Successful Pulsed-field Ablation of Superior Vena Cava Fibrillation Using a Circular Multielectrode Array Catheter

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Data may be preliminary. 17 January 2025 V1 Latest version Share on Successful Pulsed-field Ablation of Superior Vena Cava Fibrillation Using a Circular Multielectrode Array Catheter Authors : Masatsugu Nozoe 0000-0002-8450-573X [email protected] , Hiroshi Mannouji , Ryo Miyake , Akihito Ishikita , Nobuhiro Suematsu , and Toru Kubota Authors Info & Affiliations https://doi.org/10.22541/au.173715475.58225247/v1 Published JACC: Case Reports Version of record Peer review timeline 310 views 172 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction: There were some reports on superior vena cava isolation (SVCI) by the pentaspline pulsed-field ablation (PFA) catheter, however, this report presents case series of superior vena cava (SVC) fibrillation that was successfully treated using a circular multielectrode array PFA catheter. Methods: We performed SVCI using a PulseSelect PFA catheter in 11 cases. SVCI was performed when the earliest activation during ectopy was inside the SVC. In the second session, SVCI was routinely performed if the myocardial sleeves were of sufficient length. Results: The mean number of PFA deliveries was 7.8±2.1 applications. The acute success of SVC isolation was achieved in all patients. Importantly, no cases of sinus node dysfunction or persistent phrenic nerve palsy were observed in this study. Conclusions: A circular multielectrode array PFA catheter is useful and safe for treating non-PV foci triggered by SVC. Successful Pulsed-field Ablation of Superior Vena Cava Fibrillation Using a Circular Multielectrode Array Catheter Masatsugu Nozoe, MD, PhD; Hiroshi Mannouji, MD, PhD; Ryo Miyake, MD; Akihito Ishikita, MD, PhD; Nobuhiro Suematsu, MD, PhD; Toru Kubota, MD, PhD Division of Cardiology, Cardiovascular and Aortic Center, Saiseikai Fukuoka General Hospital Corresponding author Masatsugu Nozoe, MD, PhD 1-3-46, Tenjin, Chuo-ku, Fukuoka, Japan, 810-0001 [email protected] TEL 81-92-771-8151, FAX 81-92-716-0185 KEYWORDS: atrial fibrillation; pulsed field ablation; circular multielectrode array catheter; superior vena cava; non-pulmonary vein foci Abstract Introduction: There were some reports on superior vena cava isolation (SVCI) by the pentaspline pulsed-field ablation (PFA) catheter, however, this report presents case series of superior vena cava (SVC) fibrillation that was successfully treated using a circular multielectrode array PFA catheter. Methods: We performed SVCI using a PulseSelect PFA catheter in 11 cases. SVCI was performed when the earliest activation during ectopy was inside the SVC. In the second session, SVCI was routinely performed if the myocardial sleeves were of sufficient length. Results: The mean number of PFA deliveries was 7.8±2.1 applications. The acute success of SVC isolation was achieved in all patients. Importantly, no cases of sinus node dysfunction or persistent phrenic nerve palsy were observed in this study. Conclusions: A circular multielectrode array PFA catheter is useful and safe for treating non-PV foci triggered by SVC. Learning Objectives ･ This report presents case series of superior vena cava (SVC) fibrillation that was successfully treated using a circular multielectrode array PFA catheter. ･ Circumferentially, energy delivery targeting the level 2 cm above the sinus node achieved sufficient lesion isolation without affecting the sinus node function. ･ Superior vena cava isolation (SVCI) using a circular multielectrode array PFA catheter did not affect phrenic verve activity, whereas thermal energy sometime causes injury. Background The superior vena cava (SVC) has been reported as a potential source of non-pulmonary vein (PV) triggers of atrial fibrillation (AF). However, SVC isolation (SVCI) by thermal energy has been associated with acute phrenic nerve palsy and sinus node dysfunction. 1 Pulsed-field ablation (PFA) utilizes high-voltage ultra-short pulses to induce pores in cell membranes to create non-thermal tissue ablation. The myocardium is characterized by a high susceptibility towards PFA in comparison to surrounding tissue, including the phrenic nerve and esophagus. 2 The tissue selectivity of PFA was confirmed in previous clinical studies, suggesting a potential benefit for SVC isolation. 2,3 Most reports on SVCI by PFA are based on the use of the pentaspline PFA catheter, 4 however, there are no reports on SVCI using a circular multielectrode array PFA catheter. This case report presents a case of SVC fibrillation that was successfully treated using a circular multielectrode array PFA catheter. Case 1 The patient was a 76-year-old man had a history of PV isolation using a cryo-balloon (Medtronic Arctic Front, Minneapolis, MN, USA) 8 years prior. In the first session, phrenic nerve stimulation (using diaphragm compound motor action potential and manual palpitations) revealed phrenic nerve palsy during cooling of the right superior PV, and the therapy was immediately stopped. The electrical isolation of all PVs was confirmed using a ring-shaped catheter. Phrenic nerve palsy persisted for 3 months (Figure 1A), but resolved 4 months after the first ablation. The patient had been stable without recurrence for a long time, but paroxysmal AF recurred. The second AF ablation session was performed 8 years after the first session. The HRA-CS catheter was inserted into the coronary sinus (CS) via the right internal jugular vein. After transseptal puncture, voltage mapping of the left atrium (LA) under high right atrium (HRA) pacing using the Advisor™ HD Grid Mapping Catheter (EnSite X EP system NavX mode, Abbott, Illinois, IL, USA) revealed reconnection of the left inferior PV despite isolated left superior PV and right PVs (Figure 2A). Fractionation mapping, defined as a potential with ≥ 5 fragmented deflections (set at a fractionation threshold of 5, width of 5 milliseconds (ms), refractory period of 6 ms, and sensitivity of 0.04 mV), revealed regions with electrograms exhibiting multiple deflections at the anterior antrum of the right PVs (Figure 2A). After left inferior PV re-isolation using the PulseSelect PFA system (Medtronic, Minneapolis, MN, USA), extensive PV antrum isolation including fragmented potentials at the anterior antrum of the right PV was added (Figure 2B). The total number of PFA deliveries for the LA was 48. Cavo-tricuspid isthmus ablation was performed using 10 applications of PulseSelect and a bidirectional block line was confirmed. During the procedure, atrial tachycardia (AT) spontaneously appeared. The HRA electrodes of the HRA-CS catheter located at the SVC revealed fibrillatory conduction during regular atrial tachycardia (Figure 3A, B). SVC fibrillation with a conduction block at the SVC-RA junction was thought to be the cause of the patient’s AT. A fractionation map was created using the EnSite mapping system to differentiate the area under fibrillation from that under regular AT. The fractionation map was created using combinations of the following settings: width, 5 ms; refractory period, 6 ms; roving sensitivity, 0.04 mV; and fractionation threshold, 14. Based on the width, refractory period, and sensitivity, a fractionation score was assigned to each electrogram by the mapping algorithm. The areas with a fractionation score of ≥ 14 points, suggestive of a fractionated electrogram and displayed as white-colored areas on the map, were considered SVC areas under fibrillation (Figure 4A). Atrial tachyarrhythmia spontaneously terminated and recurred immediately due to firing from the SVC (Figure 3C, D). The earliest activation site under sinus rhythm was tagged with an HD-grid catheter on the EnSite map (Figure 4A). The earliest activation site during sinus rhythm among the HRA-CS catheters was fluoroscopically identified as the HRA 3-4 electrodes (Figure 3C). Detailed sinus rhythm mapping could not be obtained because the AF appeared immediately after termination. The initiation of tachycardia was observed as fibrillatory conduction originating from the SVC. The SVC had an elongated shape on the lateral side, extending toward the inferior part, while the septal side was shorter, forming a diagonal configuration. However, for safety, the area 2 cm above the sinus node was tagged on the EnSite map, and this level was targeted as the application site for PFA. The PulseSelect catheter was then placed in the SVC with the fifth electrode targeting the isolation line downward (Figure 3E). The HRA-CS catheter was withdrawn before delivery of PFA. The first PFA discharge (biphasic, 1,500 V) immediately terminated the AF (Figure 3F), and it did not recur. Additional applications were delivered circumferentially, targeting a level 2 cm above the sinus node. The total number of PFA-deliveries for SVCI was 9. The post-mapping of the HRA under sinus rhythm revealed details of the sinus node and isolated area of the SVC (Figure 4B, C). The isolated area coincided with exactly 2 cm above the sinus node. The earliest activation site during sinus rhythm did not change before or after PFA. The heart rate at the end of the procedure was not changed for comparison with that at the beginning of the session. Chest radiography performed the following day revealed no phrenic nerve palsy despite the patient experiencing transient phrenic nerve palsy during the first cryoballoon ablation (Figure 1B). Case 2 The patient was a 55-year-old man with a history of PV isolation using a cryo-balloon who was undergoing a second session of AF ablation. Voltage mapping revealed 4 isolated PVs despite residual potentials in the right PV carina. Firing from the SVC initiated tachycardia, and the organized AF inside the SVC exhibited fibrillatory conduction (Figure 5A). The activation map using the EnSite X Voxel mode revealed the earliest activation site during sinus rhythm and SVC sleeves (Figure 5B). The PulseSelect catheter was then placed in the SVC with the fifth electrode targeting the isolation line downward. Eleven applications were delivered circumferentially toward the level 2 cm above the sinus node. Post-mapping revealed that the earliest activation site during sinus rhythm did not change, and the SVC sleeves were sufficiently isolated (Figure 5C). The HR during sinus rhythm did not change from before to after PFA. Chest radiography the following day revealed no phrenic nerve palsy. Feasibility and safety of SVC isolation using a circular multielectrode array PFA catheter We performed SVCI using a PulseSelect PFA catheter in 11 cases. SVCI was performed when the earliest activation during ectopy was inside the SVC. In the second session, SVCI was routinely performed if the myocardial sleeves were of sufficient length (Table 1). An activation map of the right atrium was obtained to identify the earliest activation during sinus rhythm, using the EnSite X EP system Voxel mode or CARTO3 (Biosense Webster Inc., Irvine, CA, USA). The length of the electrically activated SVC sleeve was measured from the earliest activation site during rhythm to the top of the area with voltage > 0.5 mV during sinus rhythm. The area 2 cm above the sinus node was tagged on 3D mapping, and this level was targeted as the application site for PFA. The PulseSelect catheter was placed in the SVC, with the fifth electrode targeting the isolation line downward. The mean number of PFA deliveries was 7.8±2.1 applications. Post-mapping under sinus rhythm revealed no changes in the earliest activation site and a sufficient area of SVC isolation. The acute success of SVC isolation was achieved in all patients. The procedural details are presented in Table 2. The isolation area of the SVC was measured by subtracting the region with voltage > 0.5 mV on the post-map from the region with voltage > 0.5 mV present on the pre-map. 5 No ST-T change was observed during the procedures. The sinus rate did not change from before to after SVC isolation, and there were no changes one month later. We did not assess phrenic nerve activity during the procedure; however, chest radiography on the day after ablation revealed no phrenic nerve palsy in any of the cases. Discussion To our knowledge, this is the first case report of SVCI using a circular multielectrode array PFA catheter. SVCI using a circular multielectrode array PFA catheter is useful and safe. Several investigators have already shown that the SVC is one of the major foci for initiating atrial tachyarrhythmias such as AT and AF. 1,4 A conduction block between the atrium and thoracic veins has been reported and is well recognized in the PVs; however, a conduction block from the SVC to the RA has also been reported. 4,5 In the Case 1, a conduction block at the exit site of the SVC–RA connection was strongly suggested because two different forms of atrial tachyarrhythmias were observed in the SVC and atrium. In our previous report treated by radiofrequency ablation, activation mapping of RA revealed a conduction block at the SVC-RA junction, and the first energy delivery could terminate the AT. 4 High density mapping of the RA might visualize an SVC-RA conduction block, and utilizing this information might help reduce the number of energy applications. Because SVCI with thermal energy carries a risk of collateral damage to adjunct structures such as the phrenic nerve, 1 reducing the number of energy deliveries is important to reduce the associated risks. To avoid creating reversible lesions by PFA, the basic concept of PFA using a circular multielectrode array catheter is the homogenization of the target lesions. When performing PVI with PulseSelect, applications are made not only in the PV antrum, but also inside the PVs to prevent PV reconnections. The tissue selectivity of PFA may allow the same approach to the SVC as to the PV. If the AT terminates with the first energy delivery at the exit site on the SVC-RA junction, additional applications circumferentially or inside the SVC are preferred. For this reason, we did not perform detailed mapping of the AT. Instead, we used fractionation mapping to visualize the SVC-RA junction. The fractionation map differentiated irregular areas under fibrillation from regular areas under the AT more easily than the activation maps of the AT, because the AT was irregular in the present case. The efficacy and safety of SVCI using PFA have been recently proven in an animal model, 6 but evidence in humans is limited to cases using pentaspline PFA catheters. 3 In our small case series, SVCI using a circular multielectrode array PFA catheter was feasible, and acute isolation was achieved in all patients. Pre- and post-mapping revealed controlled lesion formation by the circular multielectrode array PFA catheter, with the fifth electrode facing downward. We set the target of application 2 cm above the sinus node to avoid sinus node dysfunction. Based on our case series, this strategy is feasible and safe. Importantly, no cases of persistent phrenic nerve palsy were observed in this study. Conclusion A circular multielectrode array PFA catheter is useful and safe for treating non-PV foci triggered by SVC. A large number of studies and long-term follow-up are required for further examination. Funding Sources None. Disclosures The authors declare no conflicts of interest in association with the present study. References 1. Miyazaki S, Usui E, Kusa S, et. al.: Prevalence and clinical outcome of phrenic nerve injury during superior vena cava isolation and circumferential pulmonary vein antrum isolation using radiofrequency energy. Am Heart J 2014; 168: 846–853. 2. Ekanem E, Neuzil P, Reichlin T, et. al.: Safety of pulsed field ablation in more than 17,000 patients with atrial fibrillation in the MANIFEST-17 K study. Nat Med 2024; 30: 2020–2029. 3. Ollitrault P, Chaumont C, Font J, et. al.: Superior vena cava isolation using a pentaspline pulsed-field ablation catheter: feasibility and safety in patients undergoing atrial fibrillation catheter ablation. Europace 2024; 2; 26(7): euae160. 4. Nozoe M, Koyama J, Honda T, et. al.: Atrial tachycardia caused by a superior vena cava fibrillation with conduction block. Journal of Arrhythmia 2012; 28(5), 284-287 5. Miyazaki S, Yamao K, Hasegawa K: SVC Mapping Using an Ultra-high resolution 3-dimensional mapping system in patients with and without AF. J Am Coll Cardiol EP 2019; 5: 958–67 6. Koruth J, Kuroki K, Iwasawa J, et. al.: Preclinical Evaluation of Pulsed Field Ablation: Electrophysiological and Histological Assessment of Thoracic Vein Isolation. Circ Arrhythm Electrophysiol. 2019; 12(12): e007781. Figure legends Figure 1. A: Chest X-ray 3 months after the first session. Right phrenic nerve palsy was observed. B: Chest X-ray obtained the day after the second session, which involved isolation of the left and right pulmonary vein antrum enlargement and SVCI. No phrenic nerve palsy was observed. Figure 2. A: Voltage mapping of the left atrium (LA) under high right atrium (HRA) pacing using EnSite X NavX mode revealed reconnection of the left inferior pulmonary vein (PV) despite isolated left superior PV and right PVs. Fractionation mapping tool at a setting of 5 revealed regions with electrograms exhibiting multiple deflections at the anterior antrum of the right PVs. B: After left inferior PV re-isolation using the PulseSelect PFA system, extensive PV antrum isolation including fragmented potentials at the anterior antrum of the right PV were add. The total number of PFA deliveries for LA was 48 applications. Figure 3. A: Fluoroscopic view of the left anterior oblique (LAO) 50°. A diagnostic HRA-CS catheter was placed into the coronary sinus (CS) and an HD-grid catheter was located at the superior vena cava (SVC). B: The high right atrium (HRA) electrodes of the HRA-CS catheter and HD-grid catheter which was located in the SVC revealed fibrillatory conduction during atrial tachycardia (AT). The HRA electrodes (7-8 proximal and 1-2 distal) and CS electrodes (7-8 proximal and 1-2 distal) are shown from top to bottom at a paper speed of 100 mm/s. A multipolar catheter (RA, 19-20 proximal and 1-2 distal) was located at the right atrium (RA). C: Fluoroscopic view of the LAO 50°. The PulseSelect catheter was placed at the SVC. D: Atrial tachy-arrhythmias spontaneously terminated and recurred immediately due to firing from the SVC. The earliest activation site under sinus rhythm was the PulseSelect (7-8 electrodes), and among the HRA-CS catheter HRA, 3-4 electrodes were the earliest. The initiation of tachycardia was observed as fibrillatory conduction originating from the SVC. A multipolar catheter (RA; 19-20 proximal and 1-2 distal) was located at RA to right ventricle. E: Fluoroscopic view of the LAO 50°. The PulseSelect catheter was then placed in the SVC with the fifth electrode downward, targeting the isolation line. The HRA-CS catheter was withdrawn before the delivery of PFA. F: The first PFA discharge (biphasic, 1,600 V) terminated the AF immediately, and without any recurrence. Figure 4. A: The fractionation map was created using combinations of a width of 5 ms, a refractory period of 6 ms, a roving sensitivity of 0.1 mV, and a fractionation threshold of 14. The areas with a fractionation score of ≥ 14 points, suggestive of a fractionated electrogram and displayed as white-colored areas on the map, were considered to be the superior vena cava (SVC) area under fibrillation. The earliest activation site during sinus rhythm was tagged with a yellow dot. B: The post-voltage map of the high right atrium (HRA) under sinus rhythm revealed that the isolated area coincided exactly with 2 cm above the sinus node. C: The post-activation map of the HRA revealed the earliest activation site during sinus rhythm did not change from before to after PFA. Figure 5. A: A diagnostic HRA-CS catheter was placed, via right jugular vein, into the coronary sinus (CS) and an HD-grid catheter was located at the superior vena cava (SVC). Firing from the SVC initiated atrial fibrillation (AF). B: Pre-PFA activation map (left panel) and voltage map (right panel) during sinus rhythm. C: Post-PFA activation map (left panel) and voltage map (right panel) during sinus rhythm. Table 1. Characteristics of patients who underwent SVC isolation SVC, superior vena cava; SVCI, superior vena cava isolation; LA, left atrium Table 2. Details of SVC isolation in our case series SVC, superior vena cava; SVCI, superior vena cava isolation; PFA, pulsed-field ablation Supplementary Material File (figure1.pptx) Download 958.03 KB File (figure2.pptx) Download 888.30 KB File (figure3.pptx) Download 14.25 MB File (figure4.pptx) Download 962.56 KB File (figure5.pptx) Download 4.94 MB File (table1.pptx) Download 105.79 KB File (table2.pptx) Download 151.49 KB Information & Authors Information Version history V1 Version 1 17 January 2025 Peer review timeline Published JACC: Case Reports Version of Record 1 Jul 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical: cardiac mapping – 3-dimensional systems clinical: catheter ablation – atrial fibrillation clinical: catheter ablation – non-rf energy sources Authors Affiliations Masatsugu Nozoe 0000-0002-8450-573X [email protected] Saiseikai Fukuoka Sogo Byoin View all articles by this author Hiroshi Mannouji Saiseikai Fukuoka Sogo Byoin View all articles by this author Ryo Miyake Saiseikai Fukuoka Sogo Byoin View all articles by this author Akihito Ishikita Saiseikai Fukuoka Sogo Byoin View all articles by this author Nobuhiro Suematsu Saiseikai Fukuoka Sogo Byoin View all articles by this author Toru Kubota Saiseikai Fukuoka Sogo Byoin View all articles by this author Metrics & Citations Metrics Article Usage 310 views 172 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Masatsugu Nozoe, Hiroshi Mannouji, Ryo Miyake, et al. Successful Pulsed-field Ablation of Superior Vena Cava Fibrillation Using a Circular Multielectrode Array Catheter. 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