LA preablation (left panel) and postablation (right panel). (B) A right anterior oblique position. The colour purple is bipolar voltage >0.5 mV, and the colour grey is bipolar voltage <0.1 mV. LA, left atrium; LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; MA, mitral annulus; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.

Figure 3. The contact between the PV ostium and PFA catheter with different morphology. The left shows the PFA catheter with basket morphology, right shows the PFA catheter with flow morphology. See the movie in online supplemental video 6. PFA, pulsed-field ablation; PV, pulmonary venous.

Figure 4. 3D TEE-guided PFA catheter rotation to overlap the targeted ablation area. The left side shows the lesion of the previous PFA with white dots, and the right side shows the lesion of the next PFA with yellow dots. See the movie in the online supplemental video 7. PFA, pulsed-field ablation; TEE, transoesophageal echocardiography.