What is the clinical evidence from this study?

Study design: Review. Population: Atrial Fibrillation. Intervention: Radiofrequency Catheter Ablation.

January 29, 2024Open Access

Understanding Lesion Creation Biophysics and Improved Lesion Assessment during Radiofrequency Catheter Ablation. The Perfect Combination to Achieve Durable Lesions in Atrial Fibrillation Ablation

EGEly GraciaBrigham and Women's Hospital AMAndrés F. Miranda‐ArboledaBrigham and Women's Hospital CHCarolina HoyosElectrophysiology

Key Result

A combination of lesion assessment techniques, including impedance, contact force, and ablation indices, is recommended to achieve durable lesions and improve long-term outcomes during radiofrequency catheter ablation for atrial fibrillation.

Structured PICO

Population

Patients with atrial fibrillation undergoing pulmonary vein isolation

Intervention

Radiofrequency catheter ablation utilizing various lesion assessment techniques (impedance, EGM changes, contact force, ablation indices, imaging)

Comprehensive lesion assessment using a combination of biophysical parameters and imaging techniques is crucial for achieving durable pulmonary vein isolation in atrial fibrillation ablation.

Limitations

Each lesion assessment approach has its limitations, necessitating a combination of techniques for comprehensive evaluation.
Impedance drops lack a clear cutoff and corresponding time that accurately predicts transmurality.
Electrogram-based approaches are susceptible to artifacts and can be challenging to interpret in patients with persistent atrial fibrillation or prior ablations.
The Lesion Size Index (LSI) is currently only available in one manufacturer's algorithm and is primarily supported by small observational studies.

Abstract

Atrial fibrillation (AF) is a prevalent arrhythmia, while pulmonary vein isolation (PVI) has become a cornerstone in its treatment. The creation of durable lesions is crucial for successful and long-lasting PVI, as inconsistent lesions lead to reconnections and recurrence after ablation. Various approaches have been developed to assess lesion quality and transmurality in vivo, acting as surrogates for improved lesion creation and long-term outcomes utilizing radiofrequency (RF) energy. This review manuscript examines the biophysics of lesion creation and different lesion assessment techniques that can be used daily in the electrophysiology laboratory when utilizing RF energy. These methods provide valuable insights into lesion effectiveness, facilitating optimized ablation procedures and reducing atrial arrhythmia recurrences. However, each approach has its limitations, and a combination of techniques is recommended for comprehensive lesion assessment during AF catheter ablation. Future advancements in imaging techniques, such as magnetic Resonance Imaging (MRI), optical coherence tomography, and photoacoustic imaging, hold promise in further enhancing lesion evaluation and guiding treatment strategies.

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