Pulsed field ablation using a circular electrode array catheter in patients with atrial fibrillation: A workflow optimization study evaluating the role of mapping

Figures

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  Fig. 1. Workflow optimization.

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  Fig. 2. Technical aspects of catheter maneuverability. A. Rotation of PF catheter during ablation at the PV ostium. This figure shows the rotation of the horse-shoe-figured/circular electrode array PFA catheter while ablating in the LSPV at 3′, 6′, 12′ and 9′ o’clock to cover the whole PV antrum and to aim for continuous ablation lesions. Each position is shown in LAO (purple) and RAO (red) as two views are needed to validate positioning. Note, that anterior (counterclockwise) movement of the sheath was performed to ablate the ridge region at the first ablation site (position 1). B: Positioning of the PF catheter at the pulmonary vein. After wiring the PV, the “snake configuration” was used at the RSPV to advance the catheter’s electrodes into the PV (B1-B2). Then, the slider on the catheter’s handle was slightly pulled back to regain circular shape of the catheter (B3). Afterwards, the circular PF catheter was pulled back to the ostium of the PV for the first ablation position (B3-B4). C: Addressing all PV branches. This is an example of a RIPV with two branches (upper and inferior branch). As shown in the images C1 and C2, both branches were separately wired and the PFA catheter was…

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  Fig. 3. Conduction sites after failed first pass isolation in phase I, II and III. The asterixis “*” mark the site of conduction during remapping after initial ablation with 8 PFA applications per pulmonary vein. Of note, at the end of the procedure all conduction sites were successfully ablated and all PVs were isolated. LIPV, left inferior pulmonary vein; LPV, left pulmonary veins; LSPV, left superior pulmonary vein; PV, pulmonary vein; RIPV, right inferior pulmonary vein; RPV, right pulmonary veins, RSPV, right superior pulmonary vein.

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  Fig. 4. Procedure and fluoroscopy times. Fig. 4. shows the different laboratory markers pre- and post-ablation on the following day. LDH indicates lactate dehydrogenase, * p-Value = 0.0169, *** p-value = 0.0007.

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  Fig. 5. Hemolysis parameters pre- and post- pulsed field ablation.

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  Fig. 6. Example of conduction gaps after first pass PFA with 8 applications. In this phase I patient, initial mapping in AF was performed with the PFA catheter as the mapping catheter (1A), followed by ablation with 8 PFA applications per PV (1B). During remapping insufficient ablation with conduction gaps of the left pulmonary veins (anterior carina, 2A) and RIPV (inferior, 2B) were detected. Additional PFA was delivered (3A and 3B). The remap of the left and right PVs is shown (4A and 4B). In the final remap, all veins were successfully isolated (5A and 5B).

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  Fig. 7. Wide antral pulmonary vein isolation. A: A1: Example of Pre-ablation left atrial map created with PFA catheter. A2: Post-PFA left atrial map demonstrating wide antral ablation lesions and catheter positions (A3). B: Example of antral ablation lesion set for right pulmonary veins B1: pre-ablation, B2 post-PFA and catheter positioning B3. C: Example of antral ablation lesion set for left pulmonary veins C1: pre-ablation, C2 post-PFA and catheter positioning C3.