Optimal Force-Time Integral for Pulmonary Vein Isolation According to Anatomical Wall Thickness Under the Ablation Line

Akio Chikata, Takeshi Kato, Satoru Sakagami, Chieko Kato, Takahiro Saeki, Keiichi Kawai, Shin-Ichiro Takashima, Hisayoshi Murai, Soichiro Usui, Hiroshi Furusho, Shuichi Kaneko, Masayuki Takamura, Akio Chikata, Takeshi Kato, Satoru Sakagami, Chieko Kato, Takahiro Saeki, Keiichi Kawai, Shin-Ichiro Takashima, Hisayoshi Murai, Soichiro Usui, Hiroshi Furusho, Shuichi Kaneko, Masayuki Takamura

Abstract

Background: Low contact force and force-time integral (FTI) during catheter ablation are associated with ineffective lesion formation, whereas excessively high contact force and FTI may increase the risk of complications. We sought to evaluate the optimal FTI for pulmonary vein (PV) isolation based on atrial wall thickness under the ablation line.

Methods and results: Contact force parameters and FTI during anatomical ipsilateral PV isolation for atrial fibrillation and atrial wall thickness were assessed retrospectively in 59 consecutive patients for their first PV isolation procedure. The PV antrum was divided into 8 segments, and the wall thickness of each segment under the ablation line was determined using multidetector computed tomography. The FTI for each ablation point was divided by the wall thickness of the PV antrum segment where each point was located to obtain FTI/wall thickness. In total, 5335 radiofrequency applications were delivered, and 85 gaps in PV isolation ablation lines and 15 dormant conductions induced by adenosine were detected. The gaps or dormant conductions were significantly associated with low contact force, radiofrequency duration, FTI, and FTI/wall thickness. Among them, FTI/wall thickness had the best prediction value for gaps or dormant conductions by receiver operating characteristic curve analysis. FTI/wall thickness of <76.4 gram-seconds per millimeter (gs/mm) predicted gaps or dormant conductions with sensitivity (88.0%) and specificity (83.6%), and FTI/wall thickness of <101.1 gs/mm was highly predictive (sensitivity 97.0%; specificity 69.6%).

Conclusions: FTI/wall thickness is a strong predictor of gap and dormant conduction formation in PV isolation. An FTI/wall thickness ≈100 gs/mm could be a suitable target for effective ablation.

Keywords: atrial fibrillation; atrial wall thickness; contact force; force–time integral; pulmonary vein isolation.

© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1
Figure 1
Myocardial thickness of each segment under the ablation line (lower panels) and distribution of acute gaps and dormant conductions (DCs) after pulmonary vein isolation (upper panels). Yellow circles represent acute gaps, blue circles represent DCs. LI‐BT indicates left inferior bottom; LIPV, left inferior pulmonary vein; LL‐CR, left lateral carina ridge; LL‐IR, left lateral inferior ridge; LL‐SR, left lateral superior ridge; LP‐I, left posterior inferior; LP‐M, left posterior middle; LP‐S, left posterior superior; LSPV, left superior pulmonary vein; LS‐RF, left superior roof; RA‐C, right anterior carina; RA‐I, right anterior inferior; RA‐S, right anterior superior; RI‐BT, right inferior bottom; RIPV, right inferior pulmonary vein; RP‐I, right posterior inferior; RP‐M, right posterior middle; RP‐S, right posterior superior; RSPV, right superior pulmonary vein; RS‐RF, right superior roof.
Figure 2
Figure 2
Receiver operating characteristic curve analysis for acute gap and dormant conduction (DC) predictability. FTI/wall thickness showed the best prediction value with an area under the curve (AUC) of 0.9242 (95% CI 0.9060–0.9425, P<0.001 vs AUCs of FTI and the other contact force [CF] parameters). FTI, average CF, maximum CF, and RF duration had AUCs of 0.8101, 0.7046, 0.6246, and 0.7161, respectively. The best threshold for FTI/wall thickness for predicting acute gaps or DCs was 76.4 gs/mm (sensitivity 88.0%; specificity 83.6%). An FTI/wall thickness of <101.1 gs/mm was highly predictive of acute gap or DC (sensitivity 97.0%; specificity 69.6%). Avg indicates average; FTI, force–time integral; gs, gram‐seconds; Max, maximum.

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