1Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland; 2Universitätsmedizin Göttingen Herzzentrum, Klinik für Kardiologie und Pneumologie Göttingen, Deutschland; 3GZO Spital Wetzikon Klinik für Kardiologie und Angiologie Wetzikon, Schweiz
Background
Catheter ablation of atrial fibrillation (AF) aiming at pulmonary vein isolation (PVI) is a time-demanding procedure. Ablation settings using high power and short energy (HPSD) application have been introduced into clinical practice. Modern mapping catheters allow for high-density mapping during ablation procedures. We systematically assessed the implementation of high-density mapping catheters and HPSD ablation protocols into our institutional routine workflow and its impact on procedural timings, efficacy and safety.
Methods
Three ablation setups for PVI were analyzed: 1) Ablation under guidance of a lesion quality index (Ablation index=AI) (30/35W AI) alongside mapping with a circular catheter; 2) HPSD using 50 W under AI-guidance and mapping with a pentaspline mapping catheter (50W AI); 3) HPSD ablation with 90W over 4 seconds with a novel catheter allowing for high energy setting ablation and mapping with a pentaspline catheter (90W/4-sec group). Lab cycle analysis was performed on 6 procedural steps (Preprocedural preparation, vascular access and transseptal puncture, left atrial mapping, ablation, validation of PVI and vascular closure, post-procedural preparation) using a specific computer application (Lab Optimization Tool, Biosense Webster). Total procedure times as well as “skin-to-skin” times from vascular access to closure were assessed. Follow-up included clinical investigation, TTE, ECG and Holter ECG (24-72 hours after 6 and 12 months and every 6 to 12 months afterwards.
Results
A total of 307 patients were analyzed (30/35W AI n=102, 50W AI n=102, 90W/4 sec n=103). Patients baseline data are shown in Table 1. Skin-to-skin times (105.3±22.7 minutes (30/35W AI) vs. 81.4±21.3 minutes (50W AI) vs 69.5±12.2 minutes (90W/4 sec), P=<0.001) and total laboratory times (132.8±42.1 minutes vs. 107.4±25.7 minutes vs 95.2±14.0 minutes, p<0.001) were significantly different among study groups (Figure 1, Table 2). Laboratory interval analysis showed shortened mapping and ablation times resulted in above mentioned differences (Figure 1, Table 2). Arrhythmia-free survival after 12 months was not significantly different among study groups (log rank P=0.96) (Figure 2).
Conclusion
The incorporation of high-density mapping and HPSD into AF ablation led to procedural time shortening durations without compromising effectiveness and safety in AF ablation.
Table 1
|
Parameter |
35/30 W |
50 W |
90 W |
P value |
|
Patients, n |
102 |
102 |
103 | |
|
Female, n (%) |
35 (34.3) |
32 (31.4) |
32 (31.1) |
0.86 |
|
Age (years) |
67.7±11.4 |
65.4±11.2 |
66.9±10.4 |
0.32 |
|
LA diameter (mm) |
45.6±3.3 |
46.1±3.1 |
45.5±4.2 |
0.44 |
|
LVEF (%) |
51.1±9.7 |
50.9±10.2 |
52.1±7.7 |
0.61 |
|
Paroxysmal AF, n (%) |
37 (36.3) |
35 (34.3) |
34 (33.0) |
0.89 |
|
Persistent AF, n(%) |
67 (65.7) |
70 (68.6) |
69 (67.0) |
0.90 |
|
CHA2DS2-VASC-Score, median (IQR) |
2 (2;4) |
3 (2;4) |
2 (1;3) |
0.92 |
Data are presented as n (%) or mean±standard deviation.
Table 2
|
Parameter |
Pre-procedural [min] |
Vascular access + TSP [min] |
Mapping [min] |
Ablation [min] |
Validation + vascular closure [min] |
Post-procedural [min] |
“Skin-to-skin“ [min] |
Total duration [min] |
|
30/35W AI-guided |
20.7±7.1 |
30.2±10.7 |
19.3±5.7 |
51.1±14.1 |
4.7±2.4 |
6.8±3.0 |
105.3±22.7 |
132.8±42.1 |
|
50W AI-guided |
19.1±6.6 |
28.5±12.7 |
15.2±5.2 |
34.2±11.8 |
3.5±1.8 |
6.9±2.1 |
81.4±21.3 |
107.4±25.7 |
|
90W / 4 sec |
19.0±5.9 |
27.7±10.2 |
13.1±6.9 |
25.4±8.9 |
3.3±2.1 |
6.7±1.7 |
69.5±12.2 |
95.2±14.0 |
|
P value |
0.11 |
0.27 |
<0.001 |
<0.001 |
<0.001 |
0.83 |
<0.001 |
<0.001 |
Data are presented as mean±SD.
Figure 1
Figure 2