Esophageal safety in CLOSE‐guided 50 W high‐power‐short‐duration pulmonary vein isolation: The PREHEAT‐PVI‐registry

Abstract

Introduction: Pulmonary vein isolation (PVI) using high-power-short-duration (HPSD) radiofrequency ablation (RF) is emerging as the standard of care for treatment of atrial fibrillation (AF). While procedural short-term to midterm efficacy and efficiency are very promising, this registry aims to investigate esopahgeal safety using an optimized ablation approach.Methods: In a single-center experience, 388 consecutive standardized first-time AF ablation were performed using a CLOSE-guided-fixed-50 W-circumferential PVI and substrate modification without intraprocedural esophageal temperature measurement. Three hundred patients underwent postprocedural esophageal endoscopy to diagnose and grade endoscopically detected esophageal lesions (EDEL) and were included in the analysis.Results: EDEL were detected in 35 of 300 patients (11.6%), 25 of 35 were low-grade Kansas-city-classification (KCC) 1 lesions with fast healing tendencies. Six patients suffered KCC 2a lesions, 4 patients had KCC 2b lesions (1.3% of all patients). No esophageal perforation or fistula formation was observed. Patient baseline characteristics, especially patients age, gender, and body mass index did not influence EDEL incidence. Additional posterior box isolation did not increase the incidence of EDEL. In patients diagnosed with EDEL, mean catheter contact force during posterior wall ablation was higher (11.9 ± 1.8 vs. 14.7 ± 3 g, p < .001), mean RF duration was shorter (11.9 ± 1 vs. 10.7 ± 1.2 s, p < .001), while achieved ablation index was not different between groups (434 ± 4.9 vs. 433 ± 9.5, n.s.). Conclusion:Incidence of EDEL after CLOSE-guided-50 W-HPSD PVI is lower compared to historical cohorts using standard-power RF settings. Catheter contact force during posterior HPSD ablation should not exceed 15 g.

Mitigating esophageal injury after atrial fibrillation ablation guided by ablation index; CLOSEr to goal

“…In the POWER‐AF study, using 45 W in the posterior wall required an average of 13 s (range: 11–14 s) to achieve a target AI of 400 9 . Similar ablation duration was required to reach AI of 400 using 50 W in this study, with maximum RF duration on the posterior wall reported up to 19.9 ± 3.5 s in patients who developed EDEL 5 . As acknowledged by the authors in the Discussion, there is a more narrow safety margin with high power ablation, and therefore prolonged high power applications may negate the safety benefits of HPSD biophysics 3,9 .…”

“…9 Similar ablation duration was required to reach AI of 400 using 50 W in this study, with maximum RF duration on the posterior wall reported up to 19.9 ± 3.5 s in patients who developed EDEL. 5 As acknowledged by the authors in the Discussion, there is a more narrow safety margin with high power ablation, and therefore prolonged high power applications may negate the safety benefits of HPSD biophysics. 3,9 Steam pops have been shown to occur before target AI of >450 are reached when using high power ablation, particularly at higher starting impedances.…”

“…al. 5 focuses on the safety of the combined high-power CLOSE-guided ablation approach, using endoscopy in 300 patients to identify esophageal lesions following AF ablation. In this study, PVI and in some cases posterior wall isolation was performed with contiguous 50 W RF applications, delivered on the posterior wall of the left atrium until an AI target of 400 was reached.…”

“…This manuscript by Francke et. al 5 . focuses on the safety of the combined high‐power CLOSE‐guided ablation approach, using endoscopy in 300 patients to identify esophageal lesions following AF ablation.…”

Acute oesophageal safety and long-term follow-up of AI-guided high-power short-duration with 50 W for atrial fibrillation ablation

“…showing significantly higher EDEL rates of nearly 12% with a CLOSE-guided 50 W protocol with target AI values of 550/400. 34 Notably, again posterior box lesion did not increase EDEL risk. Reduction of target AI for posterior lesions from 380 to 350/320 was associated with reduced occurrence of EDEL as well as gastroparesis.…”