Assessment of the transmural unipolar electrogram morphology change radius during contact force-guided pulmonary vein isolation using the VISITAG™ Module and CARTOREPLAY™

Aims To investigate the radius of transmural (TM) ablation effect at the left atrial posterior wall (LAPW) during contact force (CF)-guided pulmonary vein isolation (PVI), using pure R unipolar electrogram (UE) morphology change – a histologically validated marker of radiofrequency (RF)-induced TM atrial ablation. Methods Following PVI in 24 consecutive patients (30W, continuous RF), VISITAG™ Module and CARTOREPLAY™ (Biosense Webster Inc.) RF and UE data at left and right-sided LAPW annotated sites 1 and 2 were analysed. Results Acutely durable PVI without spontaneous / dormant recovery was achieved following 15s and 10-11s RF, at sites 1 and 2, respectively (p<0.0001). At site 1, RS UE morphology was noted pre-ablation, with RF-induced pure R UE morphology change in 47/48 (98%). Left and right-sided second RF site annotation was at 5.8mm and 5.2mm from site 1 respectively (p=0.64), yet immediate pure R UE morphology was noted in 35/48 (73%). For second-annotated sites, 30 demonstrated inter-ablation site transition time ≤17ms; pure R UE morphology was noted at annotation onset in 22/30 (73%), with overall median time to pure R morphology change significantly shorter than at site 1 – 0.0s, versus 4.1s and 5.3s, for left and right-sided first-annotated LAPW sites, respectively (p<0.0001). Conclusion When the first and second-annotated LAPW RF sites were within 7mm, 73% second-annotated sites demonstrated immediate pure R UE morphology change. These analyses support a paradigm of shorter RF duration at immediately adjacent sites during continuous RF application, and may usefully inform the further development of “tailored” approaches towards CF-guided PVI. What’s known? The VISITAG™ Module and CARTOREPLAY™ permit investigations into the tissue effects of RF energy delivery in vivo , via objective annotation methodology and retrospective evaluation of histologically validated unipolar electrogram (UE) criteria for transmural (TM) atrial ablation. Greater RF energy effect is seen at left compared to right-sided first-annotated left atrial posterior wall (LAPW) sites during pulmonary vein isolation (PVI). What’s new? Following ∼15s RF delivery at first-annotated LAPW sites and aiming for ≤6mm inter-ablation site distance during continuous RF delivery, 73% second-annotated sites demonstrated immediate TM UE morphology change. At second-annotated sites, ∼10s RF resulted in acutely durable PVI in all. Greater left-sided RF energy effect was observed, not explained by differences in RF duration, mean CF or catheter position stability. The radius of TM RF effect may be determined at the LAPW following CF and VISITAG™ Module-guided PVI.