Personalized pulmonary vein antrum isolation guided by left atrial wall thickness for persistent atrial fibrillation

Abstract

Aims Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF. Methods and results Consecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50–67), fluoroscopy time was 43 s (IQR 20–71), and radiofrequency (RF) time was 16.5 min (IQR 14.3–18.4). The median AI tailored to the local LAWT was 387 (IQR 360–410) for the anterior wall and 335 (IQR 300–375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up. Conclusion In this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).

Predictors of pulmonary vein non‐reconnection in the second procedure after ablation index‐guided pulmonary vein isolation for atrial fibrillation and its impact on the outcome

“…11 They also showed similar results in persistent AF. 12 These results indicated that a high rate of AT recurrence-free survival in the CLOSE protocol was not related to the higher AI target values but to the higher rate of FPI.…”

Where is the gap after a 90 W/4 s very‐high‐power short‐duration ablation of atrial fibrillation?: Association with the left atrial‐pulmonary vein voltage and wall thickness

“…However, wall thickness measurements do not provide a real‐time assessment of these variables, and accurately measuring the wall thickness just underneath the ablation tags is limited because of technical difficulties in incorporating such information into the 3D mapping system. Specific software that detects the wall thickness and integrates it into the CARTO mapping system could be more feasible in this regard 15 . On the other hand, the LA EGM voltage amplitude is a simple real‐time variable that can be obtained at sites accurately mapped in 3D.…”

Personalized pulmonary vein isolation with very high-power short-duration lesions guided by left atrial wall thickness: the QDOT-by-LAWT randomized trial

“… 1 In all patients, an MDCT study was obtained prior to the ablation procedure; post-processing aimed for the reconstruction of MDCT-derived 3D maps with LAWT information was performed, as previously described. 14 The exclusion criteria were age <18 years, previous atrial fibrillation (AF) ablation procedure, impossibility to obtain a pre-procedural MDCT, any clinical condition contraindicating general anaesthesia or high-frequency low-tidal volume (HFLTV) ventilation, and inability to provide a signed informed consent. All patients who fulfilled the inclusion criteria were consecutively enrolled and randomized to either the study arm (‘QDOT-by-LAWT’) or the control arm (‘CLOSE’) in a 1:1 fashion ( Figure 1 ).…”

“…Multidetector computed tomography images were analysed with ADAS 3D™ software (ADAS3D Medical, Barcelona, Spain) to obtain 3D LAWT maps; the 3D LAWT map rendering process was previously described. 8 , 14 Briefly, left atrium (LA) endocardial layer was delineated semi-automatically using a threshold-based segmentation, while the epicardial layer was defined in an automatic way by using an artificial intelligence–based segmentation pipeline integrated into the software, which could be then manually re-adjusted by the user. Finally, LAWT was automatically computed at each point as the distance between each endocardial point and its projection onto the epicardial shell.…”

“… 9–13 It has been recently shown that pre-procedural multidetector computed tomography (MDCT)-derived images can be used to obtain 3D LAWT maps. 8 , 14 Integrating these LAWT maps into the navigation system provides a real-time knowledge of the local LAWT in contact with the ablation catheter tip during the ablation. 8 It could permit a LAWT-guided ablation strategy that alternates between the vHPSD mode and the standard-power ablation mode, potentially leading to improved lesion transmurality and enhanced PVI durability.…”