Pulsed field ablation

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Pulsed field ablation (PFA) is a non-thermal (not using extreme heat or cold) method of biological ablation (removal of structure or functionality) utilizing high-amplitude pulsed (microsecond duration) electric fields to create irreversible electroporation in tissues. [1] [2] It is used most widely to treat tumors (cancer) or cardiac arrhythmias. [3]

Contents

Background

Atrial fibrillation frequently results from bursts of tachycardia that originate in muscle bundles extending from the atrium to the pulmonary veins. [4] Pulmonary vein isolation ablation technology has used thermal methods (radiofrequency ablation or, less often, cryoablation) to destroy pulmonary vein cells. [5] As with thermal methods of ablation, in pulsed field ablation, a thin, flexible tube (catheter) is inserted into a blood vessel in the groin and threaded up into the heart to ablate the areas of the pulmonary vein causing excessively rapid electrical signals. [6]

Advantages

A major reason for recurrence of atrial fibrillation after ablation has been the belief of electrical pulmonary vein reconnection, which has not been seen for PFA. [7] In one study, atrial fibrillation recurrence in the thermal ablation group was 39% compared to 11% in the PFA group. [8] PFA can achieve pulmonary vein isolation faster than other ablation methods. [1] [8] Compared to radiofrequency ablation, PFA produces lesions of greater uniformity. [5]

Safety

Cell death following PFA is usually due to apoptosis, which is a far less damaging and inflammatory form of cell death than necrosis. [1] [3] In contrast to thermal methods of ablation, PFA specifically kills cardiomyocytes (cardiac muscle cells) without injuring surrounding tissues. [1] [2] Thermal ablation methods can damage the esophagus, phrenic nerve, and coronary vessels (as high as 5% [8] ), which are spared by PFA. [1] One study showed an overall complication rate of 0.7% for PFA and no occurrence of phrenic nerve, esophageal, or pulmonary vein injury. [9]

Challenges

Because PFA is a relatively newer ablation technique, there is a lack of uniformity in the parameters for its delivery. [8] Better standardization could help reduce instances of coronary artery spasm and pulmonary artery hemorrhage, which can occur. [8] The equipment cost and lack of specialized training have limited the widespread use of PFA, making it unavailable to many patients. [8]

Recent (2024) comparisons of PFA with thermal methods have shown reduced time spent in surgery, but no superiority in safety and no better reduction of atrial fibrillation. [10] When used in areas other than the pulmonary vein, injuries have been seen. [10]

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a sub-specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Pulmonary vein</span> Veins that transfer oxygenated blood from the lungs to the heart

The pulmonary veins are the veins that transfer oxygenated blood from the lungs to the heart. The largest pulmonary veins are the four main pulmonary veins, two from each lung that drain into the left atrium of the heart. The pulmonary veins are part of the pulmonary circulation.

<span class="mw-page-title-main">Atrial flutter</span> Abnormal heart rhythm beginning in the atria

Atrial flutter (AFL) is a common abnormal heart rhythm that starts in the atrial chambers of the heart. When it first occurs, it is usually associated with a fast heart rate and is classified as a type of supraventricular tachycardia. Atrial flutter is characterized by a sudden-onset (usually) regular abnormal heart rhythm on an electrocardiogram (ECG) in which the heart rate is fast. Symptoms may include a feeling of the heart beating too fast, too hard, or skipping beats, chest discomfort, difficulty breathing, a feeling as if one's stomach has dropped, a feeling of being light-headed, or loss of consciousness.

<span class="mw-page-title-main">Mitral stenosis</span> Heart disease with narrowing of valve

Mitral stenosis is a valvular heart disease characterized by the narrowing of the opening of the mitral valve of the heart. It is almost always caused by rheumatic valvular heart disease. Normally, the mitral valve is about 5 cm2 during diastole. Any decrease in area below 2 cm2 causes mitral stenosis. Early diagnosis of mitral stenosis in pregnancy is very important as the heart cannot tolerate increased cardiac output demand as in the case of exercise and pregnancy. Atrial fibrillation is a common complication of resulting left atrial enlargement, which can lead to systemic thromboembolic complications such as stroke.

<span class="mw-page-title-main">Jugular venous pressure</span> Blood pressure in a vein of the neck

The jugular venous pressure is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different forms of heart and lung disease. Classically three upward deflections and two downward deflections have been described.

<span class="mw-page-title-main">Atrium (heart)</span> Part of the human heart

The atrium is one of the two upper chambers in the heart that receives blood from the circulatory system. The blood in the atria is pumped into the heart ventricles through the atrioventricular mitral and tricuspid heart valves.

<span class="mw-page-title-main">Catheter ablation</span> Removal or termination of an electrical pathway from parts of the heart

Catheter ablation is a procedure that uses radio-frequency energy or other sources to terminate or modify a faulty electrical pathway from sections of the heart of those who are prone to developing cardiac arrhythmias such as atrial fibrillation, atrial flutter and Wolff-Parkinson-White syndrome. If not controlled, such arrhythmias increase the risk of ventricular fibrillation and sudden cardiac arrest. The ablation procedure can be classified by energy source: radiofrequency ablation and cryoablation.

<span class="mw-page-title-main">Radiofrequency ablation</span> Interventional procedure

Radiofrequency ablation (RFA), also called fulguration, is a medical procedure in which part of the electrical conduction system of the heart, tumor, sensory nerves or a dysfunctional tissue is ablated using the heat generated from medium frequency alternating current. RFA is generally conducted in the outpatient setting, using either a local anesthetic or twilight anesthesia. When it is delivered via catheter, it is called radiofrequency catheter ablation.

The mini-maze procedures are cardiac surgery procedures intended to cure atrial fibrillation (AF), a common disturbance of heart rhythm. They are procedures derived from the original maze procedure developed by James Cox, MD.

The Cox maze procedure, also known as maze procedure, is a type of heart surgery for atrial fibrillation.

<span class="mw-page-title-main">Michel Haïssaguerre</span>

Michel Haïssaguerre is a French cardiologist and electrophysiologist. His investigations have been the basis for development of new markers and therapies for atrial and ventricular fibrillation.

The Sensei X robotic catheter is a medical robot designed to enhance a physician’s ability to perform complex operations using a small flexible tube called a catheter. As open surgical procedures that require large incisions have given way to minimally invasive surgeries in which the surgeon gains access to the target organs through small incisions using specialized surgical tools. One important tool used in many of these procedures is a catheter used to deliver many of things a surgeon needs to do his work, to impact target tissue and deliver a variety of medicines or disinfecting agents to treat disease or infection.

<span class="mw-page-title-main">Atrial fibrillation</span> Irregular beating of the atria of the heart

Atrial fibrillation is an abnormal heart rhythm (arrhythmia) characterized by rapid and irregular beating of the atrial chambers of the heart. It often begins as short periods of abnormal beating, which become longer or continuous over time. It may also start as other forms of arrhythmia such as atrial flutter that then transform into AF.

<span class="mw-page-title-main">Left atrial appendage occlusion</span> Medical treatment

Left atrial appendage occlusion (LAAO), also referred to as left atrial appendage closure (LAAC), is a procedure used to reduce the risk of blood clots from the left atrial appendage entering the bloodstream and causing a stroke in those with non-valvular atrial fibrillation.

The management of atrial fibrillation (AF) is focused on preventing temporary circulatory instability, stroke and other ischemic events. Control of heart rate and rhythm are principally used to achieve the former, while anticoagulation may be employed to decrease the risk of stroke. Within the context of stroke, the discipline may be referred to as stroke prevention in atrial fibrillation (SPAF). In emergencies, when circulatory collapse is imminent due to uncontrolled rapid heart rate, immediate cardioversion may be indicated.

<span class="mw-page-title-main">Arrhythmia</span> Group of medical conditions characterized by irregular heartbeat

Arrhythmias, also known as cardiac arrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults – is called tachycardia, and a resting heart rate that is too slow – below 60 beats per minute – is called bradycardia. Some types of arrhythmias have no symptoms. Symptoms, when present, may include palpitations or feeling a pause between heartbeats. In more serious cases, there may be lightheadedness, passing out, shortness of breath, chest pain, or decreased level of consciousness. While most cases of arrhythmia are not serious, some predispose a person to complications such as stroke or heart failure. Others may result in sudden death.

An Af-nest or Atrial Fibrillation Nest (AFN) is a locus or cluster in the atrial wall with distinct electrical features and properties originated by fibrillar myocardium. It plays as an "electrical multiplier" re-feeding the atrial fibrillation.

<span class="mw-page-title-main">Topera Medical</span>

Topera, Inc. is a cardiac arrhythmia mapping company for targeting catheter ablation company launched in San Diego, California and specializes in mapping electrical signals of the heart. Topera's headquarters are located in Palo Alto, California. The company uses 3D analysis and mapping to detect the sources of atrial fibrillation, atrial flutter, and atrial tachycardia and ventricular tachycardia to identify targets for catheter ablation.

<span class="mw-page-title-main">Yaariv Khaykin</span> Canadian cardiologist

Yaariv Khaykin is a Canadian cardiologist and a clinical researcher in the area of electrophysiology. He is the director of the Newmarket Electrophysiology Research Group at the Southlake Regional Health Centre. He has published research into complex ablation and pioneered cardiac ablation methods.

Ganglionated plexi (GP) comprise the intrinsic cardiac autonomic nervous system composed of autonomic ganglia of the heart atrium and ventricles. Cholinergic neurons throughout the GPs project to all areas of the heart, The GP are embedded in the epicardial fat pads, consisting of only a few neurons or as many as 400 neurons. Vagus nerve stimulation has been shown to inhibit the activity of the GP, possibly through Nav1.8.

References

  1. 1 2 3 4 5 Bradley CJ, Haines DE (2020). "Pulsed field ablation for pulmonary vein isolation in the treatment of atrial fibrillation". Journal of Cardiovascular Electrophysiology . 31 (8): 2136–2147. doi:10.1111/jce.14414. PMID   32107812.
  2. 1 2 Schaack D, Schmidt B, Chun KJ (2023). "Pulsed Field Ablation for Atrial Fibrillation". Arrhythmia & Electrophysiology Review. 12: e11. doi:10.15420/aer.2022.45. PMC   10326665 . PMID   37427302.
  3. 1 2 Napotnik TB, Polajžer T, Miklavčič D (2021). "Cell death due to electroporation - A review". Bioelectrochemistry . 141: 107871. doi:10.1016/j.bioelechem.2021.107871. PMID   34147013.
  4. ↑ McGarry TJ, Narayan SM (2012). "The anatomical basis of pulmonary vein reconnection after ablation for atrial fibrillation: wounds that never felt a scar?". Journal of the American College of Cardiology . 50 (10): 939–941. doi:10.1016/j.jacc.2011.11.032. PMC   3393092 . PMID   22381430.
  5. 1 2 Matos CD, Hoyos C, Osorio J (2023). "Pulsed Field Ablation of Atrial Fibrillation: A Comprehensive Review". Reviews in Cardiovascular Medicine. 24 (11): 337. doi:10.31083/j.rcm2411337. PMC   11272841 . PMID   39076426.
  6. ↑ Ames A, Stevenson WG (206). "Catheter ablation of atrial fibrillation". Circulation . 113 (13): e666-8. doi:10.1161/CIRCULATIONAHA.105.613083. PMID   16585395.
  7. ↑ Reddy VY, Neuzil P, Jais P (2019). "Pulsed Field Ablation for Pulmonary Vein Isolation in Atrial Fibrillation". Journal of the American College of Cardiology . 74 (3): 15–326. doi: 10.1016/j.jacc.2019.04.021 . PMID   31085321.
  8. 1 2 3 4 5 6 Iyengar SK, Iyengar S, Srivathsan K (2023). "The promise of pulsed field ablation and the challenges ahead". Frontiers in Cardiovascular Medicine . 10: 1235317. doi: 10.3389/fcvm.2023.1235317 . PMC   10627215 . PMID   37937293.
  9. ↑ Verma A, Haines DE, DeLurgio DB (2023). "Pulsed Field Ablation for the Treatment of Atrial Fibrillation: PULSED AF Pivotal Trial". Circulation . 147 (19): 422–1432. doi:10.1161/CIRCULATIONAHA.123.063988. PMC   10158608 . PMID   36877118.
  10. 1 2 Deering TF, Bunch TJ, Smith AM (2024). "Pulsed field ablation: A promise with future broad-based applicability or a pause needing further analysis-Is catheter ablation at a crossroads? A critical appraisal of the new challenger-pulsed field ablation". Heart Rhythm . 21 (8): 1242–1244. doi:10.1016/j.hrthm.2024.03.1763. PMID   38548125.
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