Quantitative assessment of transient autonomic modulation after single-shot pulmonary vein isolation with pulsed-field ablation.

INTRODUCTION: Pulmonary vein isolation (PVI) with thermal energy is characterized by concomitant ablation of the surrounding ganglionated plexi (GP). Pulsed-field ablation (PFA) selectively targets the myocardium and seems associated with only negligible effects on the autonomic nervous system (ANS). However, little is known about the dynamic effects of PFA on the GP immediately after PVI. This study sought to investigate the degree and acute vagal modulation induced by the FarapulseTM PFA system during PVI compared with single-shot thermal ablation. METHODS: A total of 76 patients underwent first-time PVI with either FarapulseTM PFA (PFA group, n = 40) or cryoballoon ablation (thermal ablation group, n = 36) for paroxysmal atrial fibrillation (AF). The effect on the ANS in the two groups was assessed before and after PVI with extracardiac vagal stimulation (ECVS). To capture any transient effects of PFA on the ANS, in a subgroup of PFA patients ECVS was repeated at three predefined timepoints: (1) before PVI (T0); (2) immediately after PVI (T1); and (3) 10 min after the last energy application (T2). RESULTS: Despite similar baseline values, the vagal response induced by ECVS after PVI almost disappeared in the thermal ablation group but persisted in the PFA group (thermal group: 840 [706-1090] ms, p < .001 compared to baseline; PFA group: 11 466 [8720-12 293] ms, p = .70 compared to baseline). Intraprocedural vagal reactions (defined as RR increase >50%, transitory asystole, or atrioventricular block) occurred more frequently with PFA than thermal ablation (70% vs. 28%, p = .001). Moreover, heart rate 24 h post-PVI increased more with thermal ablation than with PFA (16.5 ± 9.0 vs. 2.6 ± 6.1 beats/min, p < .001). In the subgroup of PFA patients undergoing repeated ANS modulation assessment (n = 11), ECVS demonstrated that PFA determined a significant acute suppression of the vagal response immediately after PVI (p < .001 compared to baseline), which recovered almost completely within 10 min. CONCLUSION: PVI with the FarapulseTM PFA system is associated with only transitory and short-lasting vagal effects on the ANS which recover almost completely within a few minutes after ablation. The impact of this phenomenon on AF outcome needs to be further investigated.

Universal Method of Compatibility Assessment for Novel Ablation Technologies With Different 3D Navigation Systems.

Background: New technologies for ablation procedures are often produced by different companies with no cross-compatibility out of the box. This is not a negligible clinical problem since those separately developed devices are often used together. The aim of this study was to develop a bench-testing method to assess compatibility between the DiamondTemp ablation system (DTA) and the Rhythmia electroanatomic mapping system (EAM). Methods: Different setups were tested. DTA was connected to the Rhythmia EAM using the following configurations: 3.1. An Ensite EPT GenConnect box (GCB) and Rhythmia Maestro GCB (Maestro GCB, native Rhythmia setup); 3.2. The Medtronic GCB-E and Maestro GCB; 3.3. The Medtronic GCB-E out via the Medtronic GCB-E directly to the Rhythmia at box 1 (pin A61 to A64). Results: The DTA location was represented in real-time on the Rhythmia EAM. A proper tracking of the DTA was observed in all setups tested by visual comparison of physical catheter movements and its representation on EAM. In configuration 3.1, a significant shift was observed after the first radio frequency (RF) application; however, further applications caused no further shift. In setup 3.2, no significant shift was observed. The setup 3.3 showed a massive shift in the catheter position before ablation compared to baseline points acquired using the Orion catheter as a reference. Conclusions: A universal and reproducible solution for compatibility testing between the various mapping systems and the ablation catheters has been described. DTA has been demonstrated as compatible with Rhythmia EAM with satisfactory results if a specific setup is used.

The assessment of pulmonary vein potentials using the new achieve advance during cryoballoon ablation of atrial fibrillation.

BACKGROUND: The new version of inner lumen mapping catheter (Achieve Advance™; Medtronic, Minnesota, USA) includes a new solid core which provides improved rotational response, as compared to the current Achieve Mapping Catheter. In the present study, we sought to analyze the rate of visualisation of real-time recordings using this new device comparing it with a large cohort of patients having undergone second generation cryoballoon (CB) ablation using the previous Achieve mapping catheter. METHODS: All patients having undergone CB ablation using the Achieve Advance and the last 150 consecutive patients having undergone CB ablation using the previous Achieve were analysed. Exclusion criteria were presence of an intracavitary thrombus, uncontrolled heart failure, moderate or severe valvular disease and contraindications to general anesthesia. RESULTS: A total of 200 consecutive patients (60.1 ±â€¯9.5 years, 75% males) were evaluated (50 Achieve Advance and 150 old Achieve). Real-time recordings were significantly more prevalent in the "new Achieve Advance" population compared with the "old Achieve" group (73.5% vs 56.8%; p = 0.0001). Real-time recordings could be more frequently visualized in the "Achieve Advance" group in all veins except RIPV (LSPV: 86% vs 71.3%, p = 0.04; LIPV: 84% vs 62.7%, p = 0.005; RSPV: 78% vs 52%, p < 0.0001; RIPV: 46% vs 41.3%, p = 0.3). CONCLUSIONS: The rate of visualisation of real-time recordings is significantly higher using the new Achieve Advance if compared to the previous Achieve mapping catheter in the setting of CB ablation. Real-time recordings can be visualized in approximately 73.5% of veins with this new device.