Past and Future of Catheter Ablation
- ablation techniques
- arrhythmias, cardiac
- catheter ablation
- collateral circulation
Successful catheter-based management of cardiac arrhythmia involves accurate identification of the arrhythmogenic substrate and complete, permanent elimination of that substrate without collateral injury. Despite >30 years of intensive research and innovation that has included novel energy sources, the seemingly straightforward objectives have been elusive. Limited advances have translated to clinical practice, including improved methods of delivering existing energy sources (irrigated catheters, balloon technology, and assessment of contact), but a permanent and effective energy source with efficient tissue specificity to eliminate the possibility of unnecessary collateral damage has not surfaced.
Articles see p 728 & 734
In this issue of Circulation Arrhythmia & Electrophysiology, Neven et al1 and van Driel et al2 from the laboratory of Wittkampf report 2 separate studies involving the use of irreversible electroporation (IRE) for cardiac ablation. They report in the first article2 the relative effects of IRE versus radiofrequency energy on the risk of pulmonary vein stenosis. In the second article,1 they examine the ability to create transmural lesions with IRE applied epicardially in the left ventricle with minimal collateral damage, specifically the potential for an ablation source to create transmural lesions without 2 of the most worrisome complications associated with thermal injury (scar leading to pulmonary vein stenosis and coronary arterial trauma).
Electroporation should be considered in the historical context of direct current (DC) ablation, the beginnings of catheter ablation. Direct current energy may produce effects by affecting the cell membrane, thermal injury, or barotrauma.3–5 In addition, nonhomogenous DC ablation lesions may be proarrhythmic.6 The relative merits of radiofrequency and DC ablation were studied extensively in the early 1980s and suggested better safety and efficacy with radiofrequency ablation.7,8
The term electroporation can be thought of more traditionally in the context of DC ablation …