Takigawa Masateru, Miyazaki Shinsuke, Yamamoto Tasuku, Martin Claire A, Nozaki Sayumi, Yamaguchi Junji, Kawamura Iwanari, Ikenouchi Takashi, Negishi Miho, Goto Kentaro, Shigeta Takatoshi, Nishimura Takuro, Takamiya Tomomasa, Tao Susumu, Goya Masahiko, Sasano Tetsuo
Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, 113-8510, Tokyo, Japan.
Royal Papworth Hospital, Cambridge, CB20AY.
J Cardiovasc Electrophysiol. 2025 Jan;36(1):111-123. doi: 10.1111/jce.16453. Epub 2024 Nov 6.
Very high-power short-duration (vHPSD) ablation creates shallower lesions, potentially reducing efficacy. This study aims to identify factors leading to insufficient lesions during pulmonary vein antral isolation (PVAI) with vHPSD-ablation and to develop an optimized PVAI strategy using this technology.
PVAI was performed on 41 atrial fibrillation patients using vHPSD-ablation (90 W/4 s). Lesion parameters were recorded and analyzed to identify predictors of insufficient lesions. An optimized PVAI strategy, based on these predictors, was tested in subsequent 42 patients.
In total, 3099 RF-applications, including 103(3.3%) insufficient lesions, were analyzed. First-pass PVAI was achieved in 19/40(47.5%) right PVs and 24/41(58.5%) left PVs. Multivariate analysis identified significant predictors of insufficient lesions: local largest bipolar voltage (Bi-V), average contact force, baseline impedance, impedance drop, temperature rise, inter-lesion distance (ILD), and anatomical location (carina or not). An ILD:4-6 mm increased the risk of insufficient lesions 2.2-fold, and lesions at the carina increased it 3.6-fold for both ILD < 4 mm and ILD:4-6 mm. Local largest Bi-V was the strongest predictor for insufficient lesions. The optimized PVAI approach, utilizing vHPSD-ablation with an ILD < 4 mm in non-carinal areas with Bi-V < 4 mV, and high-power ablation-index guided ablation (HPAI, 50 W, ablation-index:450-550) in remaining areas, achieved first-pass PVAI in 92.7% of right PVs and 88.1% of left PVs, using vHPSD-ablation in approximately 65% of total RF-applications. The optimized PVAI achieved significantly higher first-pass PVI rate (p < .0001) with shorter ablation time (p = .04).
Appropriate use of vHPSD and HPAI, based on local largest Bi-V and anatomical information, may achieve high first-pass PVAI rates in shorter ablation time with minimal energy delivery.
超高功率短持续时间（vHPSD）消融产生的损伤较浅，可能会降低疗效。本研究旨在确定在使用vHPSD消融进行肺静脉前庭隔离（PVAI）期间导致损伤不足的因素，并开发一种使用该技术的优化PVAI策略。
对41例心房颤动患者使用vHPSD消融（90W/4s）进行PVAI。记录并分析损伤参数，以确定损伤不足的预测因素。基于这些预测因素的优化PVAI策略在随后的42例患者中进行了测试。
总共分析了3099次射频应用，包括103次（3.3%）损伤不足的情况。右肺静脉19/40（47.5%）和左肺静脉24/41（58.5%）实现了首次通过PVAI。多因素分析确定了损伤不足的显著预测因素：局部最大双极电压（Bi-V）、平均接触力、基线阻抗、阻抗下降、温度升高、病变间距离（ILD）和解剖位置（是否靠近隆突）。当ILD为4 - 6mm时，损伤不足的风险增加2.2倍，对于ILD < 4mm和ILD为4 - 6mm的情况，隆突处的病变使其风险增加3.6倍。局部最大Bi-V是损伤不足的最强预测因素。优化的PVAI方法是，在Bi-V < 4mV的非隆突区域使用ILD < 4mm的vHPSD消融，在其余区域使用高功率消融指数引导消融（HPAI，50W，消融指数：450 - 550），在约65%的总射频应用中使用vHPSD消融，右肺静脉92.7%和左肺静脉88.1%实现了首次通过PVAI。优化的PVAI实现了显著更高的首次通过PVI率（p <.0001），且消融时间更短（p = 0.04）。
基于局部最大Bi-V和解剖信息适当使用vHPSD和HPAI，可能在更短的消融时间内以最小的能量传递实现高首次通过PVAI率。
