Pulsed-field versus cryoballoon ablation for atrial fibrillation-Impact of energy source on sedation and analgesia requirement.

INTRODUCTION: Pulsed field ablation (PFA) represents a novel, nonthermal energy modality that can be applied for single-shot pulmonary vein isolation (PVI) in atrial fibrillation (AF). Comparative data with regard to deep sedation to established single-shot modalities such as cryoballoon (CB) ablation are scarce. The aim of this study was to compare a deep sedation protocol in patients receiving PVI with either PFA or CB. METHODS: Prospective, consecutive AF patients undergoing PVI with a pentaspline PFA catheter were compared to a retrospective CB-PVI cohort of the same timeframe. Study endpoints were the requirements of analgesics, cardiorespiratory stability, and sedation-associated complications. RESULTS: A total of 100 PVI patients were included (PFA n = 50, CB n = 50, mean age 66 ± 10.6, 61% male patients, 65% paroxysmal AF). Requirement of propofol, midazolam, and sufentanyl was significantly higher in the PFA group compared to CB [propofol 0.14 ± 0.04 mg/kg/min in PFA vs. 0.11 ± 0.04 mg/kg/min in CB (p = .001); midazolam 0.00086 ± 0.0004 mg/kg/min in PFA vs. 0.0006295 ± 0.0003 mg/kg/min in CB (p = .002) and sufentanyl 0.0013 ± 0.0007 µg/kg/min in PFA vs. 0.0008 ± 0.0004 µg/kg/min in CB (p < .0001)]. Sedation-associated complications did not differ between both groups (PFA n = 1/50 mild aspiration pneumonia, CB n = 0/50, p > .99). Nonsedation-associated complications (PFA: n = 2/50, 4%, CB: n = 1/50, 2%, p > .99) and procedure times (PFA 75 ± 31, CB 84 ± 32 min, p = .18) did not differ between groups. CONCLUSIONS: PFA is associated with higher sedation and especially analgesia requirements. However, the safety of deep sedation does not differ to CB ablation.

Contemporary catheter ablation of complex atrial tachycardias after prior atrial fibrillation ablation: pulsed field vs. radiofrequency current energy ablation guided by high-density mapping.

AIMS: Catheter ablation (CA) of post-ablation left atrial tachycardias (LATs) can be challenging. So far, pulsed field ablation (PFA) has not been compared to standard point-by-point radiofrequency current (RFC) energy for LAT ablation. To compare efficacy of PFA vs. RFC in patients undergoing CA for LAT. METHODS AND RESULTS: Consecutive patients undergoing LAT-CA were prospectively enrolled (09/2021-02/2023). After electro-anatomical high-density mapping, ablation with either a pentaspline PFA catheter or RFC was performed. Patients were matched 1:1. Ablation was performed at the assumed critical isthmus site with additional ablation, if necessary. Right atrial tachycardia (RAT) was ablated with RFC. Acute and chronic success were assessed. Fifty-six patients (n = 28 each group, age 70 ± 9 years, 75% male) were enrolled.A total of 77 AT (n = 67 LAT, n = 10 RAT; 77% macroreentries) occurred with n = 32 LAT in the PFA group and n = 35 LAT in the RFC group. Of all LAT, 94% (PFA group) vs. 91% (RFC group) successfully terminated to sinus rhythm or another AT during ablation (P = 1.0). Procedure times were shorter (PFA: 121 ± 41 vs. RFC: 190 ± 44 min, P < 0.0001) and fluoroscopy times longer in the PFA group (PFA: 15 ± 9 vs. RFC: 11 ± 6 min, P = 0.04). There were no major complications. After one-year follow-up, estimated arrhythmia free survival was 63% (PFA group) and 87% (RFC group), [hazard ratio 2.91 (95% CI: 1.11-7.65), P = 0.0473]. CONCLUSION: Pulsed field ablation of post-ablation LAT using a pentaspline catheter is feasible, safe, and faster but less effective compared to standard RFC ablation after one year of follow-up. Future catheter designs and optimization of the electrical field may further improve practicability and efficacy of PFA for LAT.

Influence of Fracture Reduction on the Functional Outcome after Intramedullary Nail Osteosynthesis in Proximal Humerus Fractures.

Background: Optimal treatment of proximal humeral fractures (PHF) is still controversial. Therefore, we aim to investigate the influence of fracture reduction after intramedullary nailing of a PHF on the clinical outcome. Methods: Patients treated with intramedullary nail for PHF from 2013−2018, (minimum follow-up 12 months) were retrospectively included. Constant Score (CS), DASH and Simple Shoulder Test (SST) were collected. Postoperative radiographs were used to determine head-shaft-alignment (HSA), head-shaft-displacement (HSD), integrity of the medial hinge and the cranialization of the greater tuberosity (CGT). The results of fracture reduction were categorized as either "anatomical", "acceptable" or as "malreduction". Malreduction exists when at least one of the following parameters are present: HSA > 150/< 110°, HSD >5 mm, CTM > 5 mm or lack of integrity of the medial hinge. Results: 42 patients (mean age 65.5 ± 14.1 years, 15 male, 27 female) with a mean follow-up time of 43 months were included. The average CS was 60 ± 30, DASH 49.8 ± 24.3 and SST 62.9 ± 26.9. There was an "anatomic" reduction in 9 (21.4%), "acceptable" in 7 (16.6%) and a "malreduction" in 26 (62%) patients. Comparing the combined "anatomical" and "acceptable" reduction group with the "malreduction" group, worse scores were observed in the "malreduction" group (CS 67.2 vs. 55.2, DASH 45.2 vs. 51.9, SST: 69.3 vs. 58.6) without statistical significance (CS: p = 0.095, DASH: p = 0.307, SST: p = 0.400). By means of multiple logistic regression analyses no statistically significant risk factors were identified for lower DASH, CS and SST scores. Conclusions: Anatomical fracture reduction using intramedullary nails has a positive effect on postoperative outcome for the 3 scores recorded, without reaching statistical significance.