Efficacy of Intravenous Nitrates for the Prevention of Coronary Artery Spasm During Pulsed Field Ablation of the Mitral Isthmus
2023; Lippincott Williams & Wilkins; Volume: 17; Issue: 1 Linguagem: Italiano
10.1161/circep.123.012426
ISSN1941-3149
AutoresRoberto Mené, Serge Bovéda, Domenico G. Della Rocca, Vasileios Sousonis, Giampaolo Vetta, Sarah Zeriouh, Ioannis Doundoulakis, Andrés Betancur, Mohamed Benadel, Nicolas Combes, Andrea Sarkozy, Gian–Battista Chierchia, Carlo de Asmundis, Jean Paul Albenque, Stéphane Combes,
Tópico(s)Atrial Fibrillation Management and Outcomes
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 17, No. 1Efficacy of Intravenous Nitrates for the Prevention of Coronary Artery Spasm During Pulsed Field Ablation of the Mitral Isthmus Open AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessResearch ArticlePDF/EPUBEfficacy of Intravenous Nitrates for the Prevention of Coronary Artery Spasm During Pulsed Field Ablation of the Mitral Isthmus Roberto Menè, Serge Boveda, Domenico Giovanni Della Rocca, Vasileios Sousonis, Giampaolo Vetta, Sarah Zeriouh, Ioannis Doundoulakis, Andres Betancur, Mohamed Benadel, Nicolas Combes, Andrea Sarkozy, Gian Battista Chierchia, Carlo de Asmundis, Jean Paul Albenque and Stéphane Combes Roberto MenèRoberto Menè https://orcid.org/0000-0003-1671-1977 Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (R.M.). , Serge BovedaSerge Boveda https://orcid.org/0000-0002-1280-7042 Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). , Domenico Giovanni Della RoccaDomenico Giovanni Della Rocca https://orcid.org/0000-0003-3837-3462 Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Network Guard-Heart, Brussels, Belgium (D.G.D.R., G.V., I.D., A.S., G.B.C., C.d.A.). , Vasileios SousonisVasileios Sousonis https://orcid.org/0000-0002-8041-4574 Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). , Giampaolo VettaGiampaolo Vetta https://orcid.org/0000-0002-1120-0492 Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Network Guard-Heart, Brussels, Belgium (D.G.D.R., G.V., I.D., A.S., G.B.C., C.d.A.). , Sarah ZeriouhSarah Zeriouh https://orcid.org/0009-0003-3832-000X Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). , Ioannis DoundoulakisIoannis Doundoulakis https://orcid.org/0000-0003-2184-3296 Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Network Guard-Heart, Brussels, Belgium (D.G.D.R., G.V., I.D., A.S., G.B.C., C.d.A.). , Andres BetancurAndres Betancur https://orcid.org/0009-0000-7725-1973 Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Network Guard-Heart, Brussels, Belgium (D.G.D.R., G.V., I.D., A.S., G.B.C., C.d.A.). , Mohamed BenadelMohamed Benadel Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). , Nicolas CombesNicolas Combes https://orcid.org/0000-0002-5238-7791 Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). , Andrea SarkozyAndrea Sarkozy https://orcid.org/0000-0001-6327-0487 Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Network Guard-Heart, Brussels, Belgium (D.G.D.R., G.V., I.D., A.S., G.B.C., C.d.A.). , Gian Battista ChierchiaGian Battista Chierchia Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Network Guard-Heart, Brussels, Belgium (D.G.D.R., G.V., I.D., A.S., G.B.C., C.d.A.). , Carlo de AsmundisCarlo de Asmundis https://orcid.org/0000-0001-9351-0760 Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Network Guard-Heart, Brussels, Belgium (D.G.D.R., G.V., I.D., A.S., G.B.C., C.d.A.). , Jean Paul AlbenqueJean Paul Albenque Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). and Stéphane CombesStéphane Combes Correspondence to: Stéphane Combes, MD, Heart Rhythm Management Department, Clinique Pasteur, 45 Ave de Lombez, 31076 Toulouse, France. Email E-mail Address: [email protected] https://orcid.org/0000-0002-0040-676X Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France (R.M., S.B., V.S., S.Z., A.B., M.B., N.C., J.P.A., S.C.). Originally published14 Dec 2023https://doi.org/10.1161/CIRCEP.123.012426Circulation: Arrhythmia and Electrophysiology. 2024;17Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 16, 2024: Previous Version of Record December 14, 2023: Ahead of Print Pulsed field ablation (PFA) is a promising strategy for the treatment of cardiac arrhythmias but carries a considerable risk of coronary artery spasm (CAS) when targeting anatomic structures adjacent to the coronary arteries, such as the mitral isthmus (MI) or the cavotricuspid isthmus (CTI).1,2 This complication could hinder the use of PFA for persistent atrial fibrillation or atrial flutters, where MI or CTI applications are often necessary. The aim of this study was to evaluate the efficacy of intravenous nitrates in preventing CAS during the PFA of the MI.Starting from November 2022, we enrolled all patients undergoing PFA of the MI, as part of a previously described procedure for persistent atrial fibrillation,3 at 2 centers. Two minutes before the first application on the MI, 1 to 2 mg (depending on blood pressure) of isosorbide dinitrate (ISDN) was administered intravenously. The occurrence of procedural CAS was monitored and compared between this group (ISDN+ group) and a historical cohort of consecutive patients (November 2021 to November 2022) not pretreated with prophylactic nitrates (ISDN− group). CAS was defined as ST-segment changes during applications on the MI, resolving after nitrates administration or spontaneously within 5 minutes, in the absence of other causes of ischemia. All procedures were performed with the Farapulse system (5 biphasic pulses of 2.0 kV per application). The study was approved by the local institutional review boards, and patients provided written informed consent. Data were compared with Fisher exact, χ2, and t tests as appropriate (SPSS 29.0). P≤0.05 was considered significant. Data are available from the corresponding author upon reasonable request.A total of 182 patients (age, 68±10 years; 29% females) were included. Baseline characteristics in both groups (ISDN+: n=79 and ISDN−: n=103) were similar, including the history of coronary artery disease (22.3% versus 13.9%; P=0.149) and angioplasty (12.6% versus 8.9%; P=0.421). Successful isolation of pulmonary veins and the posterior wall was achieved in 180 of 180 (100%) and 179 of 179 (100%) cases, respectively, while a bidirectional MI block was documented in 179 of 182 (98.3%) patients. More applications were delivered on the MI in the ISDN+ group (14 [interquartile range, 11–39] versus 12 [interquartile range, 8–28]; P=0.018).All cases of CAS occurred in the ISDN− (10 of 103 patients, 9.7%) compared with none in the ISDN+ group (0 of 79 patients, 0%; P=0.005). Two patients developed significant hypotension, and 9 patients required administration of ISDN to resolve the ischemia. The first 2 cases of CAS were confirmed with coronary angiography (Figure). Patients developing CAS were more frequently hypertensive (100% versus 67%; P=0.013). Complications other than CAS were rare and were only observed in the ISDN− group before the first PFA application on the MI. These included coronary artery air embolism (n=1), cardiogenic shock (n=1), nonsustained ventricular tachycardia (n=1), and oxygen desaturation (n=1).Download figureDownload PowerPointFigure. Coronary artery spasm occurring during pulsed field ablation of the mitral isthmus. A, Real-time integration of fluoroscopy with a computed tomography reconstruction of the left atrium (blue) and the left circumflex coronary artery (orange) in the left anterior oblique view showing the position of the Farawave catheter during the applications on the mitral isthmus. B, Coronary angiography demonstrating a spasm of the mid-left circumflex coronary artery (red arrow) following pulsed field ablation of the mitral isthmus. C, ECG during the coronary spasm event showing ST-segment elevation in the inferior and lateral leads. D, Coronary angiography showing spasm resolution following intracoronary administration of nitrates. E, ECG demonstrating complete regression of the ischemic signs following spasm resolution.In the same period, 12 patients (age, 66±6 years; 17% females) underwent PFA of the CTI. Of these, 2 of 4 nonpretreated patients developed CAS compared with 0 of 8 pretreated patients (P=0.091). One CAS event resulted in ventricular fibrillation.2 Of note, no drug-related hypotension or allergic reactions following ISDN administration were seen in the total 87 (MI+CTI groups) pretreated patients.We presented the largest published cohort of CAS following PFA and the first report on the efficacy of prophylactic ISDN in preventing this complication. Our study has 2 main findings. First, our data suggest that CAS occurs at a nonnegligible rate during the PFA of the MI. Second, in our cohort, prophylactic ISDN administration was safe and effectively reduced the risk of this complication.Reddy et al4 previously reported a high rate of angiographically evident (100%) and clinically evident (20%) CAS in 5 nonpretreated patients who underwent systematic coronary angiography during PFA of the CTI. In the same study, prophylactic nitrates were highly effective in preventing CAS, limiting its occurrence to 3 of 15 patients pretreated with nitroglycerin. Notably, these CAS cases occurred during the last PFA applications, consistent with the diminishing effect of nitroglycerin (half-life, 1–2 minutes).Here, we reported a comparable rate of clinically evident CAS during PFA of the MI among nonpretreated patients. Importantly, pretreatment with ISDN considerably decreased the risk of clinically evident CAS. As MI ablation procedures can be lengthy, we used the longer acting ISDN (half-life, ≈40 minutes).5 Additionally, more applications were delivered on the MI in the ISDN+ group, potentially reflecting greater operator confidence in ablating under the sustained effect of a longer lasting agent.A couple of limitations should be acknowledged. First, this is a nonrandomized study; nevertheless, the consecutive enrollment of patients and the comparable baseline characteristics of the 2 groups mitigate the risk of biases. Second, a systematic angiographic evaluation was not performed, as our aim was to only focus on clinically significant CAS.In conclusion, prophylactic ISDN appeared to be safe and effective in reducing the risk of CAS following the PFA of the MI. Future studies are needed to validate these results and to assess the efficacy of this approach in CTI ablation. In the meantime, we believe that prophylactic ISDN administration may be considered as a routine preventive strategy in all cases of PFA of the MI.ARTICLE INFORMATIONSources of FundingNone.Nonstandard Abbreviations and AcronymsCAScoronary artery spasmCTIcavotricuspid isthmusISDNisosorbide dinitrateMImitral isthmusPFApulsed field ablationDisclosures Dr Boveda consults for Medtronic, Boston Scientific, MicroPort, and ZOLL. Dr Sarkozy is a consultant for Biosense Webster, Medtronic, Biotronik, and MicroPort. Dr Battista Chierchia received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. Dr de Asmundis receives research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus Medical and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, LivaNova, Boston Scientific, AtriCure, Acutus Medical, and Daiichi Sankyo. Dr Albenque consults for Abbott and Volta Medical. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 50.Correspondence to: Stéphane Combes, MD, Heart Rhythm Management Department, Clinique Pasteur, 45 Ave de Lombez, 31076 Toulouse, France. Email scombes@clinique-pasteur.comREFERENCES1. Turagam MK, Neuzil P, Schmidt B, Reichlin T, Neven K, Metzner A, Hansen J, Blaauw Y, Maury P, Arentz T, et al. Safety and effectiveness of pulsed field ablation to treat atrial fibrillation: one-year outcomes from the MANIFEST-PF registry.Circulation. 2023; 148:35–46. doi: 10.1161/circulationaha.123.064959LinkGoogle Scholar2. Della Rocca DG, Del Monte A, Bala G, Pannone L, Ströker E, Monaco C, Almorad A, Sieira J, Sorgente A, de Asmundis C, et al. Transient inferior ST-segment elevation and ventricular fibrillation after cavotricuspid isthmus pulsed-field ablation.JACC Clin Electrophysiol. 2023; 9:704–706. doi: 10.1016/j.jacep.2022.11.027CrossrefMedlineGoogle Scholar3. Davong B, Adeliño R, Delasnerie H, Albenque J-P, Combes N, Cardin C, Voglimacci-Stephanopoli Q, Combes S, Boveda S. Pulsed-field ablation on mitral isthmus in persistent atrial fibrillation: preliminary data on efficacy and safety.JACC Clin Electrophysiol. 2023; 9:1070–1081. doi: 10.1016/j.jacep.2023.03.021CrossrefMedlineGoogle Scholar4. Reddy VY, Petru J, Funasako M, Kopriva K, Hala P, Chovanec M, Janotka M, Kralovec S, Neuzil P. Coronary arterial spasm during pulsed field ablation to treat atrial fibrillation.Circulation. 2022; 146:1808–1819. doi: 10.1161/CIRCULATIONAHA.122.061497LinkGoogle Scholar5. Sweetman S. Martindale: The Complete Drug Reference. 36th ed. Pharmaceutical Press; 2009.Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails January 2024Vol 17, Issue 1 Advertisement Article InformationMetrics © 2023 The Authors. Circulation: Arrhythmia and Electrophysiology is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited.https://doi.org/10.1161/CIRCEP.123.012426PMID: 38095067 Originally publishedDecember 14, 2023 Keywordsatrial fibrillationcatheter ablationcoronary vasospasmelectroporationisosorbide dinitratenitratesPDF download Advertisement SubjectsArrhythmiasAtrial FibrillationCatheter Ablation and Implantable Cardioverter-DefibrillatorElectrophysiology
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