Homolka Hospital, Prague, Czech Republic; Icahn School of Medicine at Mount Sinai, New York, New York.
Clinical Hospital Center Split, Split, Croatia.
J Am Coll Cardiol. 2020 Sep 1;76(9):1068-1080. doi: 10.1016/j.jacc.2020.07.007.
Unlike for paroxysmal atrial fibrillation (AF), pulmonary vein isolation (PVI) alone is considered insufficient for many patients with persistent AF. Adjunctive ablation of the left atrial posterior wall (LAPW) may improve outcomes, but is limited by both the difficulty of achieving lesion durability and concerns of damage to the esophagus-situated behind the LAPW.
This study sought to assess the safety and lesion durability of pulsed field ablation (PFA) for both PVI and LAPW ablation in persistent AF.
PersAFOne is a single-arm study evaluating biphasic, bipolar PFA using a multispline catheter for PVI and LAPW ablation under intracardiac echocardiographic guidance. A focal PFA catheter was used for cavotricuspid isthmus ablation. No esophageal protection strategy was used. Invasive remapping was mandated at 2 to 3 months to assess lesion durability.
In 25 patients, acute PVI (96 of 96 pulmonary veins [PVs]; mean ablation time: 22 min; interquartile range [IQR]: 15 to 29 min) and LAPW ablation (24 of 24 patients; median ablation time: 10 min; IQR: 6 to 13 min) were 100% acutely successful with the multispline PFA catheter alone. Using the focal PFA catheter, acute cavotricuspid isthmus block was achieved in 13 of 13 patients (median: 9 min; IQR: 6 to 12 min). The median total procedure time was 125 min (IQR: 108 to 166 min) (including a median of 28 min [IQR: 25 to 33 min] for voltage mapping), with a median of 16 min (IQR: 12 to 23 min) fluoroscopy. Post-procedure esophagogastroduodenoscopy and repeat cardiac computed tomography revealed no mucosal lesions or PV narrowing, respectively. Invasive remapping demonstrated durable isolation (defined by entrance block) in 82 of 85 PVs (96%) and 21 of 21 LAPWs (100%) treated with the pentaspline catheter. In 3 patients, there was localized scar regression of the LAPW ablation, albeit without conduction breakthrough.
The unique safety profile of PFA potentiated efficient, safe, and durable PVI and LAPW ablation. This extends the potential role of PFA beyond paroxysmal to persistent forms of AF. (Pulsed Fields for Persistent Atrial Fibrillation [PersAFOne]; NCT04170621).
与阵发性心房颤动 (AF) 不同，对于许多持续性 AF 患者，单纯进行肺静脉隔离 (PVI) 被认为是不够的。左心房后壁 (LAPW) 的辅助消融可能会改善疗效，但由于难以实现病变持久性以及担心损伤位于 LAPW 后面的食管，该方法受到限制。
本研究旨在评估脉冲场消融 (PFA) 治疗持续性 AF 时进行 PVI 和 LAPW 消融的安全性和病变持久性。
PersAFOne 是一项单臂研究，使用多线导管在心脏内超声引导下评估双相、双极 PFA 治疗 PVI 和 LAPW 消融。使用焦点 PFA 导管进行三尖瓣峡部消融。未使用食管保护策略。在 2 至 3 个月时进行有创重映射以评估病变持久性。
在 25 例患者中，多线 PFA 导管单独行急性 PVI（96 例中的 96 例肺静脉[PVs]；平均消融时间：22 分钟；四分位距 [IQR]：15 至 29 分钟）和 LAPW 消融（24 例中的 24 例；中位消融时间：10 分钟；IQR：6 至 13 分钟）均 100%即刻成功。使用焦点 PFA 导管，13 例中的 13 例（中位时间：9 分钟；IQR：6 至 12 分钟）即刻实现三尖瓣峡部阻滞。中位总手术时间为 125 分钟（IQR：108 至 166 分钟）（包括中位 28 分钟[IQR：25 至 33 分钟]用于电压映射），透视中位时间为 16 分钟（IQR：12 至 23 分钟）。术后食管胃十二指肠镜和心脏 CT 复查分别未见粘膜损伤或 PV 狭窄。侵入性重映射显示，用五线导管治疗的 85 个 PVs 中有 82 个（96%）和 21 个 LAPWs（100%）达到了持久的隔离（定义为入口阻滞）。在 3 例患者中，LAPW 消融部位的局部瘢痕消退，但无传导突破。
PFA 的独特安全性使高效、安全和持久的 PVI 和 LAPW 消融成为可能。这将 PFA 的潜在作用从阵发性扩展到持续性 AF。（脉冲场治疗持续性心房颤动 [PersAFOne]；NCT04170621）。
