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Beyond the ablation index: investigating unipolar electrogram guidance for atrial fibrillation ablation
Session:
Sessão de Posters 54 - Da energia aos endpoints na FA
Speaker:
João Manuel Pinto Ferreira de Antas Barroso
Congress:
CPC 2026
Topic:
C. Arrhythmias and Device Therapy
Theme:
05. Atrial Fibrillation
Subtheme:
05.4 Atrial Fibrillation - Treatment
Session Type:
Posters Eletrónicos
FP Number:
---
Authors:
João Barroso; Ana Lebreiro; Manuel Vaz da Silva; Cláudia Camila Dias; Luís Adão; Rui André Rodrigues
Abstract
<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong><span style="font-size:11pt">Background:</span></strong><span style="font-size:11pt"> While pulsed field ablation (PFA) is reshaping atrial fibrillation (AF) ablation strategies, radiofrequency (RF) ablation remains widely used. Metrics such as the Ablation Index (AI), which integrates power, contact force, and catheter stability, have improved procedural standardization by providing a surrogate for lesion quality. However, lesion durability ultimately depends on achieving true transmurality, and the unipolar electrogram (UE) transition to a purely positive morphology has emerged as a physiologic marker of this endpoint. How this signal-based marker relates to conventional AI-guided ablation remains uncertain. </span></span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong><span style="font-size:11pt">Purpose:</span></strong><span style="font-size:11pt"> This study aimed to evaluate how AI-guided ablation correlates with the physiologic endpoint of UE transition, comparing standard and high-power short-duration (HPSD) applications.</span></span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong><span style="font-size:11pt">Methods:</span></strong><span style="font-size:11pt"> A retrospective, point-by-point analysis of 373 RF applications was performed in consecutive pulmonary vein isolation procedures for AF under three-dimensional electroanatomical mapping guidance. Ablation was performed using an irrigated 4 mm contact force–sensing catheter, supported by a long sheath. Posterior-inferior PV segments were targeted with 90 W × 4 s HPSD applications, and antero-superior segments with 50 W, aiming for an AI ≈ 500. For HPSD lesions (n = 248), the proportion achieving UE transition within 4 s was assessed. For 50 W lesions (n = 125), RF time and AI at UE transition were compared with total RF duration and final AI using the Wilcoxon signed-rank test.</span></span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong><span style="font-size:11pt">Results: </span></strong><span style="font-size:11pt">UE transition occurred in 117/248 (47.2%) HPSD applications and 72/125 (57.6%) 50 W applications. Among 50 W lesions with UE transition, median RF time and AI at transition were 12.6 s (IQR 8.7–17.4) and 480 (IQR 390–515), significantly lower than total RF time [18 s (IQR 14.0–20.5)] and final AI [520 (IQR 510–520); p < 0.001]. At 6-month follow-up, no AF recurrence was documented.</span></span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong><span style="font-size:11pt">Conclusion: </span></strong><span style="font-size:11pt">Fixed 90 W × 4 s dosing did not consistently achieve the physiologic marker of transmurality, and approximately 40% of standard applications also failed to reach UE transition. These findings suggest that UE-guided titration may complement AI-based strategies, enabling a more individualized, physiology-driven approach to RF lesion formation in the era of energy diversification.</span></span></span></span></p>
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