Elsevier

Heart Rhythm

Volume 17, Issue 8, August 2020, Pages 1223-1231
Heart Rhythm

Clinical
Atrial Fibrillation
High-power, short-duration atrial fibrillation ablations using contact force sensing catheters: Outcomes and predictors of success including posterior wall isolation

https://doi.org/10.1016/j.hrthm.2020.03.022Get rights and content

Background

Little is known about the long-term outcomes and predictors of success of high-power, short-duration (HPSD) contact force (CF) atrial fibrillation (AF) ablations.

Objective

The purpose of this study was to determine long-term freedom from AF and predictors of freedom from AF for 50-W, 5- to 15-second CF ablation.

Methods

We examined 4-year outcomes and predictors of freedom from AF after AF ablation for 1250 consecutive patients undergoing HPSD CF ablations.

Results

Patient demographics were age 66.6 ± 10.5 years, female 30.9%, left atrial (LA) size 4.26 ± 0.66 cm, paroxysmal AF 35.7%, persistent AF 56.6%, and longstanding AF 7.7%. Initial ablation times were procedure 114.2 ± 45.9 minutes, fluoroscopy 15.5 ± 11.5 minutes, and total radiofrequency 20.6 ± 7.7 minutes. TactiCath was used in 47.7%, SmartTouch in 52.3%, and posterior wall isolation (PWI) was performed in 34%. Four-year freedom from AF after multiple ablations were paroxysmal AF 87.0%, persistent AF 71.9%, and longstanding AF 64.9%. Single procedure success was 74.9% for TactiCath, 64.7% for SmartTouch (P <.001), and 73.0% for no PWI vs 58.9% for PWI (P <.0001). PWI did not change outcomes for paroxysmal AF but had worse outcomes for nonparoxysmal AF. Multivariate analysis showed 6 independent predictors of worse outcome after initial ablation: older age (P = .014), female gender (P <.0001), persistent AF (P = .0001), larger LA size (P <.001), PWI (P = .049), and use of SmartTouch vs TactiCath catheter (P = .007). Redo ablations were performed in 13.8%, and the outcome was better when more veins had reconnected after the initial ablation and when AF was paroxysmal.

Conclusion

Analysis revealed 6 independent predictors of outcome for HPSD CF. At redo ablations, the outcome was better if more veins had reconnected and could be re-isolated.

Introduction

Atrial fibrillation (AF) ablation has become standard treatment of patients with AF. Ablation therapy reduces AF burden and alleviates symptoms. In patients with heart failure, it improves survival and reduces hospitalizations.1 Improvements in the procedural aspects of AF ablation include better 3-dimensional mapping systems, use of irrigated-tip radiofrequency (RF) ablation catheters, the introduction of contact force (CF) measurements, and methods for determining lesion formation, such as loss of pace capture during ablation2 and monitoring the Lesion Index (LSI, St Jude, St Paul, MN) and the Ablation Index (AI, Biosense Webster, Diamond Bar, CA).3 Increasing use of high-power, short-duration (HPSD) RF ablation can shorten procedure and fluoroscopy times and may improve outcomes.2,4, 5, 6 HPSD ablations have been shown to be at least as safe as other types of RF ablation.7 Studies comparing CF to non-CF ablation have been reported,8,9 but only a few have reported long-term outcomes related to the use of both CF and HPSD ablation. Most studies of CF sensing have reported on patients with paroxysmal AF but only a few have reported on patients with persistent AF.10,11 In the present study, we examined long-term outcomes in a cohort of patients with all types of AF undergoing HPSD ablation using CF catheters. We examined procedural data, clinical outcomes, predictors of outcome, and results of redo ablations.

Section snippets

Patient population

Study subjects consisted of consecutive symptomatic patients undergoing initial AF ablation at Sequoia Hospital (Redwood City, CA) from March 27, 2014, to December 31, 2017. Patients who previously had undergone AF ablation or a surgical AF procedure were excluded. Patients with a previous right atrial cavotricuspid isthmus (CTI) flutter ablation were included. All patients signed written informed consent for the ablation procedure. Data collection was prospective, analysis was retrospective,

Patient population

The subjects of this study were 1250 consecutive patients undergoing 1433 ablations for symptomatic AF. AF was paroxysmal in 447 (35.7%), persistent in 707 (56.6%), and longstanding in 96 (7.7%). Mean age was 66.6 ± 10.5 years, and 386 patients (30.9%) were female. Average LA size was 4.26 ± 0.66 cm. AF was present for 5.5 ± 6.9 years, and patients had not responded to 1.00 ± 0.89 AADs before ablation. Duration of postablation follow-up was 2.1 ± 1.0 years. Table 1 lists demographics for the

Discussion

Several studies have examined AF ablation outcomes using CF sensing catheters8,9 or HPSD ablations.2,4, 5, 6 The present study is the first large real-world evaluation of the combination of HPSD and CF sensing and examination of outcomes and predictors of success. The study found that traditional factors found with non-CF catheters, such as older age, female gender, more persistent AF, and larger LA size, still were predictive of a poorer outcome. The study also found that the particular CF

Conclusion

This study examines the procedural details and long term outcomes in a large cohort of patients undergoing AF ablation with HPSD and CF. We found 6 predictors of outcome including the catheter used and whether PWI was done. For redo ablations both the number of reconnected veins and the type of AF were predictors of outcomes.

Acknowledgments

Patricia Barberini, RN, Cynthia Lebsack, PharmD, and Glenda Rhodes assisted with data and manuscript management.

References (14)

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This research did not receive any funding from agencies in the public, private, or not-for-profit sectors. Dr Winkle has been an investor in Farapulse; and an investigator for Abbott. Dr Mead has served on the advisory board for Medtronic and iRhythm. Dr Engel has served on the advisory board of Medtronic. Dr Brodt has served as a consultant for AtriCure. All other authors have reported that they have no conflicts relevant to the contents of this paper to disclose.

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