Contact Force–Guided Pulmonary Vein Isolation The Quest for Perfection Continues.pdfVIP

JACC: CLINICAL ELECTROPHYSIOLOGY a 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER EDITORIAL COMMENT VOL. 2, NO. 6, 2016 ISSN 2405-500X/$36.00 /10.1016/j.jacep.2016.09.008 Contact Force–Guided Pulmonary Vein Isolation The Quest for Perfection Continues* Saurabh Kumar, BSC(MED)/MBBS, PHD,a Hugh Calkins, MD,b Gregory F. Michaud, MDa T he past few years have seen a burgeoning uptake in the use of contact force (CF)–sensing technology in catheter ablation of atrial ?brillation (AF). On the basis of a number of preclinical studies, it is well accepted that CF is a key determinant of lesion size, volume, and depth (1,2). There are a number of key drivers for the rapid acceptance of CF-sensing technology. The ?rst is the suboptimal procedural success rate, even for paroxysmal AF (w80% freedom from atrial arrhythmias at $3 years of follow-up after multiple procedures) despite a well-de?ned mechanism attributed to the pulmonary veins (PVs) (3). Ablation failure is thought to be due to nontransmural lesions and gaps in the ablation line; it is hoped that CF sensing might overcome the limitation of lesion nontransmurality by avoiding low force applications (4). It was also hoped that monitoring CF would lower the risk of complications, particularly the risk of cardiac tamponade, by preventing excessive CF leading to atrial perforation and/or steam pop formation (4). Another driver for the rapid acceptance of CF sensing is the realization that surrogate markers for contact, such as tactile feedback, catheter stability on ?uoroscopy or mapping systems, electrogram characteristics, and impedance (baseline or after ablation), had only modest predictive value for actual tissue contact (5,6). Even the most experienced operators quickly realized that recognition of both high and low tissue contact in the absence of CF monitoring was imprecise (4,6). A number of subsequent retrospective, case control, and prospective studies demonstrated that CF sensing red