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

Abstract

BackgroundAlthough pulmonary vein isolation (PVI) for atrial fibrillation (AF) utilizing radiofrequency (RF) applications with a very high‐power and short‐duration (vHPSD) has shortened the procedure time, the determinants of pulmonary vein (PV) gaps in the first‐pass PVI and acute PV reconnections are unclear.MethodsAn extensive encircling PVI was performed with the QDOT MICRO catheter with a vHPSD (90 W–4 s) in 30 patients with AF (19 men, 64 ± 10 years). The association of the PV gap sites (first‐pass PVI failure, acute PV reconnections [spontaneous reconnections or dormant conduction provoked by adenosine triphosphate] or both) with the left atrial (LA) wall thickness and LA bipolar voltage on the PVI line and ablation‐related parameters were assessed.ResultsPV gaps were observed in 29 (6%) of 480 segments (16 segments per patient) in 17 patients (56%). The PV gaps were associated with the LA wall thickness, bipolar voltage, and the number of RF points (LA wall thickness, 2.5 ± 0.5 vs. 1.9 ± 0.4 mm, p < .001; bipolar voltage, 2.59 ± 1.62 vs. 1.34 ± 1.14 mV, p < .001; RF points, 6 ± 2 vs. 4 ± 2, p = .008) but were not with the other ablation‐related parameters. Receiver operating characteristic curves yielded that an LA wall thickness ≥2.3 mm and bipolar voltage ≥2.40 mV were determinants of PV gaps with an area under the curve of 0.82 and 0.73, respectively.ConclusionsThe LA voltage and wall thickness on the PV‐encircling ablation line were highly associated with PV gaps using the 90 W/4 s‐vHPSD ablation.

Editorial to: 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

“…The authors final conclusion is that the left atrial voltage and the wall thickness on the ablation line were highly associated with reconduction gaps using the vHPSD only ablation protocol. 1 In our opinion, the relatively low first-pass isolation rate of 76% and the high rate of pulmonary vein recondition found in this study is explained by the utilization of a relatively large inter-lesion distance of 6 mm as suggested for ablation index guided conventional RF based catheter ablation (CLOSE protocol). However, for vHPSD ablation with its larger but more shallow lesion diameters it is crucial to perform a tighter inter-lesion distance (very close protocol) at least at the anterior aspect of the pulmonary veins with its thicker tissue.…”

“…This aspect is important and is correctly discussed by the authors themselves in the recent paper. 1 The very close technique was recently described in the FAST AND FURIOUS PVI study 2 and was proven by chronic PVI durability assessments in the remapping FAST AND FURIOUS Redo study 4 as well as cardiac magnetic resonance imaging assessments by Sciacca et al. 5 Utilizing vHPSD the lesion depth is only regulated by more overlapping lesions of 3–4 mm anteriorly and 5–6 mm posteriorly.…”

“…In the study by Hirata et al., a vHPSD only approach was utilized for PVI in 30 patients. 1 The first‐pass PVI rate was 56% for patients and 76% for pulmonary veins. At least 30 min after encircling the pulmonary veins adenosine triphosphate testing was performed to detect potential pulmonary vein reconduction.…”

“…We thank Hirata et al for their important assessment and their findings on acute pulmonary vein isolation (PVI) using 90 W/4 s-based catheter ablation utilizing the QDOT MICRO™ ablation catheter (Biosense Webster, Inc. Diamond Bar, CA, USA). 1 In general, catheter ablation for the treatment of atrial fibrillation (AF) by PVI has proven high efficacy and safety as well as promising long-term success rates. Although single-shot catheter systems provide high procedural success and safety they are mainly designed for PVI only and they lack the adaptability to different left atrial anatomies and different cardiac arrythmias.…”

“…The authors final conclusion is that the left atrial voltage and the wall thickness on the ablation line were highly associated with reconduction gaps using the vHPSD only ablation protocol. 1 …”