Application and development of pulsed electric field ablation in the treatment of atrial fibrillation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG Zhen ^1,2 , LIANG Ming ^1,3 , ZHANG Jie ¹ , SUN Jingyang ¹ ,  HAN Yaling ^1,3

1. Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, 110016, P. R. China;
2. College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, 110819, P. R. China;
3. National Key Laboratory of Frigid Zone Cardiovascular Diseases, Shenyang, 110016, P. R. China;

Corresponding author：

HAN Yaling, Email: xxgnkhyl@163.com

Keywords：

Pulse ablation; atrial fibrillation; catheter ablation; clinical research; treatment

DOI：

10.7507/1007-4848.202309003

Video：

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With the continuous development of China's aging society and the prevalence of unhealthy lifestyles, the incidence of cardiovascular disease in China has been increasing in recent years. Among them, atrial fibrillation (AF) is the most common arrhythmia disease. In recent years, pulsed field ablation ( PFA ) has been continuously applied to AF treatment as a novel treatment. This paper first introduces the principle of PFA applied to AF treatment, and introduces the research progress of PFA in different directions, such as the comparison of different ablation methods, the study of physical parameters, the study of ablation area, the study of tissue specificity and clinical research. Then, the clinical priori research of PFA is discussed, including the use of simulation software to obtain the simulation effect of different parameters, the evaluation of ablation effect during animal research, and finally the current AF treatment. Various priori studies and clinical studies are summarized, and suggestions are made for the shortcomings found in the study of AF treatment and the future research direction is prospected.

1.	Packer DL, Mark DB, Robb RA, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: The CABANA randomized clinical trial. JAMA, 2019, 321(13): 1261-1274.
2.	Gleason KT, Dennison Himmelfarb CR, Ford DE, et al. Association of sex, age and education level with patient reported outcomes in atrial fibrillation. BMC Cardiovasc Disord, 2019, 19(1): 1-12.
3.	Camm A J, Naccarelli G V, Mittal S, et al. The increasing role of rhythm control in patients with atrial fibrillation: JACC state-of-the-art review. JACC, 2022, 79(19): 1932-1948.
4.	Staerk L, Sherer JA, Ko D, et al. Atrial fibrillation: Epidemiology, pathophysiology, and clinical outcomes. Circ Res, 2017, 120(9): 1501-1517.
5.	中国心血管健康与疾病报告2022概要. 中国循环杂志, 2023, 38(6): 583-612.
6.	Schmidt B, Brugada J, Arbelo E, et al. Ablation strategies for different types of atrial fibrillation in Europe: Results of the ESC-EORP EHRA atrial fibrillation ablation long-term registry. EP Europace, 2020, 22(4): 558-566.
7.	Pelargonio G, Di Monaco A, Guida P, et al. Atrial fibrillation ablation: is common practice far from guidelines’ world? The Italian experience from a national survey. J Interv Card Electrophysiol, 2022, 63(1): 125-132.
8.	Black-Maier E, Pokorney SD, Barnett AS, et al. Risk of atrioesophageal fistula formation with contact force–sensing catheters. Heart Rhythm, 2017, 14(9): 1328-1333.
9.	Nery P B, Belliveau D, Nair GM, et al. Relationship between pulmonary vein reconnection and atrial fibrillation recurrence: A systematic review and meta-analysis. JACC Clin Electrophysiol, 2016, 2(4): 474-483.
10.	Andrade J G, Dubuc M, Guerra P G, et al. The biophysics and biomechanics of cryoballoon ablation. Pacing Clin Electrophysiol, 2012, 35(9): 1162-1168.
11.	Ranjan R, Kato R, Zviman MM, et al. Gaps in the ablation line as a potential cause of recovery from electrical isolation and their visualization using MRI. Circ Arrhythm Electrophysiol, 2011, 4(3): 279-286.
12.	Tian Z, Nan Q, Nie X, et al. The comparison of lesion outline and temperature field determined by different ways in atrial radiofrequency ablation. Biomed Eng Online, 2016, 15(Suppl 2): 439-449.
13.	Su W, Aryana A, Passman R, et al. Cryoballoon best practices Ⅱ: practical guide to procedural monitoring and dosing during atrial fibrillation ablation from the perspective of experienced users. Heart Rhythm, 2018, 15(9): 1348-1355.
14.	Darby AE. Pulsed field ablation: a novel therapeutic tool for catheter-based treatment of atrial fibrillation. Curr Cardiol Rep, 2022, 24(7): 793-799.
15.	Howard B, Haines DE, Verma A, et al. Reduction in pulmonary vein stenosis and collateral damage with pulsed field ablation compared with radiofrequency ablation in a canine model. Circ Arrhythm Electrophysiol, 2020, 13(9): e008337.
16.	Loh P, van Es R, Groen MHA, et al. Pulmonary vein isolation with single pulse irreversible electroporation: A first in human study in 10 patients with atrial fibrillation. Circ Arrhythm Electrophysiol, 2020, 13(10): e008192.
17.	Caluori G, Odehnalova E, Jadczyk T, et al. AC pulsed field ablation is feasible and safe in atrial and ventricular settings: A proof-of-concept chronic animal study. Front Bioeng Biotechnol, 2020, 8: 552357.
18.	Zang L, Gu K, Ji X, et al. Comparative analysis of temperature rise between convective heat transfer method and computational fluid dynamics method in an anatomy-based left atrium model during pulsed field ablation: A computational study. J Cardiovasc Dev Dis, 2023, 10(2): 56.
19.	Verma A, Asivatham SJ, Deneke T, et al. Primer on pulsed electrical field ablation: understanding the benefits and limitations. Circ Arrhythm Electrophysiol, 2021, 14(9): e010086.
20.	Yavin H, Brem E, Zilberman I, et al. Circular multielectrode pulsed field ablation catheter lasso pulsed field ablation: lesion characteristics, durability, and effect on neighboring structures. Circ Arrhythm Electrophysiol, 2021, 14(2): e009229.
21.	Nakatani Y, Sridi-Cheniti S, Cheniti G, et al. Pulsed field ablation prevents chronic atrial fibrotic changes and restrictive mechanics after catheter ablation for atrial fibrillation. EP Europace, 2021, 23(11): 1767-1776.
22.	Reddy V Y, Anter E, Rackauskas G, et al. Lattice-tip focal ablation catheter that toggles between radiofrequency and pulsed field energy to treat atrial fibrillation: a first-in-human trial. Circ Arrhythm Electrophysiol, 2020, 13(6): e008718.
23.	Cochet H, Nakatani Y, Sridi-Cheniti S, et al. Pulsed field ablation selectively spares the oesophagus during pulmonary vein isolation for atrial fibrillation. EP Europace, 2021, 23(9): 1391-1399.
24.	Ji X, Zhang H, Zang L, et al. The effect of discharge mode on the distribution of myocardial pulsed electric field—a simulation study for pulsed field ablation of atrial fibrillation. J Cardiovasc Dev Dis, 2022, 9(4): 95.
25.	Meckes D, Emami M, Fong I, et al. Pulsed-field ablation: Computational modeling of electric fields for lesion depth analysis. Heart Rhythm O2, 2022, 3(4): 433-440.
26.	Zang L, Gu K, Ji X, et al. Effect of anisotropic electrical conductivity induced by fiber orientation on ablation characteristics of pulsed field ablation in atrial fibrillation treatment: A computational study. J Cardiovasc Dev Dis, 2022, 9(10): 319.
27.	Song Y, Zheng J, Fan L. Nonthermal irreversible electroporation to the esophagus: Evaluation of acute and long-term pathological effects in a rabbit model. J Am Heart Assoc, 2021, 10(22): e020731.
28.	Hunter D W, Kostecki G, Fish JM, et al. In vitro cell selectivity of reversible and irreversible: Electroporation in cardiac tissue. Circ Arrhythm Electrophysiol, 2021, 14(4): e008817.
29.	González-Suárez A, Irastorza RM, Deane S, et al. Full torso and limited-domain computer models for epicardial pulsed electric field ablation. omput Methods Programs Biomed, 2022, 221: 106886.
30.	González-Suárez A, O’Brien B, O’Halloran M, et al. Pulsed electric field ablation of epicardial autonomic ganglia: Computer analysis of monopolar electric field across the tissues involved. Bioengineering, 2022, 9(12): 731.
31.	González-Suárez A, Pérez JJ, O’Brien B, et al. In silico modelling to assess the electrical and thermal disturbance provoked by a metal intracoronary stent during epicardial pulsed electric field ablation. J Cardiovasc Dev Dis, 2022, 9(12): 458.
32.	Caluori G, Odehnalova E, Jadczyk T, et al. AC pulsed field ablation is feasible and safe in atrial and ventricular settings: a proof-of-concept chronic animal study. Front Bioeng Biotechnol, 2020, 8: 552357.
33.	Koruth JS, Kuroki K, Iwasawa J, et al. Endocardial ventricular pulsed field ablation: A proof-of-concept preclinical evaluation. EP Europace, 2020, 22(3): 434-439.
34.	Song Y, Zheng J, Fan L. Nonthermal Irreversible Electroporation to the Esophagus: Evaluation of Acute and Long‐Term Pathological Effects in a Rabbit Model. J Am Heart Assoc, 2021, 10(22): e020731.
35.	Yavin H, Shapira-Daniels A, Barkagan M, et al. Pulsed field ablation using a lattice electrode for focal energy delivery: biophysical characterization, lesion durability, and safety evaluation. Circ Arrhythm Electrophysiol, 2020, 13(6): e008580.
36.	Reddy V Y, Anic A, Koruth J, et al. Pulsed field ablation in patients with persistent atrial fibrillation. J Am Coll Cardiol, 2020, 76(9): 1068-1080.
37.	Verma A, Boersma L, Haines D E, et al. First-in-human experience and acute procedural outcomes using a novel pulsed field ablation system: the PULSED AF pilot trial. Circ Arrhythm Electrophysiol, 2022, 15(1): e010168.
38.	Gunawardene MA, Schaeffer BN, Jularic M, et al. Pulsed‐field ablation combined with ultrahigh‐density mapping in patients undergoing catheter ablation for atrial fibrillation: practical and electrophysiological considerations. J Cardiovasc Electrophysiol, 2022, 33(3): 345-356.
39.	Blockhaus C, Guelker JE, Feyen L, et al. Pulsed field ablation for pulmonary vein isolation: Real-world experience and characterization of the antral lesion size compared with cryoballoon ablation. J Interv Cardiac Electrophysiol, 2023, 66(3): 567-575.
40.	Lemoine MD, Fink T, Mencke C, et al. Pulsed-field ablation-based pulmonary vein isolation: Acute safety, efficacy and short-term follow-up in a multi-center real world scenario. Clin Res Cardiol, 2023, 112(6): 795-806.
41.	Chen S, Chun JKR, Bordignon S, et al. Pulsed field ablation-based pulmonary vein isolation in atrial fibrillation patients with cardiac implantable electronic devices: practical approach and device interrogation (PFA in CIEDs). J Interv Card Electrophysiol, 2022: 1-10.
42.	Verma A, Haines DE, Boersma LV, et al. Pulsed field ablation for the treatment of atrial fibrillation: PULSED AF pivotal trial. Circulation, 2023, 147(19): 1422-1432.
43.	My I, Lemoine MD, Butt M, et al. Acute lesion extension following pulmonary vein isolation with two novel single shot devices: Pulsed field ablation versus multielectrode radiofrequency balloon. J Cardiovasc Electrophysiol, 2023.
44.	Kuroki K, Whang W, Eggert C, et al. Ostial dimensional changes after pulmonary vein isolation: pulsed field ablation vs radiofrequency ablation. Heart Rhythm, 2020, 17(9): 1528-1535.
45.	Loh P, van Es R, Groen MHA, et al. Pulmonary vein isolation with single pulse irreversible electroporation: A first in human study in 10 patients with atrial fibrillation. Circ:Arrhyth Electrophysiol, 2020, 13(10): e008192.
46.	Reddy VY, Neuzil P, Koruth JS, et al. Pulsed field ablation for pulmonary vein isolation in atrial fibrillation. J Am Coll Cardiol, 2019, 74(3): 315-326.
47.	Ruwald MH, Johannessen A, Hansen ML, et al. Pulsed field ablation in real-world atrial fibrillation patients: Clinical recurrence, operator learning curve and re-do procedural findings. J Interv Card Electrophysiol, 2023: 1-12.
48.	Stojadinović P, Wichterle D, Peichl P, et al. Autonomic changes are more durable after radiofrequency than pulsed electric field pulmonary vein ablation. Clin Electrophysiol, 2022, 8(7): 895-904.

1. Packer DL, Mark DB, Robb RA, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: The CABANA randomized clinical trial. JAMA, 2019, 321(13): 1261-1274.
2. Gleason KT, Dennison Himmelfarb CR, Ford DE, et al. Association of sex, age and education level with patient reported outcomes in atrial fibrillation. BMC Cardiovasc Disord, 2019, 19(1): 1-12.
3. Camm A J, Naccarelli G V, Mittal S, et al. The increasing role of rhythm control in patients with atrial fibrillation: JACC state-of-the-art review. JACC, 2022, 79(19): 1932-1948.
4. Staerk L, Sherer JA, Ko D, et al. Atrial fibrillation: Epidemiology, pathophysiology, and clinical outcomes. Circ Res, 2017, 120(9): 1501-1517.
5. 中国心血管健康与疾病报告2022概要. 中国循环杂志, 2023, 38(6): 583-612.
6. Schmidt B, Brugada J, Arbelo E, et al. Ablation strategies for different types of atrial fibrillation in Europe: Results of the ESC-EORP EHRA atrial fibrillation ablation long-term registry. EP Europace, 2020, 22(4): 558-566.
7. Pelargonio G, Di Monaco A, Guida P, et al. Atrial fibrillation ablation: is common practice far from guidelines’ world? The Italian experience from a national survey. J Interv Card Electrophysiol, 2022, 63(1): 125-132.
8. Black-Maier E, Pokorney SD, Barnett AS, et al. Risk of atrioesophageal fistula formation with contact force–sensing catheters. Heart Rhythm, 2017, 14(9): 1328-1333.
9. Nery P B, Belliveau D, Nair GM, et al. Relationship between pulmonary vein reconnection and atrial fibrillation recurrence: A systematic review and meta-analysis. JACC Clin Electrophysiol, 2016, 2(4): 474-483.
10. Andrade J G, Dubuc M, Guerra P G, et al. The biophysics and biomechanics of cryoballoon ablation. Pacing Clin Electrophysiol, 2012, 35(9): 1162-1168.
11. Ranjan R, Kato R, Zviman MM, et al. Gaps in the ablation line as a potential cause of recovery from electrical isolation and their visualization using MRI. Circ Arrhythm Electrophysiol, 2011, 4(3): 279-286.
12. Tian Z, Nan Q, Nie X, et al. The comparison of lesion outline and temperature field determined by different ways in atrial radiofrequency ablation. Biomed Eng Online, 2016, 15(Suppl 2): 439-449.
13. Su W, Aryana A, Passman R, et al. Cryoballoon best practices Ⅱ: practical guide to procedural monitoring and dosing during atrial fibrillation ablation from the perspective of experienced users. Heart Rhythm, 2018, 15(9): 1348-1355.
14. Darby AE. Pulsed field ablation: a novel therapeutic tool for catheter-based treatment of atrial fibrillation. Curr Cardiol Rep, 2022, 24(7): 793-799.
15. Howard B, Haines DE, Verma A, et al. Reduction in pulmonary vein stenosis and collateral damage with pulsed field ablation compared with radiofrequency ablation in a canine model. Circ Arrhythm Electrophysiol, 2020, 13(9): e008337.
16. Loh P, van Es R, Groen MHA, et al. Pulmonary vein isolation with single pulse irreversible electroporation: A first in human study in 10 patients with atrial fibrillation. Circ Arrhythm Electrophysiol, 2020, 13(10): e008192.
17. Caluori G, Odehnalova E, Jadczyk T, et al. AC pulsed field ablation is feasible and safe in atrial and ventricular settings: A proof-of-concept chronic animal study. Front Bioeng Biotechnol, 2020, 8: 552357.
18. Zang L, Gu K, Ji X, et al. Comparative analysis of temperature rise between convective heat transfer method and computational fluid dynamics method in an anatomy-based left atrium model during pulsed field ablation: A computational study. J Cardiovasc Dev Dis, 2023, 10(2): 56.
19. Verma A, Asivatham SJ, Deneke T, et al. Primer on pulsed electrical field ablation: understanding the benefits and limitations. Circ Arrhythm Electrophysiol, 2021, 14(9): e010086.
20. Yavin H, Brem E, Zilberman I, et al. Circular multielectrode pulsed field ablation catheter lasso pulsed field ablation: lesion characteristics, durability, and effect on neighboring structures. Circ Arrhythm Electrophysiol, 2021, 14(2): e009229.
21. Nakatani Y, Sridi-Cheniti S, Cheniti G, et al. Pulsed field ablation prevents chronic atrial fibrotic changes and restrictive mechanics after catheter ablation for atrial fibrillation. EP Europace, 2021, 23(11): 1767-1776.
22. Reddy V Y, Anter E, Rackauskas G, et al. Lattice-tip focal ablation catheter that toggles between radiofrequency and pulsed field energy to treat atrial fibrillation: a first-in-human trial. Circ Arrhythm Electrophysiol, 2020, 13(6): e008718.
23. Cochet H, Nakatani Y, Sridi-Cheniti S, et al. Pulsed field ablation selectively spares the oesophagus during pulmonary vein isolation for atrial fibrillation. EP Europace, 2021, 23(9): 1391-1399.
24. Ji X, Zhang H, Zang L, et al. The effect of discharge mode on the distribution of myocardial pulsed electric field—a simulation study for pulsed field ablation of atrial fibrillation. J Cardiovasc Dev Dis, 2022, 9(4): 95.
25. Meckes D, Emami M, Fong I, et al. Pulsed-field ablation: Computational modeling of electric fields for lesion depth analysis. Heart Rhythm O2, 2022, 3(4): 433-440.
26. Zang L, Gu K, Ji X, et al. Effect of anisotropic electrical conductivity induced by fiber orientation on ablation characteristics of pulsed field ablation in atrial fibrillation treatment: A computational study. J Cardiovasc Dev Dis, 2022, 9(10): 319.
27. Song Y, Zheng J, Fan L. Nonthermal irreversible electroporation to the esophagus: Evaluation of acute and long-term pathological effects in a rabbit model. J Am Heart Assoc, 2021, 10(22): e020731.
28. Hunter D W, Kostecki G, Fish JM, et al. In vitro cell selectivity of reversible and irreversible: Electroporation in cardiac tissue. Circ Arrhythm Electrophysiol, 2021, 14(4): e008817.
29. González-Suárez A, Irastorza RM, Deane S, et al. Full torso and limited-domain computer models for epicardial pulsed electric field ablation. omput Methods Programs Biomed, 2022, 221: 106886.
30. González-Suárez A, O’Brien B, O’Halloran M, et al. Pulsed electric field ablation of epicardial autonomic ganglia: Computer analysis of monopolar electric field across the tissues involved. Bioengineering, 2022, 9(12): 731.
31. González-Suárez A, Pérez JJ, O’Brien B, et al. In silico modelling to assess the electrical and thermal disturbance provoked by a metal intracoronary stent during epicardial pulsed electric field ablation. J Cardiovasc Dev Dis, 2022, 9(12): 458.
32. Caluori G, Odehnalova E, Jadczyk T, et al. AC pulsed field ablation is feasible and safe in atrial and ventricular settings: a proof-of-concept chronic animal study. Front Bioeng Biotechnol, 2020, 8: 552357.
33. Koruth JS, Kuroki K, Iwasawa J, et al. Endocardial ventricular pulsed field ablation: A proof-of-concept preclinical evaluation. EP Europace, 2020, 22(3): 434-439.
34. Song Y, Zheng J, Fan L. Nonthermal Irreversible Electroporation to the Esophagus: Evaluation of Acute and Long‐Term Pathological Effects in a Rabbit Model. J Am Heart Assoc, 2021, 10(22): e020731.
35. Yavin H, Shapira-Daniels A, Barkagan M, et al. Pulsed field ablation using a lattice electrode for focal energy delivery: biophysical characterization, lesion durability, and safety evaluation. Circ Arrhythm Electrophysiol, 2020, 13(6): e008580.
36. Reddy V Y, Anic A, Koruth J, et al. Pulsed field ablation in patients with persistent atrial fibrillation. J Am Coll Cardiol, 2020, 76(9): 1068-1080.
37. Verma A, Boersma L, Haines D E, et al. First-in-human experience and acute procedural outcomes using a novel pulsed field ablation system: the PULSED AF pilot trial. Circ Arrhythm Electrophysiol, 2022, 15(1): e010168.
38. Gunawardene MA, Schaeffer BN, Jularic M, et al. Pulsed‐field ablation combined with ultrahigh‐density mapping in patients undergoing catheter ablation for atrial fibrillation: practical and electrophysiological considerations. J Cardiovasc Electrophysiol, 2022, 33(3): 345-356.
39. Blockhaus C, Guelker JE, Feyen L, et al. Pulsed field ablation for pulmonary vein isolation: Real-world experience and characterization of the antral lesion size compared with cryoballoon ablation. J Interv Cardiac Electrophysiol, 2023, 66(3): 567-575.
40. Lemoine MD, Fink T, Mencke C, et al. Pulsed-field ablation-based pulmonary vein isolation: Acute safety, efficacy and short-term follow-up in a multi-center real world scenario. Clin Res Cardiol, 2023, 112(6): 795-806.
41. Chen S, Chun JKR, Bordignon S, et al. Pulsed field ablation-based pulmonary vein isolation in atrial fibrillation patients with cardiac implantable electronic devices: practical approach and device interrogation (PFA in CIEDs). J Interv Card Electrophysiol, 2022: 1-10.
42. Verma A, Haines DE, Boersma LV, et al. Pulsed field ablation for the treatment of atrial fibrillation: PULSED AF pivotal trial. Circulation, 2023, 147(19): 1422-1432.
43. My I, Lemoine MD, Butt M, et al. Acute lesion extension following pulmonary vein isolation with two novel single shot devices: Pulsed field ablation versus multielectrode radiofrequency balloon. J Cardiovasc Electrophysiol, 2023.
44. Kuroki K, Whang W, Eggert C, et al. Ostial dimensional changes after pulmonary vein isolation: pulsed field ablation vs radiofrequency ablation. Heart Rhythm, 2020, 17(9): 1528-1535.
45. Loh P, van Es R, Groen MHA, et al. Pulmonary vein isolation with single pulse irreversible electroporation: A first in human study in 10 patients with atrial fibrillation. Circ:Arrhyth Electrophysiol, 2020, 13(10): e008192.
46. Reddy VY, Neuzil P, Koruth JS, et al. Pulsed field ablation for pulmonary vein isolation in atrial fibrillation. J Am Coll Cardiol, 2019, 74(3): 315-326.
47. Ruwald MH, Johannessen A, Hansen ML, et al. Pulsed field ablation in real-world atrial fibrillation patients: Clinical recurrence, operator learning curve and re-do procedural findings. J Interv Card Electrophysiol, 2023: 1-12.
48. Stojadinović P, Wichterle D, Peichl P, et al. Autonomic changes are more durable after radiofrequency than pulsed electric field pulmonary vein ablation. Clin Electrophysiol, 2022, 8(7): 895-904.

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