OBJECTIVES: The authors report the first acute clinical experience of atrial fibrillation ablation with PEF-both epicardial box lesions during cardiac surgery, and catheter-based PV isolation. BACKGROUND: Standard energy sources rely on time-dependent conductive heating/cooling and ablate all tissue types indiscriminately. Pulsed electric field (PEF) energy ablates nonthermally by creating nanoscale pores in cell membranes. Potential advantages for atrial fibrillation ablation include: 1) cardiomyocytes have among the lowest sensitivity of any tissue to PEF-allowing tissue selectivity, thereby minimizing ablation of nontarget collateral tissue; 2) PEF is delivered rapidly over a few seconds; and 3) the absence of coagulative necrosis obviates the risk of pulmonary vein (PV) stenosis. METHODS: PEF ablation was performed using a custom over-the-wire endocardial catheter for percutaneous transseptal PV isolation, and a linear catheter for encircling the PVs and posterior left atrium during concomitant cardiac surgery. Endocardial voltage maps were created pre- and post-ablation. Continuous and categorical data are summarized and presented as mean ± SD and frequencies. RESULTS: At 2 centers, 22 patients underwent ablation under general anesthesia: 15 endocardial and 7 epicardial. Catheter PV isolation was successful in all 57 PVs in 15 patients (100%) using 3.26 ± 0.5 lesions/PV: procedure time 67 ± 10.5 min, catheter time (PEF catheter entry to exit) 19 ± 2.5 min, total PEF energy delivery time <60 s/patient, and fluoroscopy time 12 ± 4.0 min. Surgical box lesions were successful in 6 of 7 patients (86%) using 2 lesions/patient. The catheter time for epicardial ablation was 50.7 ± 19.5 min. There were no complications. CONCLUSIONS: These data usher in a new era of tissue-specific, ultrarapid ablation of atrial fibrillation.

Department of Cardiac Surgery Homolka Hospital Prague Czech Republic

Department of Cardiology Division of Electrophysiology IHU LIRYC ANR 10 IAHU 04 University of Bordeaux CHU Bordeaux Bordeaux France

Department of Cardiology Homolka Hospital Prague Czech Republic

Department of Cardiothoracic Surgery Baylor Medical Center Dallas Texas

Department of Electrophysiology Division of Cardiology Icahn School of Medicine at Mount Sinai New York New York

Department of Electrophysiology Division of Cardiology Icahn School of Medicine at Mount Sinai New York New York; Department of Cardiology Homolka Hospital Prague Czech Republic

Medico Surgical Service of Valvulopathies and Cardiomyopathies Adult Cardiac Surgery IHU LIRYC ANR 10 1AHU 04 University of Bordeaux CHU Bordeaux Bordeaux France

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JACC Clin Electrophysiol. 2018 Aug;4(8):996-998. doi: 10.1016/j.jacep.2018.05.020. PubMed

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