Real World Contact Force Ablation

Healthcare systems around the world have been required to adapt to deal with the coronavirus pandemic. While some countries have been able to continue working almost as normal, others have seen systems and hospitals overwhelmed. With these challenges, systems, hospitals and medical staff have had to change the way they work, often dramatically. There has been a period of introspection across society, and what seemed important before now appears irrelevant, and changes that were resisted before having now been happily accepted. With this backdrop, how has the management and treatment of patients with arrhythmias changed?

Virtual clinics and video calling have become an accepted part of the way we work now, and the resulting rise of remote and wearable diagnostics has been dramatic. The use of devices such as the Apple Watch and other wearable ECG monitors have moved considerably into the mainstream and are likely to yield an even higher number of patients requiring medical expertise and treatment. In many ways, electrophysiologists can adapt easily as we lean towards the ECG as our main diagnostic tool when physical examination is restricted. However, direct face-to-face contact is now harder to achieve, and the control of quality information to patients is as important as it ever has been.

Interventional treatment of arrhythmias, in particular AF, while a relatively mature technique still has unanswered questions. As a community we have often focused on the underlying mechanism or trying to understand different forms of signal analysis. While process improvements were discussed, they were rarely the primary focus. In the current situation, with more limited access and time, the way in which we treat patients is much more important. Having patients in hospital for the least amount of time possible is now a priority. This has a number of important implications in the management of patients with AF. Whereas trial endpoints of mortality and stroke reduction were seen as a gold standard, perhaps more emphasis should be placed on endpoints such as reduction in hospital admissions and outpatient visits.

Day-case AF ablation has been the standard in many hospital units for a number of years, regardless of what technology has been employed. However, this has been resisted in many healthcare systems with both medical and financial reasons often cited. Now, it seems inevitable that day-case AF ablation will become the standard of care.

What other parts of the process can yield benefits by minimising the total time of the procedure? Single-shot devices are attractive, but standard point-by-point radiofrequency ablation has become much quicker, due to the standardisation of lesions, and a greater acceptance of high-power, short duration delivery. Again, this has been used in a number of labs for many years successfully, yet perhaps has not gained the respect and uptake that it should have done.

Standardisation of the process, tools that allow quicker lesion delivery, (including very high-power delivery) and electroporation will make AF ablation a shorter procedure and is likely to improve success rates. With this, will it be time to offer AF ablation sooner in a patient's journey, rather than waiting for medication failure, or repeated cardioversions? There will always be options for individual patients, but will the standard become interventional first rather than medication?

The website content and design has recently been updated and will allow for easier navigation. More content is being developed looking specifically at how we can improve the care of patients with arrhythmias in this new environment, not just maintain previous standards. Hopefully, we shall all be able to look back and find that the "new normal" has actually led to practice improvements.


Dr Matt Wright

Supported by Biosense Webster


Section advisor

Consultant Cardiologist and Electrophysiologist, Guy's and St Thomas' Hospital, London, UK

The content on this site is for information purposes only and is not a substitute for professional medical advice. The views and opinions expressed in the content on this site does not necessarily reflect or represent the views and opinions of Radcliffe Cardiology or Biosense Webster*.

Featured Articles Article icon

Standardized pulmonary vein isolation workflow to enclose veins with contiguous lesions: the multicentre VISTAX trial

EP Europace, euaa157.

Persistent atrial fibrillation ablation with contact force sensing catheter: The prospective multicenter PRECEPT Trial

Mansour, M et al. JACC: Clinical Electrophysiology 2020 [Epub ahead of print].

Economic impact of atrial fibrillation ablation with radiofrequency contact force catheter versus cryoballoon catheter

Pollak, SJ et al. J Comp Eff Res 2019;8;4: 251-264.

Recurrent atrial flutter ablation and incidence of atrial fibrillation ablation after first-time ablation for typical atrial flutter: A nation-wide Danish cohort study

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Ablation index-guided 50 W ablation for pulmonary vein isolation in patients with atrial fibrillation: Procedural data, lesion analysis, and initial results from the FAFA AI High Power Study

Chen, S et al. J Cardiovasc Electrophysiol 2019;30;12: 2724-2731.

Endoscopic evaluation of the esophagus after catheter ablation of atrial fibrillation using contiguous and optimized radiofrequency applications

Wolf, M et al. Heart Rhythm 2019;16;7: 1013-1020.

Prevalence and clinical impact of spontaneous and adenosine-induced pulmonary vein reconduction in the Contact-Force vs. Cryoballoon Atrial Fibrillation Ablation (CIRCA-DOSE) study

Andrade, JG et al. Heart Rhythm 2020 [Epub ahead of print].

Impact of interruptions in radiofrequency energy delivery on lesion characteristics

Friedman, DJ et al. Heart Rhythm 2020 [Epub ahead of print].

Combined local impedance and contact force for radiofrequency ablation assessment

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The industrialization of ablation: a highly standardized and reproducible workflow for radiofrequency ablation of atrial fibrillation

De Potter T, Hunter TD, Ming Boo L, et al. J Interv Card Electrophysiol 2019; epub ahead of press.

Cryoballoon or Radiofrequency Ablation for Atrial Fibrillation Assessed by Continuous Monitoring

Andrade J, Champagne J, Dubuc M, et al. Circulation 2019;140:1779–88.

Different tissue thermodynamics between the 40 W and 20 W radiofrequency power settings under the same ablation index/lesion size index

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Lesion Index Titration Using Contact-Force Technology Enables Safe and Effective Radiofrequency Lesion Creation at the Root of the Aorta and Pulmonary Artery

Alfonso-Almazán JM, Quintanilla JG, García-Torrent MJ, et al. Circ Arrhythmia Electrophysiol 2019;12:e007080

How is Contact Force implemented in routine clinical practice? Results from a French National and Monaco Survey

Bun SS, Lațcu DG, Taghji P, et al. J Arrhythm 2019;35:238–43.

Multicentre randomised trial comparing contact force with electrical coupling index in atrial flutter ablation

Begg GA, O’Neill J, Sohaib A, et al. PLoS One 2019;14:e0212903.

The role of Marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation

Vlachos K, Denis A, Takigawa M, et al. Heart Rhythm 2019;16:1341–7.

Analysis of late reconnections after pulmonary vein isolation: Impact of interlesion contiguity and ablation index

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Limitations of lesion quality estimated by ablation index: An in vitro study

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Pulmonary Vein Isolation with Very High Power–Short Duration Temperature-Controlled Lesions: The First-in-Human QDOT-FAST Multicenter Trial

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RESCUE-AF in Patients Undergoing Atrial Fibrillation Ablation

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Eliminating the effects of motion during radiofrequency lesion delivery using a novel contact‐force controller

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Comparison of high‐power short‐duration (HPSD) ablation of atrial fibrillation using a contact force‐sensing catheter and conventional technique: Initial results

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Characteristics of early recurrences detected by continuous cardiac monitoring influencing the long‐term outcome after atrial fibrillation ablation

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Pulmonary vein isolation using a higher power shorter duration CLOSE protocol with a surround flow ablation catheter

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A multicentered evaluation of ablation at higher power guided by ablation index: Establishing ablation targets for pulmonary vein isolation

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High-Power (40–50 W) Radiofrequency Ablation Guided by Unipolar Signal Modification for Pulmonary Vein Isolation

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Atrial fibrillation ablation in patients with transvenous devices: Safety and insights into getting rid of the 30-second rule defining procedural success

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Long-term outcomes after low power, slower movement versus high power, faster movement irrigated-tip catheter ablation for atrial fibrillation

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Low complication rates using high power (45-50 W) for short duration for atrial fibrillation ablations

Winkle RA, Mohanty S, Patrawala RA, et al. Heart Rhythm 2019;16:165–9.

Comparison Between Contact Force Monitoring and Unipolar Signal Modification as a Guide for Catheter Ablation of Atrial Fibrillation

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Long-term efficacy and safety of radiofrequency catheter ablation of atrial fibrillation in patients with cardiac implantable electronic devices and transvenous leads

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Single-Procedure Cure With Atrial Fibrillation Ablation: May The ‘Force’ Be With You

Gupta D. EP Europace 2018;20:f284–5.

SmartTouch™ – The Emerging Role Of Contact Force Technology In Complex Catheter Ablation

Arrhythmia & Electrophysiology Review 2012; 1 :59–62

Role of Contact Force Sensing in Catheter Ablation of Cardiac Arrhythmias: Evolution or History Repeating Itself?

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Contact force sensing for ablation of persistent atrial fibrillation: A randomized, multicenter trial

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Evolution Of Force Sensing Technologies

Arrhythmia & Electrophysiology Review 2017;6(2):75–9.

Higher contact force during radiofrequency ablation leads to a much larger increase in edema as compared to chronic lesion size

Thomas S, Silvernagel J, Angel N, et al. J Cardiovasc Electrophysiol 2018;29:1143–9.

Increasing The Single-Procedure Success Rate Of Pulmonary Vein Isolation

Duytschaever M, O’Neill M, Martinek M. Arrhythm Electrophysiol Rev 2017;6:217–21.

Two Year, Single Center Clinical Outcome After Catheter Ablation For Paroxysmal Atrial Fibrillation Guided by Lesion Index

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16th Atrial Fibrillation Symposium

Arrhythmia & Electrophysiology Review 2017;6(4 Suppl 1):1-24

Ablation Index for Catheter Ablation of Atrial Fibrillation ― Clinical Applicability and Comparison With Force-Time Integral

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Safety and long-term effectiveness of paroxysmal atrial fibrillation ablation with a contact force-sensing catheter: real-world experience from a prospective, multicentre observational cohort registry

De PotterT, Van Herendael H, Balasubramaniam R, et al. EP Europace 2018;20:f410–8.

Outcomes of 200 consecutive, fluoroless atrial fibrillation ablations using a new technique

Liu X, Palmer J. Pacing Clin Electrophysiol 2018;41:1404–11.

High-Power and Short-Duration Ablation for Pulmonary Vein Isolation: Biophysical Characterization

Leshem E, Zilberman I, Tschabrunn CM, et al. JACC Clini Electrophysiol 2018;4:467–79.

Less Pulmonary Vein Reconnection at Redo Procedures Following Radiofrequency Point-by-Point Antral Pulmonary Vein Isolation With the Use of Contemporary Catheter Ablation Technologies

Sandorfi G, Rodriguez-Mañero M, Saenen J, et al. JACC Clin Electrophysiol 2018;4:1556–65.

Atrial Fibrillation Ablation: Simplicity Is the Answer

Wright M. JACC Clin Electrophysiol 2018;4:109–11.

Bridging the Generation Gap in Atrial Fibrillation Ablation Technologies

Gupta D, Chin SH. JACC Clin Electrophysiol 2018;4:1566–8.

Evaluation of a Strategy Aiming to Enclose the Pulmonary Veins With Contiguous and Optimized Radiofrequency Lesions in Paroxysmal Atrial Fibrillation: A Pilot Study

Taghji P, El Haddad M, Phlips T, et al. JACC Clin Electrophysiol 2018;4:99–108.

Pulmonary Vein Reconnection No Longer Occurs in the Majority of Patients After a Single Pulmonary Vein Isolation Procedure

De Pooter J, Strisciuglio T, El Haddad M, et al. JACC Clin Electrophysiol 2019;5:295–305.

Atrial fibrillation ablation using very short duration 50 W ablations and contact force sensing catheters

Winkle RA, Moskovitz R, Hardwin Mead R, et al. J Interv Card Electrophysiol 2018;52:1–8.

Life-Threatening Complications of Atrial Fibrillation Ablation: 16-Year Experience in a Large Prospective Tertiary Care Cohort

Rehman KA, Wazni OM, Barakat AF, et al. JACC Clin Electrophysiol 2019;5:284–91.

Evaluation of left atrial linear ablation using contiguous and optimized radiofrequency lesions: the ALINE study

Wolf M, El Haddad M, Fedida J, et al. EP Europace 2018;20:f401–9.

Ablation Index as a predictor of long-term efficacy in premature ventricular complex ablation: A regional target value analysis

Casella N, Gasperetti A, Gianni C, et al. Heart Rhythm 2019;16:888–95.

Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the ‘CLOSE’-protocol

Phlips T, Taghji P, El Haddad M, et al. EP Europace 2018;20:f419–27.

Lesion Index–Guided Ablation Facilitates Continuous, Transmural, and Durable Lesions in a Porcine Recovery Model

Whitaker J, Fish J, Harrison JL, et al. Circ Arrhythmia Electrophysiol 2018;11:e005892.

Longer Duration Versus Increasing Power During Radiofrequency Ablation Yields Different Ablation Lesion Characteristics

Borne RT, Sauer WH, Zipse MM, et al. JACC Clin Electrophysiol 2018;4:902–8.

The best of two worlds? Pulmonary vein isolation using a novel radiofrequency ablation catheter incorporating contact force sensing technology and 56-hole porous tip irrigation

Maurer T, Rottner L, Makimoto H. et al. Clin Res Cardiol 2018;107:1003–12.

Characteristics of Radiofrequency Catheter Ablation Lesion Formation in Real Time In Vivo Using Near Field Ultrasound Imaging

Wright M, Harks E, Deladi S, et al. JACC Clin Electrophysiol 2018;4:1062–72.

How much is enough? An appraisal of high‐power short‐duration radiofrequency ablation for pulmonary vein isolation

Raja DC, Sanders P, Pathak RK. J Cardiovasc Electrophysiol 2019;30:2205–8.

High‐power short‐duration ablation: Turn up the heat to cool down the esophagus

Winkle RA. J Cardiovasc Electrophysiol 2019;30:1884–5.

Effect of Contact Vector Direction on Achieving Pulmonary Vein Isolation

Hoshiyama T, Fukushima H, Noda K, et al. Circ Arrhythm Electrophysiol 2019;12:e007320.

Review Of The Safety And Effectiveness Of The THERMOCOOL SMARTTOUCH® SF Catheter Evaluated For Treating Symptomatic PersistenT AF

Safety and Effectiveness of TactiCath™ Contact Force, Sensor Enabled™ (TactiCath SE) Catheter for Ablation of Drug Refractory, Symptomatic, Persistent Atrial Fibrillation, NCT03650556

THERMOCOOL SMARTTOUCH®SF Catheters With Ablation Index Study, NCT03963349

Evaluation of QDOT MICRO™ Catheter for Pulmonary Vein Isolation in Subjects With Paroxysmal Atrial Fibrillation, NCT03775512

Comparison of Contact-force Monitoring Irrigated Tip Catheter and Mesh-like Irrigated Tip Catheter in Atrial Fibrillation Ablation: Prospective Randomized Trial, NCT04264117

Registry for Real-world Experience of Catheter Ablation for Symptomatic Paroxysmal Atrial Fibrillation, NCT04088071

Evaluation of Ablation Index and VISITAG™ (ABI-173), NCT03062046

Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF, NCT04198701

PVI Alone Versus Additional Low-Voltage Substrate Modification During SR Guiding By Contact-Force Catheter In Older Patients With Paroxysmal AF, NCT03462628

Contact-Force-Sensing-Based Radiofrequency Catheter Ablation in Paroxysmal Supraventricular Tachycardias, NCT04078685

Randomised Prospective Trial Comparing Contact Force and Non-contact Force Guided Catheter Ablation for Cavotricuspid Isthmus Dependent Atrial Flutter, NCT02825498

CardioFocus vs. Contact Force Guided Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation, NCT03056222

Wide Area Circumferential Ablation With Contact Force Versus Cryoballoon Ablation, NCT03564925

Safety and efficacy of the ThermoCool SmartTouch SurroundFlow catheter for atrial fibrillation ablation: A meta-analysis

Chen, CF et al. Clin Cardiol 2020;43;3: 267-274.

Updated systematic review and meta-analysis of the impact of contact force sensing on the safety and efficacy of atrial fibrillation ablation: discrepancy between observational studies and randomized control trial data

Virk, SA et al. Europace 2019;21;2: 239-249.

The Role Of The Electrophysiologist In Convergent Ablation

Arrhythmia & Electrophysiology Review 2020;9(1):8–14.

Atrial fibrillation ablation with a spring sensor-irrigated contact force-sensing catheter compared with other ablation catheters: systematic literature review and meta-analysis

Macle, L et al. BMJ Open 2019;9;6: e023775

Contact Force and Ablation Index

Virk, SA et al. Card Electrophysiol Clin 2019;11;3: 473-479.

When It Comes to Defining the Outcomes of Catheter Ablation of Atrial Fibrillation, an Implantable Monitor Is a Great Place to Start

Calkins H. Circulation 2019;140:1789–91.

High-power, Short-duration Radiofrequency Ablation for the Treatment of AF

Arrhythmia & Electrophysiology Review 2019;8(4):265–72.

Feasibility, Safety, and Efficacy of Posterior Wall Isolation During Atrial Fibrillation Ablation

Thiyagarajah A, Kadhim K, Lau DH, et al. Circ Arrhythm Electrophysiol 2019;12:e007005.

Catheter Ablation Versus Medical Therapy for Atrial Fibrillation

Asad ZUA, Yousif A, Khan MS, et al. Circ Arrhythm Electrophysiol 2019;12:e007414.

ThermoCool® SmartTouch® Catheter – The Evidence So Far For Contact Force Technology And The Role Of VisiTag™ Module

Arrhythmia & Electrophysiology Review 2013;3(1):44-7