Early Recurrences of Atrial Arrhythmias and Their Impact on Late Recurrence After Pulmonary Vein Isolation With Pulsed Field Ablation of Paroxysmal Atrial Fibrillation
Study Details
Study Description
Brief Summary
This is a prospective, single-arm study conducted in University Hospital of Split, Department of Cardiology. Patients treated with PFA for symptomatic paroxysmal atrial fibrillation will be asked to participate in the study. An implantable loop recorder (ILR) will be placed immediately after the PFA procedure for rhythm monitoring. Early recurrences will be subsequently divided into very early recurrences (up to 1 month post-procedure) and early recurrences (1-3 months post-procedure). Late recurrences will be defined as those 3 to 12 months post-procedure. Patients will be monitored routinely through follow up visits during which ILR will be interrogated and eventual symptoms will be assessed. Follow-up visits will be scheduled 1, 3, 6, 12 months post-procedure. Median follow-up will be 12 months. Data for the study will be obtained from a loop monitor to assess the arrhythmia burden during follow-up visits in the University Hospital of Split Arrhythmia Clinic.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
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Detailed Description
This is a prospective, single-arm study conducted in the University Hospital of Split, Department of Cardiology. Patients treated with PFA for symptomatic paroxysmal atrial fibrillation will be asked to participate in the study. An implantable loop recorder (ILR) will be placed immediately after the PFA procedure for rhythm monitoring. Early recurrences will be subsequently divided into very early recurrences (up to 1-month post-procedure) and early recurrences (1-3 months post-procedure). Late recurrences will be defined as those 3 to 12 months post-procedure. Patients will be monitored routinely through follow-up visits during which ILR will be interrogated and eventual symptoms will be assessed. Follow-up visits will be scheduled 1, 3, 6, and 12 months post-procedure. The median follow-up will be 12 months. Data for the study will be obtained from a loop monitor to assess the arrhythmia burden during follow-up visits in the University Hospital of Split Arrhythmia Clinic.
For PVI, the "single-shot" multielectrode PFA catheter will be used. This catheter consists of 5 splines, with 4 electrodes per spline and 1 electrode available for intracardiac electrogram recording or 3-dimensional electroanatomic visualization. When used in conjunction with the PFA generator, an electric field is created that ablates tissue using irreversible electroporation. The catheter shape is changed through the manipulation of a slider mechanism on the handle of the catheter. The diameter of the catheter is measured in the fully deployed "flower" configuration and is available in 2 sizes (31 or 35 mm). Energy is delivered through all of the electrodes in a proprietary sequence.
All patients will be asked to provide written informed consent for their respective protocol before undergoing the study.
All procedures will be performed with conscious sedation and propofol bolus synchronized to sets of PFA applications. The procedures will be performed with uninterrupted oral anticoagulation, and left atrial thrombus will be excluded either through pre-procedure CT or intracardiac echocardiography (ICE) (AcuNav, Siemens, Munich, Germany) at the time of the procedure. Pre- and post-ablation diaphragm motion will be evaluated to observe changes in phrenic nerve function during the procedure. Esophageal temperature monitoring will not be utilized due to the nonthermal nature of PFA.
A single transseptal puncture will be performed with an 8.5-F sheath and exchanged for the 13-F PFA sheath in the left atrium, or a transseptal puncture will be performed directly with the PFA sheath. Intravenous heparin will be administered as boluses and continuous infusions to obtain an activated clotting time ≥300 s prior to ablation and throughout the procedure. A 0.035-inch, 180-cm extra-stiff, straight guidewire will be used to cannulate each vein over which the multielectrode PFA catheter will be deployed into the desired shape and advanced into position at the antrum of each vein. The antral level of catheter positioning will be monitored with ICE imaging and fluoroscopy. Patients with left common PV anatomy will receive therapy at the level of the common antrum with 2 sets of therapy delivered, 1 with the guidewire in a superior branch and 1 with the guidewire in an inferior branch.
Acute isolation of the treated vein will be determined by the mapping electrodes on each spline of the PFA catheter. Once all veins have been treated, a 3-dimensional electroanatomic voltage map will be created to confirm PV isolation and visualize the level of isolation of each lesion set. Entrance or exit block will be confirmed following a 20-min wait period after the last PFA application was delivered with a circular mapping catheter (Lasso, Biosense Webster, Irvine, California).
All patients will be implanted with an ILR (Medtronic Reveal LINQTM; Medtronic, Minneapolis, MN). After ablation procedure, the ILR will be inserted subcutaneously in the left fourth intercostal space. The procedure itself takes up to 15 minutes and local anesthetic will be administered prior to the implantation. The antiarrhythmic drugs, except beta-blocker, will be routinely discontinued.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| ERAF after PFA Patients with an early recurrence after pulsed field ablation of paroxysmal atrial fibrillation. |
Other: Monitoring of paroxysmal atrial fibrillation recurrence after pulsed field catheter ablation
We will interrogate implanted loop recorder to see how many patients had an early recurrence of AF (up to 3 months after the procedure). Then we will compare the late recurrence rate (3-12 months post-procedure) between groups with and without early recurrences.
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| no ERAF after PFA Patients without an early recurrence after pulsed field ablation of paroxysmal atrial fibrillation. |
Other: Monitoring of paroxysmal atrial fibrillation recurrence after pulsed field catheter ablation
We will interrogate implanted loop recorder to see how many patients had an early recurrence of AF (up to 3 months after the procedure). Then we will compare the late recurrence rate (3-12 months post-procedure) between groups with and without early recurrences.
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Outcome Measures
Primary Outcome Measures
- Late AF recurrence [12 months]
Recurrences 3-12 months post-procedure (AF burden defined by loop recorder findings)
Secondary Outcome Measures
- Adverse event rate [12 months]
Adverse event rate defined as any untoward medical occurrence, unintended disease or injury related to all aspects of the ablation procedure (death, air embolism, myocardial infarction, stroke, esophageal injury, PV stenosis, puncture site hematoma, vascular lesions).
- ate recurrence rate in patients with very early recurrence [12 months]
AF recurrence in patients with very early AF recurrence (1 month post procedure)
Eligibility Criteria
Criteria
Inclusion Criteria:
- Age >18, index PFA procedure after one failed or intolerant group I or III of the antiarrhythmic drug in patients with symptomatic paroxysmal AF (AF with self-terminating episodes lasting no longer than 7 continuous days). Willing and able to provide informed consent.
Exclusion Criteria:
-1. Any know contraindication to AF ablation or anticoagulation. 2. History of previous left atrial ablation or surgical treatment. 3. Secondary AF due to reversible or non-cardiac cause such as thyroid disease and electrolyte imbalance.
- Asymptomatic AF patients, persistent AF, permanent AF patients. 5. History of clotting or bleeding disease or cryoglobulinemia. 6. Pregnant or lactating. 7. Other conditions that may make the patient a poor candidate for procedure such as mental illness, terminal illness, vulnerable patient population.
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | University Hospital Center Split | Split | Splitsko-dalmatinska | Croatia | 21000 |
Sponsors and Collaborators
- University of Split, School of Medicine
Investigators
None specified.Study Documents (Full-Text)
None provided.More Information
Publications
- Calkins H, Gache L, Frame D, Boo LM, Ghaly N, Schilling R, Deering T, Duytschaever M, Packer DL. Predictive value of atrial fibrillation during the postradiofrequency ablation blanking period. Heart Rhythm. 2021 Mar;18(3):366-373. doi: 10.1016/j.hrthm.2020.11.020. Epub 2020 Nov 24.
- Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d'Avila A, Natasja de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T; Document Reviewers:. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2018 Jan 1;20(1):e1-e160. doi: 10.1093/europace/eux274. Review.
- Grubman E, Pavri BB, Lyle S, Reynolds C, Denofrio D, Kocovic DZ. Histopathologic effects of radiofrequency catheter ablation in previously infarcted human myocardium. J Cardiovasc Electrophysiol. 1999 Mar;10(3):336-42.
- Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. doi: 10.1093/eurheartj/ehaa612. Erratum in: Eur Heart J. 2021 Feb 1;42(5):507. Eur Heart J. 2021 Feb 1;42(5):546-547. Erratum in: Eur Heart J. 2021 Oct 21;42(40):4194.
- Kawamura I, Neuzil P, Shivamurthy P, Petru J, Funasako M, Minami K, Kuroki K, Dukkipati SR, Koruth JS, Reddy VY. Does pulsed field ablation regress over time? A quantitative temporal analysis of pulmonary vein isolation. Heart Rhythm. 2021 Jun;18(6):878-884. doi: 10.1016/j.hrthm.2021.02.020. Epub 2021 Feb 27.
- Kim YG, Boo KY, Choi JI, Choi YY, Choi HY, Roh SY, Shim J, Kim JS, Kim YH. Early Recurrence Is Reliable Predictor of Late Recurrence After Radiofrequency Catheter Ablation of Atrial Fibrillation. JACC Clin Electrophysiol. 2021 Mar;7(3):343-351. doi: 10.1016/j.jacep.2020.09.029. Epub 2021 Jan 27.
- Malmborg H, Christersson C, Lönnerholm S, Blomström-Lundqvist C. Comparison of effects on coagulation and inflammatory markers using a duty-cycled bipolar and unipolar radiofrequency pulmonary vein ablation catheter vs. a cryoballoon catheter for pulmonary vein isolation. Europace. 2013 Jun;15(6):798-804. doi: 10.1093/europace/eus411. Epub 2013 Jan 29.
- Mariani MA, Pozzoli A, Maat G, Alfieri OR, Benussi S. What Does The Blanking Period Blank? J Atr Fibrillation. 2015 Dec 31;8(4):1268. doi: 10.4022/jafib.1268. eCollection 2015 Dec.
- Reddy VY, Anic A, Koruth J, Petru J, Funasako M, Minami K, Breskovic T, Sikiric I, Dukkipati SR, Kawamura I, Neuzil P. Pulsed Field Ablation in Patients With Persistent Atrial Fibrillation. J Am Coll Cardiol. 2020 Sep 1;76(9):1068-1080. doi: 10.1016/j.jacc.2020.07.007.
- Reddy VY, Dukkipati SR, Neuzil P, Anic A, Petru J, Funasako M, Cochet H, Minami K, Breskovic T, Sikiric I, Sediva L, Chovanec M, Koruth J, Jais P. Pulsed Field Ablation of Paroxysmal Atrial Fibrillation: 1-Year Outcomes of IMPULSE, PEFCAT, and PEFCAT II. JACC Clin Electrophysiol. 2021 May;7(5):614-627. doi: 10.1016/j.jacep.2021.02.014. Epub 2021 Apr 28.
- Reddy VY, Neuzil P, Koruth JS, Petru J, Funosako M, Cochet H, Sediva L, Chovanec M, Dukkipati SR, Jais P. Pulsed Field Ablation for Pulmonary Vein Isolation in Atrial Fibrillation. J Am Coll Cardiol. 2019 Jul 23;74(3):315-326. doi: 10.1016/j.jacc.2019.04.021. Epub 2019 May 11.
- Stewart MT, Haines DE, Verma A, Kirchhof N, Barka N, Grassl E, Howard B. Intracardiac pulsed field ablation: Proof of feasibility in a chronic porcine model. Heart Rhythm. 2019 May;16(5):754-764. doi: 10.1016/j.hrthm.2018.10.030. Epub 2018 Oct 30.
- Tanno K, Kobayashi Y, Kurano K, Kikushima S, Yazawa T, Baba T, Inoue S, Mukai H, Katagiri T. Histopathology of canine hearts subjected to catheter ablation using radiofrequency energy. Jpn Circ J. 1994 Feb;58(2):123-35.
- Willems S, Khairy P, Andrade JG, Hoffmann BA, Levesque S, Verma A, Weerasooriya R, Novak P, Arentz T, Deisenhofer I, Rostock T, Steven D, Rivard L, Guerra PG, Dyrda K, Mondesert B, Dubuc M, Thibault B, Talajic M, Roy D, Nattel S, Macle L; ADVICE Trial Investigators*. Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation: Insights From the ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) Trial. Circ Arrhythm Electrophysiol. 2016 Aug;9(8). pii: e003909. doi: 10.1161/CIRCEP.115.003909.
- 2181-147/01/06/M.S.-21-02