Nitroglycerin to Ameliorate Coronary Artery Spasm During Focal Pulsed-Field Ablation for Atrial Fibrillation

Yury Malyshev; Petr Neuzil; Jan Petru; Moritoshi Funasako; Pavel Hala; Karel Kopriva; Christopher Schneider; Anitha Achyutha; Annelies Vanderper; Daniel Musikantow; Mohit Turagam; Srinivas R Dukkipati; Vivek Y Reddy

doi:10.1016/j.jacep.2023.12.015

Nitroglycerin to Ameliorate Coronary Artery Spasm During Focal Pulsed-Field Ablation for Atrial Fibrillation

JACC Clin Electrophysiol. 2024 Feb 7:S2405-500X(24)00011-2. doi: 10.1016/j.jacep.2023.12.015. Online ahead of print.

Affiliations

¹ Icahn School of Medicine at Mount Sinai, New York, New York, USA.
² Homolka Hospital, Prague, Czech Republic.
³ Farapulse-Boston Scientific, Inc, Menlo Park, California, USA.
⁴ Icahn School of Medicine at Mount Sinai, New York, New York, USA; Homolka Hospital, Prague, Czech Republic. Electronic address: vivek.reddy@mountsinai.org.

PMID: 38385916
DOI: 10.1016/j.jacep.2023.12.015

Abstract

Background: In treating atrial fibrillation, pulsed-field ablation (PFA) has comparable efficacy to conventional thermal ablation, but with important safety advantages: no esophageal injury or pulmonary vein stenosis, and rare phrenic nerve injury. However, when PFA is delivered in proximity to coronary arteries using a pentaspline catheter, which generates a broad electrical field, severe vasospasm can be provoked.

Objectives: The authors sought to study the vasospastic potential of a focal PFA catheter with a narrower electrical field and develop a preventive strategy with nitroglycerin.

Methods: During atrial fibrillation ablation, a focal PFA catheter was used for cavo-tricuspid isthmus ablation. Angiography of the right coronary artery (some with fractional flow reserve measurement) was performed before, during, and after PFA. Beyond no nitroglycerin (n = 5), and a few testing strategies (n = 8), 2 primary nitroglycerin administration strategies were studied: 1) multiple boluses (3-2 mg every 2 min) into the right atrium (n = 10), and 2) a bolus (3 mg) into the right atrium with continuous peripheral intravenous infusion (1 mg/min; n = 10).

Results: Without nitroglycerin, cavo-tricuspid isthmus ablation provoked moderate-severe vasospasm in 4 of 5 (80%) patients (fractional flow reserve 0.71 ± 0.08). With repetitive nitroglycerin boluses, severe spasm did not occur, and mild-moderate vasospasm occurred in only 2 of 10 (20%). Using the bolus + infusion strategy, severe and mild-moderate spasm occurred in 1 and 3 of 10 patients (aggregate 40%). No patient had ST-segment changes.

Conclusions: Ablation of the cavotricuspid isthmus using a focal PFA catheter routinely provokes right coronary vasospasm. Pretreatment with high doses of parenteral nitroglycerin prevents severe spasm.

Keywords: atrial fibrillation; catheter ablation; cavo-tricuspid isthmus; cavo-tricuspid isthmus ablation; nitroglycerin; pulsed field ablation; spasm; vasospasm.