Letter from the Editor in Chief
DOI: 10.19102/icrm.2015.060501
MOUSSA MANSOUR, MD, FHRS, FACC
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Dear Reader,
Pulmonary vein isolation (PVI) is the cornerstone of ablation for atrial fibrillation (AF). Gap formation and restoration of electrical conduction between the pulmonary veins and the left atrium has been increasingly recognized as the most important reason for recurrence of AF. The durability of PV isolation depends on the quality and contiguity of the ablation lesions, which are determined primarily by catheter stability. Cardiac and respiratory motions render catheter stability difficult in some patients and lead to suboptimal ablation lesion formation and subsequently recurrence of AF. The experience of the operator together with the technique and technology usedare important factors affecting catheter stability. These tools and techniques are summarized in the interesting article by Rafael et al. in this issue of the Journal entitled “Techniques to Optimize Catheter Contact Force during Ablation of Atrial Fibrillation”. In this article the authors describe practical tools and techniques used to improve catheter stability. These include contact force sensing, steerable sheath, high frequency jet ventilation, and high rate pacing.
Contact force sensing has been recently introduced and its use has been supported by data from numerous pre-clinical and clinical studies demonstrating its benefit. This technology has been shown to increase the rate of durability of PV isolation and the success rate of the procedure, as well as decrease the rate of repeat ablation. One key finding in most of thestudies is that the efficacy of contact force sensing depends on obtaining optimal force. Among the technologies used to optimize catheter stability and obtain adequate contact force is the steerable sheath. It minimizes catheter movement against the beating heart and facilitates ablation in challenging areas such as the ridge between the left superior vein and the left atrial appendage. Another technique used to reduce cardiac motion and improve catheter stability is high rate pacing which reduces the stroke volume and subsequently cardiac motion. Respiratory motion is another reason for the lack of adequate force and can be minimized by the use of high frequency jet ventilation.
All the tools and techniques describe above target different elements of catheter instability and their benefit can be maximized if used in combination. At our center, the standard practice consists of the use of steerable sheath and high frequency jet ventilation to achieve optimal force. In addition adenosine is routinely infused to unmask any reversible ablation lesion that may haveoccurred. This multi-component strategy has been very beneficial to our practice.
As always, I hope that you find this issue of the Journal valuable to you and your practice. Best wishes for a productive Scientific Meeting of the Heart Rhythm Society.
Warm regards,
Moussa Mansour, MD, FHRS, FACC
Editor-in-Chief
The Journal of Innovations in Cardiac Rhythm Management
MMansour@InnovationsInCRM.com
Director, Cardiac Electrophysiology Laboratory,
Director, Atrial Fibrillation Program
Massachusetts General Hospital
Boston, MA
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