Optimizing persistent atrial fibrillation re-ablation: procedural outcomes of Marshall-plan strategy with a dual-energy lattice-tip catheter ablation
S Saygi, O Saluveer, H Bastani, E Charitakis, F Akertsrom, N Drca, F Braunschweig, M Jensen-UrstadAbstract
Introduction
Marshall-plan strategy, ethanol ablation of Marshall vein (VoM) in combination with creating posterolateral mitral isthmus line (PLMI), roof line, and cavotricuspid isthmus (CTI) line along with pulmonary vein isolation (PVI) in persistent AF, has provided better results compared to the PVI only strategy. Besides the advantages of Marshall-plan, long procedure and fluoroscopy time, and challenging coronary sinus (Cs) and VoM anatomy, are the main limitations of this method. Recent data showed that the dual-energy source, radiofrequency (RF) and pulsed field (PF), in the same catheter might offer better efficacy and safety in creating lesions and obviate the need for ethanol ablation of VoM.
Purpose
This prospective single center study analyzes the acute procedural outcomes of Marshall-plan strategy using a dual-energy lattice-tip catheter to create lines of block in patients undergoing re-ablation for persistent AF.
Methods
The study included consecutive patients who underwent re-ablation for persistent AF utilizing a Marshall-plan strategy consisting of roof line/posterior box isolation, PLMI, and CTI ablation along with a re-PVI as needed, using a dual-energy lattice-tip catheter (picture 1). PF energy for roof line/posterior box isolation and RF energy for CTI ablation were the only allowed energy modalities. Endocardial RF and PF energy were sequentially used for PLMI ablation. In the event of absent bidirectional PLMI block following endocardial ablation or re-conduction during a 20-minute waiting period, supplementary PF ablation was performed from the CS. The primary efficacy endpoint is the acute bidirectional block over the lines and durable bidirectional block over PLMI after 20-minute waiting time (Picture 1).
Results
Forty-five patients underwent Marshall-plan strategy (baseline characteristics, picture 2). The primary efficacy endpoint was 100% for roof line/posterior box isolation (n=45), 95% for CTI ablation (n=40, failed: 2), and 98% for PLMI line (n=45, failed: 1). Acute PLMI block was achieved by only endocardial ablation in 41 patients (91.1%, n=45), but 11 of them (26.8%, n=41) showed re-conduction during the waiting period. The bidirectional block was achieved with additional Cs ablations in 10 of 11. In one patient, a durable bidirectional block could not be achieved due to failed cannulation of Cs with the ablation catheter. Table shows procedural details (picture 2). Procedural complications included 2 transient episodes of atrioventricular block during posterior wall PF ablation, which resolved after atropine administration, and 2 post-procedural urinary tract infections.
Conclusion
The dual-energy lattice-tip catheter appears effective and safe for creating acute durable lesions without the need for VoM ethanol ablation. However, re-conduction over the PLMI line during the waiting time suggests that endocardial ablation alone might be insufficient, requiring ablation from the CS.Picture 1Picture 2