High Frequency Low Tidal Volume ventilation during ablation of Afib can significantly improve catheter stability. After concluding a single center experience, we implemented the technique in a large multi center network, with significant improvements in procedural time while maintaining safety outcomes.

1. Impact Of High-frequency Low-tidal-volume
Mechanical Ventilation On First-pass Pulmonary
Vein Isolation And Procedural Times
During Atrial Fibrillation Ablation:
A Multicenter Experience
Jose Osorio MD FHRS

2. Disclosures
• Biosense-Webster: Consulting, research grants
• Boston Scientific: consulting, research grants
• Medtronic: research grants
• Abbott: research grants
• HRCRS: ownership
• Real-World Experience of Catheter Ablation for the Treatment of Paroxysmal
and Persistent Atrial Fibrillation (REAL-AF) registry (NCT04088071) is
sponsored by HRCRS and funded by Biosense-Webster

3. Impact of General Anesthesia
During AF Ablation
• Improved Contact Force
– Reduced Gaps
• Improved Outcomes
• Reduces PV reconnection
Chikata A et al. Heart Vessels. 2017;32(8):997-1005.
Martin CA et al. Europace. 2017;20(6):935-942.
Hama Y et al. EP Europace. 2017;19(suppl_3):iii50-iii50.
Di Biase L et al. Heart Rhythm. 2011;8(3):368-372.

4. High Frequency JET Ventilation
Provides superior Catheter Stability
• Reduces respiratory related motion
• Improves catheter stability
• Pacing at 500ms  Additive benefits
• Cost and complexity
Aizer A et al. JCE 2020 Jul;31(7):1678-1686
Goode JS Jr et al. Heart Rhythm. 2006

5. High Frequency Low Tidal Volume Ventilation In AF Ablation
A Simpler Alternative?
• 595 consecutive patients
• Conventional ventilation
• HFLV group
• Similar ablation procedure
• HPSD 40-50 watts
Osorio et al. HRS 2021
Gabriels J et al. JACC EP. 2019;5

6. Conventional ventilation
(12 breaths/min and tidal volume 500 ml)

7. Conventional ventilation  HFLV
(30 breaths/min and 200 tidal volume)

8. HFLV Ventilation in AF Ablation
Reduced Procedure Times
Osorio J; HRS 2021

9. Objective
• To evaluate the impact of HFLV on short-term efficacy,
efficiency, and safety in a large multicenter study.

10. Methods
• 25 institutions
– 1,052 patients
– Prospectively enrolled in REAL-AF registry
• January 2018 to November 2021.
• Investigators meet regularly
– Single center experience of HFLV presented

11. Methods
Catheter Ablation for Paroxysmal Atrial Fibrillation
Ventilation Strategy
Standard Ventilation
All patients - April of 2020
HFLV implemented progressively

12. HFLV Ventilation in AF Ablation
Reduced Procedure and RF Times
p< 0.001
103.3
77.5
0
20
40
60
80
100
120
140
160
Control Group HFLV Group
Minutes
Procedure Time
23.6
18.2
16.4
12.4
0
5
10
15
20
25
30
35
Total RF Time PV RF Time
Minutes
Total RF Time PV RF Time
Control Group HFLV Group
p< 0.001
p< 0.001

13. HFLV Ventilation in AF Ablation
Improvement in First Pass Isolation
84%
90%
78%
80%
84%
75%
40%
50%
60%
70%
80%
90%
100%
Total Left PVs Right PVs
First Pass PVI Rates
HFLV Group Control Group
p=0.02
p=0.01
p=0.37

14. HFLV Ventilation in AF Ablation
Decrease in procedure time >> RF time
23.6
16.4
79.7
61.1
0
20
40
60
80
100
120
Control Group HFLV Group
Time
(minutes)
18 min shorter
7 min shorter
RF time

15. HFLV Ventilation in AF Ablation
Complications and How to Avoid it
• No reported anesthesia related complications
– Similar AE rates both groups
• Use HFLV during ablation only
• CO2 retention
– Breaks between PVs
– Recruitment breaths
• Low oxygen saturation
– Increase PEEP

16. Standard Ventilation  HFLV  HFLV + Pacing

17. • HFLV is a safe and simple technique
• Significant impact:
• Procedure time
• PV RF time
• Improvements in First Pass Isolation
• ? Long-term outcomes
Conclusion

18. • Allyson L. Varley, MPH, PhD
• Brigham Godfrey, RN, MSHCT
• Christopher Thorne, PhD
• Gustavo X. Morales, MD
• Anil Rajendra, MD, FHRS
• Gunther Schrappe
• Joshua R. Silverstein, MD, FHRS
• Paul C. Zei, MD, PhD, FHRS
• Jorge Romero, MD, FHRS
• Paul Varosy, MD, FHRS
Thank you
Co-Authors and Collaborators