Key result
Procedural strategies including high power (50 W) ablation (OR 1.32; 95% CI 1.05-1.65) and increasing posterior force significantly predicted higher odds of first pass isolation during AF ablation.
Why the study?
Achievement of first pass isolation during AF ablation reflects effective lesion formation and predicts freedom from arrhythmia recurrence, but its clinical and procedural predictors remain to be determined.
What are the clinical and procedural predictors of first pass isolation of the pulmonary veins during atrial fibrillation ablation?
Cohort (n=2,671)
Yes
What are the clinical and procedural predictors of first pass isolation of the pulmonary veins during atrial fibrillation ablation?
Odds Ratio: 1.32 (95% CI 1.05–1.65)
First pass isolation during atrial fibrillation ablation is significantly influenced by modifiable procedural strategies such as high power and nonstandard ventilation, as well as operator experience and patient comorbidities.
These predictors should not yet alter ablation protocols; hypothesis-generating and requires prospective validation.
INTRODUCTION: During atrial fibrillation ablation (AFA), achievement of first pass isolation (FPI) reflects effective lesion formation and predicts long-term freedom from arrhythmia recurrence. We aim to determine the clinical and procedural predictors of pulmonary vein FPI. METHODS: We reviewed AFA procedures in a multicenter prospective registry of AFA (REAL-AF). A multivariate ordinal logistic regression, weighted by inverse proceduralist volume, was used to determine predictors of FPI. RESULTS: A total of 2671 patients were included with 1806 achieving FPI in both vein sides, 702 achieving FPI in one, and 163 having no FPI. Individually, age, left atrial (LA) scar, higher power usage (50 W), greater posterior contact force, ablation index >350 posteriorly, Vizigo™ sheath utilization, nonstandard ventilation, and high operator volume (>6 monthly cases) were all related to improved odds of FPI. Conversely sleep apnea, elevated body mass index (BMI), diabetes mellitus, LA enlargement, antiarrhythmic drug use, and center's higher fluoroscopy use were related to reduced odds of FPI. Multivariate analysis showed that BMI > 30 (OR 0.78 [0.64-0.96]) and LA volume (OR per mL increase = 1.00 [0.99-1.00]) predicted lower odds of achieving FPI, whereas significant left atrial scarring (>20%) was related to higher rates of FPI. Procedurally, the use of high power (50 W) (OR 1.32 [1.05-1.65]), increasing force posteriorly (OR 2.03 [1.19-3.46]), and nonstandard ventilation (OR 1.26 [1.00-1.59]) predicted higher FPI rates. At a site level, high procedural volume (OR 1.89 [1.48-2.41]) and low fluoroscopy centers (OR 0.72 [0.61-0.84]) had higher rates of FPI. CONCLUSION: FPI rates are affected by operator experience, patient comorbidities, and procedural strategies. These factors may be postulated to impact acute lesion formation.
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Kreidieh et al. (2024) conducted a cohort in Atrial fibrillation (n=2,671). High power (50 W) ablation vs. Standard/lower power ablation was evaluated on First pass isolation (FPI) of the pulmonary veins (OR 1.32, 95% CI 1.05-1.65). Procedural strategies including high power (50 W) ablation (OR 1.32; 95% CI 1.05-1.65) and increasing posterior force significantly predicted higher odds of first pass isolation during AF ablation.
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