Can “tissue tickness” guide our ablation strategy?
Schillaci et al. have tested the KODEX-EPD system in patients with
cavo-tricuspid isthmus-dependent atrial flutter, showing that the
tickest atrial wall was pretty close to tricuspid valve (3.6±0.5 mm vs
2.4±0.3 mm, p<0.001) and a trend towards a progressive
decrease of atrial wall thickness was observed moving the mapping
catheter from the tricuspid valve to the inferior vena cava. This
should suggest that more RF power needs to be transferred deeply in
the atrial portion close to the valve as compared to the area towards
the inferior vena cava. They claim to have used power between 30 and
40 Watts all along the line with a “point-by-point” RF delivering
approach, reaching an acute bidirectional block in each patient. It
would have been conceivable that RF delivering would be at higher
power close to the tricuspid valve as to achieve a deeper lesion (and
hopefully a durable one). Unfortunately, they do not describe any
significant change in RF delivering while they are ablating. In fact,
it is well known that missing the atrial portion close to the
tricuspid valve is one of the reasons of resumption of conduction
through the cavo-tricuspid isthmus. Moreover, the possibility to
measure the substrate thickness before RF delivery could change the
way to perform RF ablation, allowing a tailored energy delivering thus
increasing the efficiency of the ablation procedures and potentially
reducing the risk of complications.
The dream of “an eye through”By measuring the myocardial tissue thickness in any part of each cardiac
chamber, we might envision to titrate the transfer of energy in relation
to specific tissue characterization. This could be particularly crucial
in the atria, where the wall thickness is reduced compared to the
ventricles or close to the valves. Tailoring the power can increase the
safety profile and reduce the likelihood of complications. None of the
currently available 3D non-fluoroscopic mapping systems provides
detailed information about the tissue thickness; the incorporation of a
function (i.e. Wall Viewer) capable to yield thickness measurement could
greatly improve our ability to effectively produce “durable” lesions
and, thus improve the long-term clinical outcome of ablation procedures.
Furthermore, one of potential advantages of the application of “tissue
thickness measurement” over the cardiac MRI, is the real time
information provided that can guide the strategy of ablation based on
the “ ablating by measuring” conceptFuture applicationsTheoretically, the analysis of tissue characterization in terms of wall
thickness can be of value in the ventricles as well; just imaging to
investigate not only the scar extension in ischemic or non-ischemic
ventricular arrhythmias but also viewing “in depth” the pathological
area could guide the ablation strategy, accordingly. Needless to say
that the lesion created through different energy sources (RF, Cryo,
Laser, PFA, etc) and the ablative techniques employed (impedance-driven,
irrigated-tip electrode, high power-short duration) can have different
and variable impact on effectiveness and durability of the lesion itself
also in relation to the tissue thickness. Schillaci et al. have had the
privilege to test the novel KODEX-EPD function showing the potential
capability of the system to analyze the myocardial wall thickness and
provide crucial information during RF energy delivering. They need to be
congratulated for having paved a new avenue in the field and now we hope
other EP “runners” could join the “ultramarathon” of ablation and
produce brilliant results.
References
- Kotadia I, Williams ISM, Roney CH, et al (2021) Dielectric imaging
accurately measures regional cardiac chamber wall thickness – An in
vivo study. doi:https://doi.org/10.1016/j.hrthm.2021.06.570
- Schillaci V, Stabile G, Arestia A, Shopova G, Agresta A, Salito A,
Gianniti CM, Natalizia A, De Simone A, Solimene F. Dielectric-based
Tissue Thickness Measured during Radiofrequency Catheter Ablation.
Journal of Cardiovascular Electroph, 2022….
- Romanov A, Dichterman E, Schwartz Y, et al (2019) High-resolution,
real-time, and nonfluoroscopic 3-dimensional cardiac imaging and
catheter navigation in humans using a novel dielectric-based system.
Heart Rhythm 16(12):1883-1889.
- Maurer T, Mathew S, Schlüter M, et al (2019) High-Resolution Imaging
of LA Anatomy Using a Novel Wide-Band Dielectric Mapping System: First
Clinical Experience. JACC Clin Electrophysiol 5(11):1344-1354.
- Maurer T, Mathew S, Schlüter M, et al (2019) High-Resolution Imaging
of LA Anatomy Using a Novel Wide-Band Dielectric Mapping System: First
Clinical Experience. JACC Clin Electrophysiol 5(11):1344-1354.
- Chinitz LA, Barbhaiya C, Fabbricatore D, et al (2021) Dielectric-based
tissue thickness measured with a radiofrequency ablation catheter:
initial clinical results.
doi:https://doi.org/10.1016/j.hrthm.2021.06.218