Derivation and validation of a VISITAG™-guided contact force ablation protocol for pulmonary vein isolation

Aims Following radiofrequency (RF) pulmonary vein isolation (PVI), atrial fibrillation (AF) recurrence mediated by recovery of pulmonary vein (PV) conduction is common. I examined whether comparative VISITAG (Biosense Webster Inc.) data analysis at sites showing intra-procedural recovery of PV conduction versus acutely durable ablation could inform the derivation of a more effective VISITAG-guided contact force (CF) PVI protocol.\n\nMethods and results Retrospective analysis of VISITAG Module annotated ablation site data in 10 consecutive patients undergoing CF-guided PVI without active VISITAG guidance. Employing 2mm positional stability range and lenient CF filter (force-over-time 10%, minimum 2g), inter-ablation site distance >10-12mm, adjacent 0g-minimum CF and short RF duration (3-5s) were associated with intra-procedural recovery of PV conduction. A VISITAG-guided CF PVI protocol was derived employing [≤]6mm inter-ablation site distances, minimum target ablation site duration [≥]9s / force time integral (FTI) 100gs and 100% 1g-minimum CF filter. Seventy-two consecutive VISITAG-guided CF PVI procedures were then undertaken using this protocol, with PVI achieved in all utilising 23.8[8.4] minutes total RF (30W, 48{degrees}C, 17ml/min, continuous RF application). Following protocol completion, acute intra-procedural spontaneous / dormant recovery of PV conduction requiring touch-up RF occurred in 1.4% / 1.8% of PVs, respectively. At 14[5] months follow-up in all 34 patients with paroxysmal AF [≥]6 months post-ablation, 30 (88%) were free from atrial arrhythmia, off class I/III anti-arrhythmic medication.\n\nConclusion VISITAG provides means to identify and then avoid factors associated with intra-procedural recovery of PV conduction. This VISITAG Module-guided CF PVI protocol demonstrated excellent intra-procedural and long-term efficacy.\n\nCondensed abstract Following CF-guided PVI, retrospective VISITAG Module analyses permitted the identification of ablation parameters associated with intra-procedural recovery of PV conduction. The derived VISITAG Module-guided CF PVI protocol employed short over RF duration yet proved efficient at achieving PVI acutely, with long-term follow-up demonstrating high clinical efficacy.