MRI head-to-head comparison of lesion quality following various ablation techniques

A late gadolinium enhancement (LGE)-MRI lesion assessment of technologies including pulsed field ablation (PFA), very high-power short-duration (VHPSD), cryoballoon, and radiofrequency found that VHPSD ablation led to the most continuous, encircling lesions.

Clinical comparisons of ablation lesion quality are currently lacking, although they can have implications for the efficacy and safety of the technologies employed. LGE-MRI can be a useful tool for the non-invasive assessment of ablation lesions [1]. Dr Till Althoff (University of Barcelona, Catalonia, Spain) presented an LGE-MRI lesion assessment of technologies including pulsed PFA(n=30), VHPSD (n=25), cryoballoon (n=40), and radiofrequency (n=43). All patients received an LGE-MRI assessment 3 months following the ablation procedure. LGE discontinuations of >3 mm were defined as gaps, while LGE covering >90% of the peri-antral circumference of ipsilateral pulmonary vein (PV) pairs were considered complete lesions.

The number of gaps per PV pair tended to be larger with PFA (median 1.5) compared with VHPSD (1.1; P=0.036), cryoballoon (1.1; P=0.012), and radiofrequency (1.2; P=0.091). Furthermore, the proportion of complete lesions was lowest with PFA (12%), followed by cryoballoon (24%), radiofrequency (26%) and VHPSD (40%). Relative to the PV circumference, the cumulative gap length was largest with PFA (median 36%) compared with VHPSD (15%), cryoballoon (19%), and radiofrequency (18%; P<0.001 for PFA vs all). Additionally, when assessing proportions of patients with a cumulative gap length of <10%, PFA was found to have the lowest number of continuous lesions (28%) compared with VHPSD (56%; P=0.003), cryoballoon (40%), and radiofrequency (45%; P=0.037). Finally, radiofrequency led to the lowest lesion width (mean 8.7 mm) compared with cryoballoon (13.3 mm; P<0.0001), VHPSD (10.9 mm), and PFA (12.7 mm; P<0.0001).

“VHPSD ablation resulted in the most continuous lesions and the highest proportion of complete PV-encircling lesions,” concluded Dr Althoff, “and VHPSD lesions were also significantly wider than conventional radiofrequency lesions,” while “PFA lesions cover relatively large areas as expected comparable to cryoballoon lesions, but these lesions seem to be more non-homogeneous.” However, longer term follow-up and higher sample sizes will be needed to inform clinical decisions.

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   1. Althoff TF, et al. Head-to-head comparison of pulsed field ablation, very high power-short duration, cryoballoon and conventional radiofrequency ablation by LGE-MRI-based ablation lesion assessment. Atrial fibrillation: ablation 2. EHRA Congress 2024, 7–9 April, Berlin, Germany.

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Posted on 29 April 20241 May 2024