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• W2133711237 abstract "HomeCirculation: Arrhythmia and ElectrophysiologyVol. 6, No. 6Unipolar Electrogram Morphology to Assess Lesion Formation During Catheter Ablation of Atrial Fibrillation Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBUnipolar Electrogram Morphology to Assess Lesion Formation During Catheter Ablation of Atrial FibrillationSuccessful Translation Into Clinical Practice Saurabh Kumar, BSc(Med)/MBBS, PhD and Gregory F. Michaud, MD, FHRS Saurabh KumarSaurabh Kumar From the Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA. Search for more papers by this author and Gregory F. MichaudGregory F. Michaud From the Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA. Search for more papers by this author Originally published1 Dec 2013https://doi.org/10.1161/CIRCEP.113.001145Circulation: Arrhythmia and Electrophysiology. 2013;6:1050–1052The past decade has seen a significant increase in catheter ablation procedures for atrial fibrillation (AF)1; however, data on the efficacy of pulmonary vein (PV) isolation (PVI) are soberingly modest, with single and multiple procedure success rates of 54% and 79% for paroxysmal AF, respectively, during long-term follow-up (≥3 years).2 The main mechanism of AF recurrence after catheter ablation is resumption of PV-left atrial (LA) conduction.3 The time-dependent inevitability of recovery of PV conduction has been consistently demonstrated in acute studies showing PV conduction in ≤93% of patients during an intraprocedural waiting period of 60 minutes after PVI.4 Furthermore, late recurrence of AF is associated with conduction recovery in ≥1 PV in >97% of patients who are having a redo procedure.2 Thus, durable PVI is critical if we are to make inroads toward enhancing procedural efficacy.Article see p 1095Gaps in the ablation line5 and failure to produce transmural lesions6 are implicated in recovery of PV conduction. PVI can be achieved after partial completion of a circumferential ring of lesions around the PVs, irrespective of intervening gaps. This is thought to result from a combination of irreversible and reversible atrial injury.7 Reversible atrial injury may stem from incomplete lesion formation that causes temporary electric uncoupling but not cell death ≤3.5 mm away from the lesion boundary, dependent on tissue temperature and tissue geometry.8 With time, tissue at the boundary of the transmural lesion recovers normal conduction during the course of 1 to 4 weeks.8 Thus, lesion gaps that exhibit conduction block frequently go undetected during the index procedure, and block persists for up to several weeks or months thereafter until tissue injury heals. Conduction block may occur in tissue with normal conductivity despite a gap of ≤1.4 mm and in abnormal tissue with a gap as large as 4 mm.9 Complex gap geometry may produce transient unidirectional and rate-dependent block.10After PVI during the initial procedure, gap detection may be facilitated by a visual log of the central portion of lesions placed on an electroanatomic mapping system and via residual electric signals detected by a multipolar mapping catheter placed at the PV-LA junction. Fundamentally, this will miss electrically silent gaps that persist as a result of aforementioned tissue stunning. Dormant conduction can be identified by use of intravenous adenosine that hyperpolarizes atrial cell membranes, permitting transient conduction at sites with incomplete cell destruction.11 Although further ablation at these sites may improve AF-free survival,12 paradoxically it also identifies those patients with a greater likelihood of AF recurrence despite additional ablation, possibly reflecting a higher likelihood of other incomplete lesions.13 A unifying message from these studies is that acute electric isolation does not reliably predict permanent electric isolation.Permanent conduction block across linear lesions requires transmural lesions. There are a limited number of reliable, easily reproducible methods for assessing intraprocedural lesion completeness. Loss of electric excitability along a circumferential PVI line markedly enhances single-procedure success of AF ablation compared with bidirectional PV-LA conduction block alone.14 Use of contact force technology can improve lesion efficacy, reduce recovery of PV conduction,15,16 and improve single-procedure efficacy17 but is not universally available at present. High-resolution MRI scanning, near-field ultrasound, and lesion thermography hold promise for lesion completeness and gap detection but are not widely available.5,7,9With this in mind, the findings reported by Bortone et al18 in this issue of Circulation: Arrhythmia and Electrophysiology provide a welcome contribution to the goal of improving durable PVI and procedural success for catheter ablation. The authors used unipolar electrogram morphology criteria that are previously validated in a porcine model19 to guide transmural lesion formation. In the Otomo study,19 loss of the negative component of the unipolar atrial electrogram (RS morphology to R morphology) differentiated transmural from nontransmural lesions (characterized by persistence of an S wave) with 100% sensitivity and specificity.19 It is important to note that unipolar, but not bipolar, signals show morphology characteristics that are independent of catheter orientation and direction of atrial activation wave front.In the present study, authors compared 2 groups of patients with paroxysmal AF undergoing PVI facilitated by an electroanatomic mapping system, merged preprocedural LA computed tomographic scan, and a circular mapping catheter. In the first group, 50 patients underwent PVI, with radiofrequencyapplication continued at each site until the development of a completely positive unipolar signal at that site. The second group of 50 patients was a historical control group who underwent PVI with 30 seconds of ablation at each site. In both groups, continuous and wide circular lesions around the PVs were created and the veins isolated 2-by-2 at the antra. The end point was bidirectional block across the PV-LA junction with a 30-minute waiting period to detect dormant conduction. Patient follow-up was standard with a 12-lead ECG and continuous 24-hour Holter monitor at 1, 3, 6, 9, and 12 months after ablation and every 6 months thereafter.The pertinent findings of the study were that the unipolar ablation group compared with the controls had a statistically significant (1) reduction in procedural time, x-ray exposure, and total ablation time by 25, 6, and 37 minutes, respectively; (2) reduction in total energy required to achieve PVI by 66 kJ; and (3) 18% absolute reduction in the risk of recurrent AF at a mean follow-up of ≈2 years after the first ablation procedure off antiarrhythmic drugs (88% versus 70%). A mean of only 15±1 seconds of radiofrequency ablation was required to achieve a unipolar R morphology (considered a transmural lesion). Intriguingly, there was a high incidence of recovery of PV conduction (38%) in the unipolar ablation group, which was lower than the control group (53%) but did not reach statistical significance. A similarly high proportion of patients required carina ablation to achieve PVI (30% versus 32%). Of note, patients did not undergo adenosine testing nor pace capture along the line during the index procedure.Of the 6 patients who had AF recurrence in unipolar RF group, all had evidence of recovery of PV conduction during the index procedure. Interestingly, at the redo procedure, gaps in the ablation line had recovered RS unipolar morphology, and ablation at these sites resulted in PV reisolation.Bortone et al18 are the first to use intraprocedural electrogram morphology as a measure of lesion effectiveness in an attempt to achieve durable PVI. The authors ought to be congratulated in successfully translating findings from an animal study into human practice and for achieving excellent midterm AF-free survival for their patients. The attractiveness of the technique is clearly the shortened procedural time, radiation exposure, and superiority in outcomes, with the implementation of a reproducible, readily available intraprocedural tool that can be applied universally.However, as with any new methodology, there are some limitations that need to be stressed. For one, loss of the negative deflection on the unipolar RS morphology is observed with reversible tissue injury, which is true of any of the indirect measurements of lesion transmurality. Additional evidence for the imperfect positive predictive value of the morphology change is the unexpectedly high rate of PV conduction recovery in the study group. We have found that rendering the ablation line unexciteable14,20 has reduced the intraprocedural rate of PV conduction recovery to <5%, although conduction recovery should be nil for a perfect lesion set.These observations also highlight limitations of the ovine model on which the electrogram-based criteria for transmurality for this study are fundamentally based. In the Otomo study,19 only thin atrial tissue was tested, which makes the method particularly relevant to ablation at the thin posterior wall of the LA adjacent to the esophagus, where limiting RF energy is critical. However, it is not clear that unipolar electrogram morphology criteria apply to lesions in thicker tissue.We have shown, from independent studies at 2 centers, that median impedance decrease nearly doubles with an average contact force >20 g at the ablation catheter tip compared with poor contact and is consistent across different force-sensing platforms.21,22 In the study by Bortone et al,18 the control group had RF ablation performed for an empirical 30 seconds at each site without any feedback on electrogram abatement or impedance changes, presumably without adjustment of the catheter to improve contact. In fact mean impedance change was identical in the unipolar ablation and the control group, which is hard to explain because catheter adjustments made in the study group should have resulted in better contact and a higher average impedance decrease. Finally, the study was not randomized, and the use of a historical control introduces considerable selection bias; thus, results can only be interpreted as hypothesis generating.We welcome the findings of Bortone et al18 because they represent an important step forward in la quête ultime for permanent PV isolation during catheter ablation for AF. More than any technique or technology or combination thereof, it is more important to appreciate that during and after RF application, if one pays meticulous attention to closing gaps and to scrutinizing the available lesion-specific information at your fingertips, more patients will have persistent PVI that will result in fewer recurrences of AF.DisclosuresDr Kumar is a recipient of the Neil-Hamilton Fairley Overseas Fellowship co-funded by the National Health and Medical Research Council and the National Heart Foundation of Australia and a recipient of the Bushell Travelling Fellowship funded by the Royal Australasian College of Physicians. Dr Michaud has received honoraria from St Jude Medical, Boston Scientfic, and Medtronic as well as research support from Boston Scientific and Biosense Webster.FootnotesThe opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.Correspondence to Gregory F. Michaud, MD, FHRS, Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail [email protected]References1. Kumar S, Walters TE, Halloran K, Morton JB, Hepworth G, Wong CX, Kistler PM, Sanders P, Kalman JM. Ten-year trends in the use of catheter ablation for treatment of atrial fibrillation vs. the use of coronary intervention for the treatment of ischaemic heart disease in Australia.Europace. June 24, 2013. doi: 10.1093/europace/eut162 [Epub ahead of print].CrossrefGoogle Scholar2. Ganesan AN, Shipp NJ, Brooks AG, Kuklik P, Lau DH, Lim HS, Sullivan T, Roberts-Thomson KC, Sanders P. Long-term outcomes of catheter ablation of atrial fibrillation: a systematic review and meta-analysis.J Am Heart Assoc. 2013; 2:e004549.LinkGoogle Scholar3. Verma A, Kilicaslan F, Pisano E, Marrouche NF, Fanelli R, Brachmann J, Geunther J, Potenza D, Martin DO, Cummings J, Burkhardt JD, Saliba W, Schweikert RA, Natale A. Response of atrial fibrillation to pulmonary vein antrum isolation is directly related to resumption and delay of pulmonary vein conduction.Circulation. 2005; 112:627–635.LinkGoogle Scholar4. Cheema A, Dong J, Dalal D, Marine JE, Henrikson CA, Spragg D, Cheng A, Nazarian S, Bilchick K, Sinha S, Scherr D, Almasry I, Halperin H, Berger R, Calkins H. Incidence and time course of early recovery of pulmonary vein conduction after catheter ablation of atrial fibrillation.J Cardiovasc Electrophysiol. 2007; 18:387–391.CrossrefMedlineGoogle Scholar5. Ranjan R, Kholmovski EG, Blauer J, Vijayakumar S, Volland NA, Salama ME, Parker DL, MacLeod R, Marrouche NF. Identification and acute targeting of gaps in atrial ablation lesion sets using a real-time magnetic resonance imaging system.Circ Arrhythm Electrophysiol. 2012; 5:1130–1135.LinkGoogle Scholar6. Kowalski M, Grimes MM, Perez FJ, Kenigsberg DN, Koneru J, Kasirajan V, Wood MA, Ellenbogen KA. Histopathologic characterization of chronic radiofrequency ablation lesions for pulmonary vein isolation.J Am Coll Cardiol. 2012; 59:930–938.CrossrefMedlineGoogle Scholar7. Arujuna A, Karim R, Caulfield D, Knowles B, Rhode K, Schaeffter T, Kato B, Rinaldi CA, Cooklin M, Razavi R, O’Neill MD, Gill J. Acute pulmonary vein isolation is achieved by a combination of reversible and irreversible atrial injury after catheter ablation: evidence from magnetic resonance imaging.Circ Arrhythm Electrophysiol. 2012; 5:691–700.LinkGoogle Scholar8. Wood MA, Fuller IA. Acute and chronic electrophysiologic changes surrounding radiofrequency lesions.J Cardiovasc Electrophysiol. 2002; 13:56–61.CrossrefMedlineGoogle Scholar9. Ranjan R, Kato R, Zviman MM, Dickfeld TM, Roguin A, Berger RD, Tomaselli GF, Halperin HR. Gaps in the ablation line as a potential cause of recovery from electrical isolation and their visualization using MRI.Circ Arrhythm Electrophysiol. 2011; 4:279–286.LinkGoogle Scholar10. Pérez FJ, Wood MA, Schubert CM. Effects of gap geometry on conduction through discontinuous radiofrequency lesions.Circulation. 2006; 113:1723–1729.LinkGoogle Scholar11. Datino T, Macle L, Qi XY, Maguy A, Comtois P, Chartier D, Guerra PG, Arenal A, Fernández-Avilés F, Nattel S. Mechanisms by which adenosine restores conduction in dormant canine pulmonary veins.Circulation. 2010; 121:963–972.LinkGoogle Scholar12. Yamane T, Matsuo S, Date T, Lellouche N, Hioki M, Narui R, Ito K, Tanigawa S, Yamashita S, Tokuda M, Yoshida H, Inada K, Shibayama K, Miyanaga S, Miyazaki H, Abe K, Sugimoto K, Yoshimura M. Repeated provocation of time- and ATP-induced early pulmonary vein reconnections after pulmonary vein isolation: eliminating paroxysmal atrial fibrillation in a single procedure.Circ Arrhythm Electrophysiol. 2011; 4:601–608.LinkGoogle Scholar13. McLellan AJ, Kumar S, Smith C, Morton JB, Kalman JM, Kistler PM. The role of adenosine following pulmonary vein isolation in patients undergoing catheter ablation for atrial fibrillation: a systematic review.J Cardiovasc Electrophysiol. 2013; 24:742–751.CrossrefMedlineGoogle Scholar14. Steven D, Sultan A, Reddy V, Luker J, Altenburg M, Hoffmann B, Rostock T, Servatius H, Stevenson WG, Willems S, Michaud GF. Benefit of pulmonary vein isolation guided by loss of pace capture on the ablation line: results from a prospective 2-center randomized trial.J Am Coll Cardiol. 2013; 62:44–50.CrossrefMedlineGoogle Scholar15. Kumar S, Morton JB, Lee J, Halloran K, Spence SJ, Gorelik A, Hepworth G, Kistler PM, Kalman JM. Prospective characterization of catheter-tissue contact force at different anatomic sites during antral pulmonary vein isolation.Circ Arrhythm Electrophysiol2012; 5:1124–1129.LinkGoogle Scholar16. Kumar S, Chan M, Lee J, Wong MC, Yudi M, Morton JB, Spence SJ, Halloran K, Kistler PM, Kalman JM. Catheter-tissue contact force determines atrial electrogram characteristics before and lesion efficacy after antral pulmonary vein isolation in humans.J Cardiovasc Electrophysiol. September 19, 2013. doi: 10.1111/jce.12293 [Epub ahead of print].Google Scholar17. Reddy VY, Shah D, Kautzner J, Schmidt B, Saoudi N, Herrera C, Jaïs P, Hindricks G, Peichl P, Yulzari A, Lambert H, Neuzil P, Natale A, Kuck KH. The relationship between contact force and clinical outcome during radiofrequency catheter ablation of atrial fibrillation in the TOCCATA study.Heart Rhythm. 2012; 9:1789–1795.CrossrefMedlineGoogle Scholar18. Bortone A, Appetiti A, Bouzeman A, Maupas E, Ciobotaru V, Boulenc JM, Pujadas-Berthault P, Rioux P. Unipolar signal modification as a guide for lesion creation during radiofrequency application in the left atrium: a prospective study in humans in the setting of paroxysmal atrial fibrillation catheter ablation.Circ Arrhythm Electrophysiol. 2013; 6. [Epub ahead of print]LinkGoogle Scholar19. Otomo K, Uno K, Fujiwara H, Isobe M, Iesaka Y. Local unipolar and bipolar electrogram criteria for evaluating the transmurality of atrial ablation lesions at different catheter orientations relative to the endocardial surface.Heart Rhythm. 2010; 7:1291–1300.CrossrefMedlineGoogle Scholar20. Steven D, Reddy VY, Inada K, Roberts-Thomson KC, Seiler J, Stevenson WG, Michaud GF. Loss of pace capture on the ablation line: a new marker for complete radiofrequency lesions to achieve pulmonary vein isolation.Heart Rhythm. 2010; 7:323–330.CrossrefMedlineGoogle Scholar21. Kumar S, Haqqani HM, Chan M, Lee J, Yudi M, Wong MC, Morton JB, Ling LH, Robinson T, Heck PM, Kelland NF, Halloran K, Spence SJ, Kistler PM, Kalman JM. Predictive value of impedance changes for real-time contact force measurements during catheter ablation of atrial arrhythmias in humans.Heart Rhythm. 2013; 10:962–969.CrossrefMedlineGoogle Scholar22. Reichlin T, Knecht S, Lane C, Kuühne M, Nof E, Chopra N, Tadros TM, Reddy VY, Schaer B, John RM, Osswald S, Stevenson WG, Sticherling C, Michaud GF. Initial impedance decrease as an indicator of good catheter contact: Insights from radiofrequency ablation with force sensing catheter.Heart Rhythm. October 28, 2013. doi:http://dx.doi.org/10.1016/j.hrthm.2013.10.048[Epub ahead of print].MedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Xie F, Chen Y, Chen X and Zhao Z (2022) Irreversible Electroporation Ablation for Atrial Fibrillation: Status and Challenges, Cardiology Discovery, 10.1097/CD9.0000000000000045, 2:1, (41-50), Online publication date: 1-Mar-2022. Jankelson L, Dai M, Aizer A, Bernstein S, Park D, Holmes D, Chinitz L and Barbhaiya C (2021) Lesion Sequence and Catheter Spatial Stability Affect Lesion Quality Markers in Atrial Fibrillation Ablation, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2020.09.027, 7:3, (367-377), Online publication date: 1-Mar-2021. van Schie M, Starreveld R, Roos-Serote M, Taverne Y, van Schaagen F, Bogers A and de Groot N (2020) Classification of sinus rhythm single potential morphology in patients with mitral valve disease, EP Europace, 10.1093/europace/euaa130, 22:10, (1509-1519), Online publication date: 1-Oct-2020. Pollnow S, Schwaderlapp G, Loewe A and Dössel O Monitoring the dynamics of acute radiofrequency ablation lesion formation in thin-walled atria – a simultaneous optical and electrical mapping study, Biomedical Engineering / Biomedizinische Technik, 10.1515/bmt-2019-0013, 65:3, (327-341) Kumar S and Michaud G (2018) Atrial Fibrillation Cardiac Electrophysiology: From Cell to Bedside, 10.1016/B978-0-323-44733-1.00076-6, (724-735), . Deshmukh A and Packer D (2017) Atrial Fibrillation Ablation Cardiac Arrhythmias, Pacing and Sudden Death, 10.1007/978-3-319-58000-5_12, (143-155), . GOULD P, BOOTH C, DAUBER K, NG K, CLAUGHTON A and KAYE G (2016) Characteristics of Cavotricuspid Isthmus Ablation for Atrial Flutter Guided by Novel Parameters Using a Contact Force Catheter, Journal of Cardiovascular Electrophysiology, 10.1111/jce.13087, 27:12, (1429-1436), Online publication date: 1-Dec-2016. Kumar S and Michaud G (2016) Catheter Ablation for Paroxysmal Atrial Fibrillation, Circulation: Arrhythmia and Electrophysiology, 9:5, Online publication date: 1-May-2016. Michaud G and Kumar S (2015) Catheter Ablation for Paroxysmal Atrial Fibrillation, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2015.04.007, 1:3, (136-138), Online publication date: 1-Jun-2015. December 2013Vol 6, Issue 6 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.113.001145PMID: 24347596 Originally publishedDecember 1, 2013 Keywordscatheter ablation, radiofrequencyEditorialscatheter ablationatrial fibrillationPDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-Defibrillator" @default.
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