Improved One-year Outcomes After Active Cooling During Left Atrial Radiofrequency Ablation

doi:10.21203/rs.3.rs-1972344/v1

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Improved One-year Outcomes After Active Cooling During Left Atrial Radiofrequency Ablation

https://doi.org/10.21203/rs.3.rs-1972344/v1

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published 20 Jan, 2023

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Background: Active esophageal cooling during pulmonary vein isolation (PVI) with radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF) is increasingly being utilized to reduce esophageal injury and atrioesophageal fistula formation. Randomized controlled data also show trends towards increased freedom from AF when using active cooling. This study aimed to compare one-year arrhythmia recurrence rates between patients treated with luminal esophageal temperature (LET) monitoring versus active esophageal cooling during left atrial ablation.

Methods: Data from two healthcare systems (including 3 hospitals and 4 electrophysiologists) were reviewed for patient rhythm status at one-year follow up after receiving PVI for the treatment of AF. Results were compared between patients receiving active esophageal cooling and those treated with traditional LET monitoring using Kaplan-Meier estimates.

Results: A total of 513 patients were reviewed; 253 received LET monitoring using either single or multi-sensor temperature probes, and 260 received active cooling. Mean age was 66.8 (SD +/-10) years, and 36.8% were female. Arrhythmias were 60.1% paroxysmal AF, 34.3% persistent AF, and 5.6% long-standing persistent AF, with no significant difference between groups. At one-year follow-up, KM estimates for freedom from AF were 58.2% for LET monitored patients and 72.2% for actively cooled patients, for absolute increase in freedom from AF of 14% with active esophageal cooling (P=.03).

Conclusions: In this first study to date of the association between esophageal protection strategy and long-term efficacy of left atrial RF ablation, a clinically and statistically significant improvement in freedom from atrial arrhythmia at one-year was found in patients treated with active esophageal cooling when compared to patients that received LET monitoring.

radiofrequency ablation

atrial fibrillation

esophageal cooling

esophageal protection

pulmonary vein isolation

procedural efficacy

Esophageal injury culminating in atrioesophageal fistula (AEF) that occurs weeks after radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF) is one of the most severe complications of pulmonary vein isolation (PVI).[1, 2] Although rates of AEF are assumed to be low at between 0.1% to 0.4%, the mortality rate is as high as 80% even with early diagnosis and treatment.[1, 3] As such, a number of strategies such as luminal esophageal temperature (LET) monitoring or esophageal deviation have been utilized in attempt to reduce the occurrence of AEF, but most have been shown to be of limited benefit, with some recent studies suggesting trends towards harm.[3-5]

Active esophageal cooling was first proposed shortly after the first report of an AEF arising from endocardial ablation.[6] Early data suggested the potential for benefits in reducing esophageal injury even with low-capacity heat extraction from direct liquid instillation.[7] A commercially available esophageal cooling device has demonstrated even greater efficacy at reducing severe esophageal lesions during RF ablation, [8, 9] resulting in increased adoption of this approach and a growing number of investigations into its effects on procedural factors.[10, 11]

One outcome that has not been evaluated is the effect of active esophageal cooling on long-term procedural outcomes. The earliest mathematical model of esophageal cooling raised the question of whether the use of an expandable cooled balloon in the esophagus could reduce the ability to achieve transmural lesions in the atrium.[6] Newer mathematical models have suggested little influence on atrial tissue temperatures when using a non-expandable active esophageal cooling device.[12, 13] Long-term follow-up data from the largest randomized controlled trial of active esophageal cooling suggest a trend towards improved freedom from arrhythmia at one year, with arrhythmia recurrence of 20.3% in actively cooled patients versus 26.8% in patients receiving LET monitoring.[14] Clinical data have shown that lesions placed immediately have a higher likelihood of achieving transmurality-associated unipolar electrograms compared to delayed lesions.[15] Improved continuity of lesion placement without pauses or relocations of the RF catheter during ablation can improve pulmonary vein isolation success and long-term freedom from arrhythmia.[16] Because active esophageal cooling allows uninterrupted lesion placement without the need to pause for temperature alarms, there is a mechanistic rationale for active esophageal cooling to improve long-term procedural efficacy over LET monitoring. With this in mind, we sought to quantify the association between one-year rhythm status and the type of esophageal protection utilized in a large cohort of patients across two healthcare systems.

Patients

This was a retrospective data review performed with Institutional Review Board approval from the two healthcare systems involved, the NorthShore University HealthSystem and the Texas Cardiac Arrhythmia Research Foundation at St. David’s South Austin Medical Center. A consent form was not required because this was secondary research that used identifiable private information recorded by the investigator in such a manner that the identity of the human subjects cannot readily be ascertained directly or through identifiers linked to the subjects. All patients who underwent PVI performed by any of four electrophysiologists in two healthcare systems encompassing 3 different hospitals over the study timeframe from January 2018 to March 2020 were included in this analysis. No patients who underwent PVI were excluded from this review. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting observational studies were followed.

Ablation Procedure

The general procedures utilized by operators at the study sites have been previously described.[10, 11] All patients were treated under general anesthesia for their ablation procedure. Electrophysiologist physicians at all sites performed primarily wide area circumferential pulmonary vein isolation with additional posterior wall isolation dependent on physician practice. In all cases, anticoagulation was administered prior to ablation with a heparinized target activated clotting time (ACT) of 300 to 350 seconds. All sites utilized the Carto system (Biosense Webster, Inc., Diamond Bar, CA, USA) to obtain electroanatomical maps and create a three-dimensional geometry using a mapping catheter (PentaRay or Lasso; Biosense Webster, Inc.). An ICE catheter (AccuNav; Siemens, Mountain View, CA, USA or Soundstar, Biosense Webster, Inc., Diamond Bar, CA, USA) was positioned in the right atrium to guide the transseptal puncture, and for ablation, an externally irrigated ablation catheter (ST/SF™; Biosense Webster, Inc.) was used in all cases, and a steerable decapolar catheter (Webster CS Catheter; Biosense Webster, Inc., Diamond Bar, CA, USA) was placed into the coronary sinus for pacing and recording. A very low to no fluoroscopy protocol was followed for all procedures.

In one healthcare system, the pulmonary veins were isolated by delivery of RF applications circumferentially to the antral regions to produce a minimum of entrance and exit block for at least 20 minutes, confirmed during isoproterenol infusion at 10 μg/min. A Smartablate™ generator (Biosense Webster, Inc.) was used to deliver RF energy, with a setpoint of 40 W on all patients and all areas of the left atrium. The Surepoint measure (Biosense Webster, Inc.) was utilized during ablations, with a target of 350 units on the posterior wall and 450 units on the anterior wall, lateral wall, and septum.

In the other healthcare system, the posterior wall was isolated using a combination of roof and floor linear lesions, along with additional lesions to further segment the posterior wall to achieve entrance and exit block (using output of 20 mA and 5 ms pulses). The pulmonary veins were isolated by delivery of RF applications circumferentially to the antral regions. Entrance and exit block was confirmed for up to 20 min. A Smartablate™ generator (Biosense Webster, Inc., Diamond Bar, CA, USA) was used to deliver RF energy, with a setpoint of 50 W on all patients and all areas of the left atrium. The Visitag Surpoint module (ablation index) was utilized during ablations, with a target of 400 units on the posterior wall, and 550 units on the anterior wall, lateral wall, and septum and an intertag distance of less than 6 mm. Patients with paroxysmal AF received only pulmonary vein isolation without additional posterior wall ablation, whereas patients with persistent AF received additional posterior wall isolation, in which lines were placed with homogenization until exit block was demonstrated throughout at highest output.

Esophageal Protection

Prior to adoption of active esophageal cooling, standard LET monitoring was utilized in all cases. In one hospital system, the majority of sensors used were single-sensor probes, with approximately 10% of them receiving a multi-sensor probe (Circa S-Cath; Circa Scientific, Inc., Englewood, CO, USA). Energy delivery was discontinued when the maximum LET on the single-sensor temperature probe or on any sensor of the multi-sensor probe rose by more than 0.2°C/s, or exceeded 39°C. In patients treated with active cooling, the position of lesions on the posterior wall was adjusted if needed to avoid ablation directly over the esophagus if the tissue thickness (atrium and esophageal wall) was less than approximately 2 mm as viewed on ICE. Otherwise, the ablation proceeded in a point-to-point fashion uninterrupted by pauses or alarms. In the other healthcare system, LET monitoring was predominantly via a multi-sensor probe (Circa S-Cath, Circa Scientific, Inc., Englewood, CO, USA). RF ablation was stopped and the site of ablation moved to a different distant area of the veins for any alarm over 0.2 °C/s, or a temperature exceeding 38.5 °C.

After the adoption of active esophageal cooling in both healthcare systems, no temperature probe was utilized with the esophageal cooling device. Ablation proceeded in a point-to-point fashion uninterrupted by pauses due to temperature elevations or overheating alarms. Active esophageal cooling was performed using the ensoETM device (Attune Medical, Chicago, IL, USA), a closed-loop silicone tube that is inserted into the esophagus in similar fashion to a standard orogastric tube (Figure 1.). The device is connected to a temperature controlled heat-exchanger which circulates 4 °C water at 2.4 L/min. Placement is confirmed via either fluoroscopy or with ICE. Except for the change to the esophageal cooling protocol, the ablation procedure for patients in each hospital remained the same.

Definitions

Atrial arrhythmia included AF, atrial flutter, and atrial tachycardia (AT). Paroxysmal AF (PAF) was considered to be episodes of AF that terminate spontaneously. Patients with persistent AF had episodes that continued for >7 days and were not self-terminating. Patients with long-standing persistent AF had ongoing long-term episodes of AF for over a year.

Determination of rhythm status

Rhythm status was determined by review of the electronic medical record or existing practice records maintained by the physician practice group. This review focused specifically on status at the 12-month follow-up visit, or the last visit attended by the patient earlier than the 12-month follow-up visit in cases in which a visit was not completed within two months of the 12-month anniversary of the index PVI procedure. In the vast majority of cases, visits were in-person, with only a small number of visits occurring via virtual or telehealth visit. Rhythm status was determined by ECG, Holter monitor, wearable patch monitor, pacemaker/defibrillator, or implantable loop recorder. Wearable patch monitoring was typically performed with commercially available devices such as Zio patch (iRhythm Technologies, San Francisco, CA) or CAM patch (Bardy Diagnostics, Bellevue, WA). Patient self-monitoring using personal devices, such as AliveCor Kardia, Fitbit, Apple Watch, etc.) also generally increased during this study period, providing another means by which patients might identify a recurrence of arrhythmia and present to the hospital.

Statistical analysis

Continuous variables are expressed as mean +/- standard deviation, with categorical variables reported in percentile value. Kaplan-Meier curves were created and analyzed using the log-rank test to compare the rate of freedom from arrhythmia between patients receiving LET monitoring and patients receiving active esophageal cooling. Assumptions for Kaplan-Meier analysis were (1) the event status consists of two mutually exclusive and collectively exhaustive states (sinus or arrhythmia), (2) the time to an event or censorship is clearly defined, (3) left-censoring should be minimized or avoided, (4) independence exists between censoring and the event, and (5) a similar amount and pattern of censorship exists in each group. The assumption of no secular trends in the data was violated by the increased use of wearable monitors over time and the greater age and comorbidities of patients undergoing ablations; however, both trends bias towards the null. Results were considered significant with a p value <0.05. Statistical analyses were performed using IBM SPSS Statistics software, version 26 (IBM, Armonk, New York).

A total of 513 patients were reviewed; 253 received LET monitoring using either single or multi-sensor temperature probes, and 260 received active cooling. Mean age was 66.5 ± 9.7 in the LET monitored group, and 66.9 ± 9.8 in the actively cooled group (Table 1). Gender was 63% male in the LET monitored group, and 64.6% male in the actively cooled group. Arrhythmias were 59.7% paroxysmal AF, 35.6% persistent AF, and 4.7% long-standing persistent AF in the LET monitored group, and 60.4% paroxysmal AF, 33.1% persistent AF, and 6.5% long-standing persistent AF in the actively cooled group.

Table 1. Patient demographics and type of atrial fibrillation.

	LET monitoring (n=253)	Active esophageal cooling (n=260)	P value
Patient Age (years)	66.5 ± 9.7	66.9 ± 9.8	0.64
Age range (years)	21.1 to 88.0	32.0 to 91.3
Gender (% male)	63.0	64.6	0.70
AF type
Paroxysmal, n (%)	151 (59.7)	157 (60.4)	0.87
Persistent, n (%)	90 (35.6)	86 (33.1)	0.55
Long-standing, n (%)	12 (4.7)	17 (6.5)	0.37

At one-year follow-up, KM estimates for freedom from AF were 58.2% for LET monitored patients and 72.2% for actively cooled patients (Figure 2.), for absolute increase in freedom from AF of 14% with active esophageal cooling (P=.03, Log-Rank).

In this first formal study to date of the association between esophageal protection strategy and long-term efficacy of left atrial RF ablation, we found a clinically and statistically significant improvement in freedom from atrial arrhythmia at one-year in patients treated with active esophageal cooling when compared to patients that received LET monitoring. Previous randomized controlled trial data have suggested trends towards greater freedom from atrial arrhythmias at long-term follow-up, but the smaller number of patients evaluated did not reach statistical significance.[14] The inclusion of a large number of patients across multiple hospitals in this analysis increases the robustness and reliability of the findings while demonstrating an important outcome effect associated with active esophageal cooling.

A mechanistic underpinning exists to explain these findings, with previous studies demonstrating the importance of lesion sequence and timing in ensuring complete isolation of the pulmonary veins after a PVI procedure. In the EFFICAS-II study, a formal measurement of lesion placement contiguity was defined as the Continuity Index (CI).[16] The CI is quantified by the number of positions in the left atrium that the RF catheter tip is moved over after prematurely ceasing RF power and moving elsewhere in the atrium to perform subsequent ablations in non-adjacent positions (Figure 3). In general, movement away from a lesion site is compelled by the development of overheating at the site, triggering a temperature alarm or an elevation in temperature that compels the operator to cease delivering RF power. The operator can then either wait for equilibration in temperature or move to a distant site to begin ablations elsewhere in the atrium before returning to the site adjacent to the overheated site to continue the sequence of lesions. In either case, the prematurely aborted lesion is left incompletely transmural, while the adjacent site becomes increasingly edematous from the nearby thermal insult, rendering the new site more difficult to obtain a transmural lesion. The result of this effect is a larger number of partially formed, non-transmural lesions, a reduction in the ability to fully isolate to pulmonary veins, and a decrease in overall efficacy of the procedure. In the EFFICAS-II study, PVI performed with a low CI (CI < 6) had a 98% (56/57) chance of remaining isolated, while PVI performed with a high CI (CI ≥ 6) had only a 62% (21/34) chance of remaining isolated.[16]

More recently, clinical data have shown that lesion placement order is an important factor in successful lesion formation.[15] Jankelson et al. reviewed 437,760 position data points during lesion placement, and found that lesions placed immediately have a higher likelihood of achieving transmurality-associated unipolar electrograms compared to delayed lesions.[15] The authors propose explanations for these findings that include the stacking of heat from prior ablation with sequential ablation, and the development of localized edema after lesion placement, resulting in impaired lesion formation with delayed lesions, while noting that edema formation is time dependent and may impede the recording of local electrograms and, thus, may play a greater role with increased temporal delay between lesions.[15, 17-22] As such, these findings provide insight regarding possible mechanisms by which sequential ablation with minimal interruption has been associated with improved ablation outcomes.[23]

Active esophageal cooling is performed without the need for temperature sensors, as the esophageal cooling device maintains a coolant temperature of 4 °C, and reduces the potential for esophageal wall temperatures to reach lethal isotherm levels.[13, 24] As a result, premature cessation of RF energy deposition during lesion placement is unnecessary, and uninterrupted lesion placement can be performed without the need to pause for temperature alarms. Thus, a low CI can be maintained throughout the procedure, with most cases resulting in a CI well under 6, and commonly equal to zero, correlating to a higher efficacy of isolation of the pulmonary veins, and a resultant improvement in freedom from arrhythmia.

Limitations

This was a retrospective review of data from patients receiving standard care outside of a formal randomized clinical trial. As such, unmeasured confounders may exist. Other than the change in esophageal protection strategy, no major changes in ablation protocol occurred, and the characteristics of patients served by the hospitals did not change during the analysis time frame, making a major bias less likely.

The increased availability of monitors available for patient purchase and use (such as Kardia, Fitbit, the Apple Watch, etc), and the increased clinical use of wearable monitors, may bias against active esophageal cooling, since an increased incidence of arrhythmia is likely to be found with this increased monitoring.[25-27] With an increased identification of arrhythmias, both symptomatic and asymptomatic, over time, the rate of arrhythmia detection in patients treated after the adoption of active esophageal cooling device is likely to have increased, and as such, the effect size found in this analysis may in fact be underestimated. Likewise, a trend in increased age and comorbidity burden among patients undergoing AF ablation exists.[28, 29] Since these factors correlate inversely with procedural success, an additional bias exists in the more recently treated group, in this case, the actively cooled cohort of patients.

In this first study to date of the association between esophageal protection strategy and long-term efficacy of left atrial RF ablation, a clinically and statistically significant improvement in freedom from atrial arrhythmia at one-year was found in patients treated with active esophageal cooling when compared to patients that received LET monitoring.

Conflict of interest

CJ reports internship with Attune Medical; JZ reports consulting for Biosense Webster and Attune Medical; JS reports summer internship with Attune Medical; WZ reports summer internship with Attune Medical; EK reports equity and employment in Attune Medical; MM reports consulting for Abbott, Biosense Webster, Attune Medical, Medtronic, Sanofi Aventis, and Philips. All other authors report no disclosures.

Funding

Research reported in this publication was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number R44HL158375. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Ethical approval

This retrospective data review was performed with Institutional Review Board approval from the two healthcare systems involved, the NorthShore University HealthSystem and the Texas Cardiac Arrhythmia Research Foundation at St. David’s South Austin Medical Center.

Informed consent

A consent form was not required because this was secondary research that used identifiable private information recorded by the investigator in such a manner that the identity of the human subjects cannot readily be ascertained directly or through identifiers linked to the subjects.

Della Rocca DG, Magnocavallo M, Natale VN, Gianni C, Mohanty S, Trivedi C, Lavalle C, Forleo GB, Tarantino N, Romero J et al: Clinical presentation, diagnosis, and treatment of atrioesophageal fistula resulting from atrial fibrillation ablation. J Cardiovasc Electrophysiol 2021, 32(9):2441-2450 doi: 10.1111/jce.15168 PMID: 34260115.
Halbfass P, Pavlov B, Muller P, Nentwich K, Sonne K, Barth S, Hamm K, Fochler F, Mugge A, Lusebrink U et al: Progression From Esophageal Thermal Asymptomatic Lesion to Perforation Complicating Atrial Fibrillation Ablation: A Single-Center Registry. Circ Arrhythm Electrophysiol 2017, 10(8) doi: 10.1161/circep.117.005233 PMID: 28798021.
Leung LWM, Akhtar Z, Sheppard MN, Louis-Auguste J, Hayat J, Gallagher MM: Preventing esophageal complications from atrial fibrillation ablation: A review. Heart Rhythm O2 2021, 2(6Part A):651-664 doi: 10.1016/j.hroo.2021.09.004 PMID: 34988511.
Schoene K, Arya A, Grashoff F, Knopp H, Weber A, Lerche M, König S, Hilbert S, Kircher S, Bertagnolli L et al: Oesophageal Probe Evaluation in Radiofrequency Ablation of Atrial Fibrillation (OPERA): results from a prospective randomized trial. Europace 2020, 22(10):1487-1494 doi: 10.1093/europace/euaa209 PMID: 32820324.
Meininghaus DG, Blembel K, Waniek C, Kruells-Muench J, Ernst H, Kleemann T, Geller JC: Temperature Monitoring and Temperature-driven irrigated Radiofrequency Energy Titration do not prevent thermally-induced Esophageal Lesions in Pulmonary Vein Isolation A randomized study controlled by esophagoscopy before and after catheter ablation. Heart Rhythm 2021 doi: 10.1016/j.hrthm.2021.02.003 PMID: 33561587.
Berjano EJ, Hornero F: A cooled intraesophageal balloon to prevent thermal injury during endocardial surgical radiofrequency ablation of the left atrium: a finite element study. Physics in Medicine and Biology 2005, 50(20):N269-279 doi: 10.1088/0031-9155/50/20/N03 PMID: 16204868.
Leung LW, Gallagher MM, Santangeli P, Tschabrunn C, Guerra JM, Campos B, Hayat J, Atem F, Mickelsen S, Kulstad E: Esophageal cooling for protection during left atrial ablation: a systematic review and meta-analysis. J Interv Card Electrophysiol 2019 doi: 10.1007/s10840-019-00661-5 PMID: 31758504.
Leung LWM, Bajpai A, Zuberi Z, Li A, Norman M, Kaba RA, Akhtar Z, Evranos B, Gonna H, Harding I et al: Randomized comparison of oesophageal protection with a temperature control device: results of the IMPACT study. Europace 2021, 23(2):205-215 doi: 10.1093/europace/euaa276 PMID: 33205201.
Tschabrunn CM, Attalla S, Salas J, Frankel DS, Hyman MC, Simon E, Sharkoski T, Callans DJ, Supple GE, Nazarian S et al: Active esophageal cooling for the prevention of thermal injury during atrial fibrillation ablation: a randomized controlled pilot study. J Interv Card Electrophysiol 2022, 63(1):197-205 doi: 10.1007/s10840-021-00960-w PMID: 33620619.
Joseph C, Sherman J, Ro A, Fisher WG, Nazari J, Metzl M: Procedural time reduction associated with active esophageal cooling during pulmonary vein isolation. J Interv Card Electrophysiol 2022 doi: 10.1007/s10840-022-01204-1 PMID: 35416632.
Zagrodzky J, Bailey S, Shah S, Kulstad E: Impact of Active Esophageal Cooling on Fluoroscopy Usage During Left Atrial Ablation. J Innov Card Rhythm Manag 2021, 12(11):4749-4755 doi: 10.19102/icrm.2021.121101 PMID: 34676132.
Montoya MM, Mickelsen S, Clark B, Arnold M, Hanks J, Sauter E, Kulstad E: Protecting the esophagus from thermal injury during radiofrequency ablation with an esophageal cooling device. Journal of atrial fibrillation 2019, 11(5):2110 doi: 10.4022/jafib.2110 PMID: 31139296.
Mercado M, Leung L, Gallagher M, Shah S, Kulstad E: Modeling esophageal protection from radiofrequency ablation via a cooling device: an analysis of the effects of ablation power and heart wall dimensions. Biomed Eng Online 2020, 19(1):77 doi: 10.1186/s12938-020-00821-z PMID: 33046057.
Leung L, El Batran A, Dhillon G, Bajpai A, Zuberi Z, Li A, Norman M, Kaba R, Akhtar Z, Evranos B et al: Oesophageal thermal protection during AF ablation: effect on left atrial myocardial ablation lesion formation and patient outcomes. EP Europace 2021, 23(Supplement_3) doi: 10.1093/europace/euab116.253 PMID:
Jankelson L, Dai M, Aizer A, Bernstein S, Park DS, Holmes D, Chinitz LA, Barbhaiya C: Lesion Sequence and Catheter Spatial Stability Affect Lesion Quality Markers in Atrial Fibrillation Ablation. JACC Clinical electrophysiology 2021, 7(3):367-377 doi: 10.1016/j.jacep.2020.09.027 PMID: 33516716.
Kautzner J, Neuzil P, Lambert H, Peichl P, Petru J, Cihak R, Skoda J, Wichterle D, Wissner E, Yulzari A et al: EFFICAS II: optimization of catheter contact force improves outcome of pulmonary vein isolation for paroxysmal atrial fibrillation. Europace 2015, 17(8):1229-1235 doi: 10.1093/europace/euv057 PMID: 26041872.
Barbhaiya CR, Kogan EV, Jankelson L, Knotts RJ, Spinelli M, Bernstein S, Park D, Aizer A, Chinitz LA, Holmes D: Esophageal temperature dynamics during high-power short-duration posterior wall ablation. Heart Rhythm 2020, 17(5 Pt A):721-727 doi: 10.1016/j.hrthm.2020.01.014 PMID: 31978595.
Lardo AC, McVeigh ER, Jumrussirikul P, Berger RD, Calkins H, Lima J, Halperin HR: Visualization and temporal/spatial characterization of cardiac radiofrequency ablation lesions using magnetic resonance imaging. Circulation 2000, 102(6):698-705 doi: 10.1161/01.cir.102.6.698 PMID: 10931812.
Weerasooriya R, Jaïs P, Sanders P, Scavée C, Hsu LF, Hocini M, Clementy J, Haïssaguerre M: Images in cardiovascular medicine. Early appearance of an edematous tissue reaction during left atrial linear ablation using intracardiac echo imaging. Circulation 2003, 108(11):e80 doi: 10.1161/01.Cir.0000083530.08597.B5 PMID: 12975247.
Okada T, Yamada T, Murakami Y, Yoshida N, Ninomiya Y, Shimizu T, Toyama J, Yoshida Y, Ito T, Tsuboi N et al: Prevalence and Severity of Left Atrial Edema Detected by Electron Beam Tomography Early After Pulmonary Vein Ablation. Journal of the American College of Cardiology 2007, 49(13):1436-1442 doi: doi.org/10.1016/j.jacc.2006.10.076 PMID:
Wright M, Harks E, Deladi S, Fokkenrood S, Brink R, Belt H, Kolen AF, Rankin D, Stoffregen W, Cockayne DA et al: Characteristics of Radiofrequency Catheter Ablation Lesion Formation in Real Time In Vivo Using Near Field Ultrasound Imaging. JACC: Clinical Electrophysiology 2018, 4(8):1062-1072 doi: doi.org/10.1016/j.jacep.2018.04.002 PMID:
Havranek S, Alfredova H, Fingrova Z, Souckova L, Wichterle D: Early and Delayed Alteration of Atrial Electrograms Around Single Radiofrequency Ablation Lesion. Frontiers in Cardiovascular Medicine 2019, 5 doi: 10.3389/fcvm.2018.00190 PMID:
Jankelson L, Dai M, Bernstein S, Park D, Holmes D, Aizer A, Chinitz L, Barbhaiya C: Quantitative analysis of ablation technique predicts arrhythmia recurrence following atrial fibrillation ablation. American Heart Journal 2020, 220:176-183 doi: https://doi.org/10.1016/j.ahj.2019.11.011 PMID:
Kulstad E, Mercado-Montoya M, Gomez-Bustamante T, Berjano E, Mickelsen S, Daniels J, Hernandez-Arango P, Schieber J: Influence of tissue thickness on thermal latency during high-power short-duration radiofrequency ablation with proactive esophageal cooling. EP Europace 2022, 24(Supplement_1) doi: 10.1093/europace/euac053.085 PMID:
Wang L, Nielsen K, Goldberg J, Brown JR, Rumsfeld JS, Steinberg BA, Zhang Y, Matheny ME, Shah RU: Association of Wearable Device Use With Pulse Rate and Health Care Use in Adults With Atrial Fibrillation. JAMA Network Open 2021, 4(5):e215821-e215821 doi: 10.1001/jamanetworkopen.2021.5821 PMID:
Wan EY, Ghanbari H, Akoum N, Itzhak Attia Z, Asirvatham SJ, Chung EH, Dagher L, Al-Khatib SM, Stuart Mendenhall G, McManus DD et al: HRS White Paper on Clinical Utilization of Digital Health Technology. Cardiovascular Digital Health Journal 2021, 2(4):196-211 doi: 10.1016/j.cvdhj.2021.07.001 PMID:
Wang YC, Xu X, Hajra A, Apple S, Kharawala A, Duarte G, Liaqat W, Fu Y, Li W, Chen Y et al: Current Advancement in Diagnosing Atrial Fibrillation by Utilizing Wearable Devices and Artificial Intelligence: A Review Study. Diagnostics (Basel) 2022, 12(3) doi: 10.3390/diagnostics12030689 PMID: 35328243.
Cheng EP, Liu CF, Yeo I, Markowitz SM, Thomas G, Ip JE, Kim LK, Lerman BB, Cheung JW: Risk of Mortality Following Catheter Ablation of Atrial Fibrillation. J Am Coll Cardiol 2019, 74(18):2254-2264 doi: 10.1016/j.jacc.2019.08.1036 PMID: 31672181.
Kim LK, Yeo I, Cheung J, Feldman DN, Swaminathan RV, Kamel H: Impact of Evolving Comorbidities on Outcomes After Catheter Ablation of Atrial Fibrillation in the United States Between 2003 and 2013. JACC: Clinical Electrophysiology 2018, 4(5):704-706 doi: https://doi.org/10.1016/j.jacep.2017.12.014 PMID:

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Improved One-year Outcomes After Active Cooling During Left Atrial Radiofrequency Ablation

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