1 69

2 70
3
4
Impact of electrode tip shape on catheter performance 71
72
5
6 Q1 in cardiac radiofrequency ablation 73
74
7 75
8 Q8 Argyrios Petras, PhD,*1 Zoraida Moreno Weidmann, MD,†1 76
9 77
10 Marina Echeverria Ferrero, MS,‡ Massimiliano Leoni, PhD,* Jose M. Guerra, MD, PhD,†2 78
11 Q2 Luca Gerardo-Giorda, PhD*x2 79
12 80
13 From the *RICAM, Austrian Academy of Sciences, Linz, Austria, †Department of Cardiology, Hospital de la 81
14 82
Santa Creu i Sant Pau, Universitat Aut
onoma de Barcelona, CIBER CV, Barcelona, Spain,
15 ‡ 83
16 BCAM–Basque Center for Applied Mathematics, Bilbao, Spain, and xInstitute for Mathematical 84
17 Methods in Medicine and Data-Based Modelling, Johannes Kepler University, Linz, Austria. 85
18 86
19 87
20 BACKGROUND The role of catheter tip shape on the safety and ef- tip become comparable to those generated by the cylindrical tip. 88
21 ficacy of radiofrequency (RF) ablation has been overlooked, The 2 tips feature different safety profiles: CF and power are the 89
22 although differences have been observed in clinical and research main determinants of pops for the spherical tip; power is the 90
23 fields. main factor for the cylindrical tip; and CF has a marginal effect. 91
24 The cylindrical tip is more prone to pop generation at higher powers. 92
25 OBJECTIVE The purpose of this study was to analyze the role of 93
Saline irrigation and blood flow effect do not depend on tip shape.
26 Q3 electrode tip shape using a computational model. 94
27 CONCLUSION Tip shape determines the performance of ablation 95
28 METHODS We simulated 108 RF ablations through a realistic catheters and has a major impact on their safety profile. The cylin- 96
29 3-dimensional computational model considering 2 clinically used, 97
drical tip shows more predictable behavior in a wide range of CF
30 open-irrigated catheters (spherical and cylindrical tip), varying con- 98
values.
31 tact force (CF), blood flow, and irrigation. Lesions are defined by the 99
32 50 C isotherm contour and evaluated by means of width, depth, 100
33 KEYWORDS Cardiac ablation; Computational modeling and simula- 101
depth at maximum width, and volume. Ablations are deemed as
34 tion; Electrode tip; Lesion science; Open irrigation; Radiofrequency; 102
safe, critical (tissue temperature .90 C), and pop (tissue temper-
35 Steam pop 103
36 ature .100 C). 104
37 105
RESULTS Tissue–electrode contact is less for the spherical tip at (Heart Rhythm O2 2022;-:1–7) © 2022 Heart Rhythm Society. Pub-
38 106
low CF but the relationship is inverted at high CF. At low CF, the cy- lished by Elsevier Inc. This is an open access article under the CC BY-
39 107
40 lindrical tip generates deeper and wider lesions and a 4-fold larger NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4. 108
41 volume. With increasing CF, the lesions generated by the spherical 0/). 109
42 110
43 111
44 Introduction ences in terms of pop formation when comparing various 112
45 currently available, open-irrigated RF ablation catheters, sug- 113
46
Radiofrequency (RF) catheter ablation is extensively used for 114
47 the treatment of tachyarrhythmias. Several improvements in gesting that catheter tip shape also may play a significant 115
48 the technology have been implemented over the years to role.2–4 However, classic research approaches have not 116
49 maximize lesion size while minimizing complications. been able to elucidate which characteristics of tip shape 117
50 Despite an optimal equilibrium with the current available may have an impact on the safety and efficacy of lesion for- 118
51 mation and how they can be used to optimize ablation. 119
52
technology, complications still occur and are not always pre- 120
53 dictable. The study and development of RF ablation has been based 121
54 It is well known that contact force (CF), power, and abla- mainly on in vivo and in vitro experiments, which have 122
55 tion time are the main determinants of lesion characteristics important limitations that are difficult to circumvent, mostly 123
56 and safety.1 However, some groups have observed differ- related to the large number and variability of factors interre- 124
57 lated in lesion formation. 125
58 126
59
The recent development of computational models for RF 127
60 1
Dr Argyrios Petras and Dr Zoraida Moreno Weidmann contributed equally ablation is a powerful tool to evaluate interacting factors in 128
61 to this manuscript and are joint first authors. 2Dr Jose M. Guerra and Dr Luca lesion formation in an independent manner.5,6 This approach 129
62 Gerardo-Giorda share last authorship. Address reprint requests and corre- allows study of specific catheter designs7 and assessment of 130
63 spondence: Dr Jose M. Guerra, Department of Cardiology, Hospital de la new protocols, such as high-power/short-duration applica- 131
64 Santa Creu i Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain. 132
65 E-mail address: jguerra@secardiologia.es.
tions.8 133
66 134
67 2666-5018/© 2022 Heart Rhythm Society. Published by Elsevier Inc. This is an open access article https://doi.org/10.1016/j.hroo.2022.07.014 135
68 under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 136

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137 Tissue characteristics 205

138 KEY FINDINGS We studied virtual porcine cardiac tissue of 20-mm thick- 206
139 207
140 - Electrode tip shape plays a crucial role in terms of the ness.11 The biophysical and mechanical parameters are sum- 208
141 safety and efficacy of radiofrequency ablation. marized in the Supplementary Material. 209
142 210
143 - The cylindrical tip has a more predictable behavior in a 211
144
Lesion assessment 212
wide range of contact force values but seems to be
145 Q4 Considering irreversible tissue damage at 50 C,12 lesions 213
more prone to steam pop generation.
146 were identified by the 50 C isotherm contour. The measured 214
147 - Each catheter design needs different specific settings dimensions were depth (D), lesion volume (V), width (W), 215
148 to achieve similar ablation efficiency while avoiding and depth of maximum width (DW), considering the zero 216
149 217
150
complications. at the undeformed endocardial surface (Figure 1). 218
151 219
152 Ablation settings 220
153 For both electrode tips, we simulated 30 seconds of ablation 221
154 222
The purpose of this study was to analyze the role of cath- for several protocols in terms of power (20–50 W) and CF
155 223
156 eter tip shape in RF ablation using our validated advanced (5g–20g). All simulated ablations are performed perpendic- 224
157 computational model,9 which accounts for the elastic defor- ular to the endocardium, resulting in progressive deformation 225
158 mation of the electrode–cardiac tissue interface, thus allow- of the tissue. The ablation protocols use a power-control 226
159 ing a full evaluation of different scenarios. Recent 227
mode without temperature limit.
160 228
161
experimental studies have highlighted the correlation be- Two blood flow protocols commonly used in in vitro ex- 229
162 tween catheter contact area and lesion size.10 Because the periments were considered2: high blood flow (0.5 m/s), rep- 230
163 catheter contact area depends on tissue deformation, which, resenting heart areas of high flow such as the cavotricuspid 231
164 in turns, depends on both CF and tip shape, our model repre- isthmus, ventricle, or outflow tracts; and low blood flow 232
165 233
sents a natural candidate to study, in an independent manner, (0.1 m/s), representing flow in areas such as below a valve
166 234
the different tip shapes and their role in RF ablation. The re- leaflet, the pulmonary veins, or the atrium. Two saline irriga-
167 235
168 sults will provide a better understanding of the pathophysi- tion rates were simulated that typically are used in RF: low 236
169 ology of RF ablation and pop occurrence and possibly rate (17 mL/min) and high rate (30 mL/min). 237
170 identification of hazardous ablation protocols. 238
171 239
172 Complication assessment 240
173 We considered a steam pop to occur when the tissue temper- 241
174 Methods ature reached 100 C.12 Whenever a pop occurred, the simu- 242
175 Computational model lation was terminated, and the time to pop was recorded. Due 243
176 244
Our computational model of RF is based on an in vitro exper- to slight fluctuations of the temperature at which steam pop
177 245
178 imental setup reported by Guerra et al.2 In brief, the model occur,13 we defined a critical area, which corresponds to 246
179 simulates a porcine heart considering fixed conditions, which simulated lesions in which the tissue temperature reaches be- 247
180 allows for standard comparison of different ablation settings. tween 90 C and 100 C. Although reaching a boiling temper- 248
181 ature does not automatically result in a pop, given the 249
The mathematical model, detailed in the Supplementary Ma-
182 250
terial, is built within a 3-dimensional computational frame- seriousness of this complication, we equated the risk of pop
183 251
184 work,10 which considers tissue elasticity, blood flow, and with the occurrence of it. Each virtual lesion was classified 252
185 its interaction with the irrigated saline and the thermoelectric as pop, critical, or safe, based on the maximum tissue temper- 253
186 interaction between the electrode and the target ablation area. ature (Tmax) reached. For each electrode tip shape, a color- 254
187 coded risk map of the protocol was drawn based on CF and 255
Simulations were performed using our self-developed
188  256
software in FEniCS-HPC (www.fenics-hpc.org) on BCAM power. The ablation protocols that led to Tmax ,90 C after
189 257
190 in-house HPC cluster (18 nodes/624 cores with 4-TB RAM). 30 seconds were classified as safe and represented in green; 258
191 No patient data or animals were used in this study. The for Tmax between 90 C and 100 C, the ablation protocol 259
192 computer model was validated in a previous study by Petras was deemed critical, represented as yellow; and for Tmax 5 260
193 100 C, the protocol was deemed pop, represented in red. 261
et al.9
194 262
We registered the time to critical temperature as a surro-
195 263
196 gate of the safe ablation interval time, defined as the time 264
197 Electrode tip shape from the beginning of an ablation to Tmax .90 C. 265
198 We considered 2 different electrode tip shapes, based on 266
199 267
200
commercially available and clinically used, open-irrigated Study design 268
201 catheters: one with a hemispherical tip and one with a cylin- The study was performed in 3 parts. (1) In the first set of ex- 269
202 drical tip. Both electrodes have diameter of 2.33 mm (7F) and periments, we studied the safety of both catheter shapes at 270
203 length of 3.5 mm, and feature 6 irrigation pores (0.5-mm different ablation protocols in terms of power (20–50 W) 271
204 diameter) (Figure 1). and CF (5g–20g). For this set, we maintained constant blood 272

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 Petras et al Impact of Electrode Shape on Cardiac RF Ablation 3

273 341
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303 371
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307 Figure 1 A: The computational model and the 2 electrode tip shapes studies. B, C: Simulated lesions with each catheter. The area of irreversible tissue lesion is 375
308 delimited by the black line, which represents the 50 C isotherm. Lesion measurements are depth (D), width (W), and depth of maximum width (DW) 376
309 377
310 378
311 flow (0.5 m/s) and low saline irrigation rate (17 mL/min), whereas very low CF offers a wide safety margin at any po- 379
312 380
which are the values used in the in vitro experiments against wer tested (up to 50 W). An increase in 1 of the 2 parameters
313 381
314 which the computational model was validated. (2) The sec- over the other shows a progressive reduction in safety. 382
315 ond set of experiments aimed to compare the impact of CF For the cylindrical tip, power proves to be the main factor 383
316 in terms of lesion size for both catheter tip shapes. For that contributing to tissue overheating. Whereas power ,30 W 384
317 purpose, we chose a routine clinical protocol of 30 W for seems to be generally safe at any CF, at 35 W the risk of 385
318 386
30 seconds and 4 different CF levels (from 5g to 20g). Blood pop rises suddenly even at low CF. In contrast, variations
319 387
320 flow and irrigation rate were kept at 0.5 m/s and 17 mL/min, of CF seem to have a marginal effect on the risk of pop. 388
321 respectively. (3) Finally, we analyzed the impact of blood The time to critical temperature (ie, safe ablation interval 389
322 flow and saline irrigation level on safety and efficacy. For time) is shown in Figure 3. This interval is larger at lower po- 390
323 each catheter, we focused on the highest power not producing wer, lower CF, and with the spherical tip rather than with cy- 391
324 392
a pop identified from the previous experiments at a standard lindrical one. Stepwise increases in CF lead to an exponential
325 393
326 CF of 10g. decline of this time for the spherical tip, whereas the decline 394
327 of the curve is smoother for the cylindrical tip. 395
328 396
329 Results 397
330
Impact of CF for each tip shape 398
A total of 108 RF catheter ablation lesions were simulated,
331 We compared 4 different CFs in a standard clinical scenario 399
combining tip shape, CF, RF power, saline irrigation rate,
332 (30 W, 30 seconds), and the results are summarized in 400
333
and blood flow. 401
Table 1 and Figure 4. We observed that at low CF, the cylin-
334 drical tip generates deeper and wider lesions (and a 4-fold 402
335 403
336
Impact of catheter tip shape on safety larger volume) than the spherical tip. With increasing CF, 404
337 The 2 catheter tip shapes show very different risk profiles the lesions generated by the spherical tip become progres- 405
338 (Figure 2). For ablations with the spherical tip, a combination sively closer to those generated by the cylindrical tip. More- 406
339 of CF and power is needed to lead to pop. A low-power de- over, increasing CF from 5g to 15g results in a 6-fold larger 407
340 livery (up to 25 W) would lead to safe lesions at any CF, lesion for the spherical tip but a mere 50% increment for the 408

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421 489
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424 492
425 Figure 2 Contact force–power steam pop risk maps for each electrode tip shape. Blood flow and irrigation rate were kept at 0.5 m/s and 17 mL/min, respec- 493
426 tively. Safe protocols are represented in green, critical in yellow, and pop in red. 494
427 495
428 496
429 cylindrical tip. A similar pattern can be observed for Tmax. safety profiles of the 2 tip shapes are very different. (4) Inde- 497
430 For the spherical tip Tmax rises from 61 C at 5g and produces pendent of tip shape, power and CF are the 2 major determi- 498
431 499
a pop (after 21.5 seconds) at 20g, whereas for the cylindrical nants of pop formation, whereas catheter irrigation and blood
432 500
433 tip Tmax only rises from 80 C at 5g to 94 C at 20g. Hence, flow have a minor impact. 501
434 lesion size and complications are determined mostly by the 502
435 power for the cylindrical tip and by the combination of power Model validation 503
436 and CF for the spherical tip. 504
Our computational model was previously validated for a
437 505
438 spherical tip against ad hoc, in vitro experimental results.9 506
439 Impact of blood flow and saline irrigation For the cylindrical tip, despite lacking a twin experimental 507
440 For this evaluation, we chose, at a conventional CF of 10g, model for validation, the simulated lesion sizes were in 508
441 the largest power not producing a pop for each tip shape: good agreement with the ex vivo experimental results recently 509
442 510
35 W for the cylindrical tip and 40 W for the spherical tip. reported by Masnok and Watanabe,10 who used a 6-hole cy-
443 511
444
Table 2 summarizes the lesion dimensions and tissue temper- lindrical electrode. Moreover, our results align with the 512
445 atures with varying blood flows and saline irrigation rates. No nonoccurrence of steam pops reported therein for 30-W/30- 513
446 steam pop is observed, although all simulated protocols are second ablations in the range of CF (up to 20g) we studied 514
447 deemed critical for both tip shapes. The overall variation of (Figure 2). 515
448 Tmax is below 2 C. 516
449 517
450 Tip shape and contact surface 518
451 Discussion Heat transfer to tissue depends directly on the contact surface 519
452 To the best of our knowledge, this is the first study to use an between the metallic region of the catheter tip and the cardiac 520
453 521
454
advanced and realistic computational model to explore in a wall.1 Although a recent experimental study stressed the 522
455 controlled and independent manner the impact of catheter importance of the contact surface between electrode and tis- 523
456 tip shape on the safety and the efficacy of RF ablation. The sue using 5 different angles of the catheter and a wide range 524
457 main findings are as follows. (1) The tip shape determines of CF values,10 the role of the catheter tip shape has been 525
458 the contact surface with the tissue and how it changes based overlooked. Our simulations clearly show how that catheter 526
459 527
460
on CF. (2) CF is more critical for the spherical tip than for the tip shape is a major determinant of the amount of surface 528
461 cylindrical tip with regard to safety and efficacy. (3) The tip area that comes into contact with the tissue. As shown 529
462 530
463 531
464 532
465 533
466 534
467 535
468 536
469 537
470 538
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471 539
472 540
473 541
474 542
475 543
476 Figure 3 Time to critical temperature for the 2 electrode tip shapes and different power/contact force combinations. 544

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 Petras et al Impact of Electrode Shape on Cardiac RF Ablation 5

545 Table 1 Lesion characteristics for the 2 tip shapes and different this occurs much faster for the spherical tip than for the cylin- 613
546 CFs drical tip, whose contact surface shows only slight variations 614
547 615
548 CF Tip D (mm) W (mm) DW (mm) V (mm3) Tmax ( C) at a wide range of CFs. Hence, at low CF the percentage in 616
549 contact is much lower for the spherical tip than the cylindrical 617
550 5g Spherical 3.29 4.84 0.77 32.7 60.8 tip (7% vs 13%); at moderate CF the percentage difference 618
551 Cylindrical 4.74 7.4 1.31 124.8 80.2 619
10g Spherical 4.69 6.84 1.49 106.4 77.6
rapidly reduces; and at CF 20g the relationship is inverted
552 (18% vs 17%). As a result, lesions generated at low CF are 620
553 Cylindrical 5.22 7.87 1.62 161.2 86.5 621
554 15g Spherical 5.60 8.27 1.28 182.3 92.6 larger with the cylindrical tip than with the spherical tip. 622
555 Cylindrical 5.60 8.43 1.71 193.4 91.2 Increasing the CF would require a reduction in power to 623
556 20g Spherical 5.55* 8.35* 0.98* 182.3* 100.0* remain in the safe zone, especially for the spherical tip. 624
557 Cylindrical 5.92 8.85 1.42 220.2 94.0 625
558 Ablation protocol is 30 W, 30 seconds. Blood flow is kept at 0.5 m/s and 626
559 irrigation rate at 17 mL/min.
Impact of CF 627
560 CF 5 contact force; D 5 depth; DW 5 depth of maximum width; Our analysis clearly shows the critical role of CF in lesion 628
561 Tmax 5 maximum tissue temperature; V 5 volume; W 5 width. formation and complications for spherical tips, whereas large 629
562 *Protocol popped at 21.4 seconds. Values measured at time of pop. 630
variations of CF have only a minor impact on cylindrical tips.
563 631
564 In line with our results, ex vivo and in vivo experimental 632
565 in Figure 4 (center panel), for the spherical tip, the tissue sur- studies based on RF lesions using a spherical catheter tip 633
566 face area that is in contact with the catheter tip has a major have shown that the increase in lesion size depends more 634
567 dependence on CF. In the absence of CF, only a small area on CF than on power: lesions obtained with 30 W/20g 635
568 of a spherical tip will be in contact with the tissue. In contrast, 636
were greater in depth and width than those obtained with
569 637
570
for the cylindrical tip, the whole base is in contact with the 40 W/10g.14 A recent study compared the lesions obtained 638
571 tissue, leading to greater power delivery. As CF increases, by matching a predefined value on the lesion size indicator 639
572 so does the contact surface for both catheters. However, provided by the navigation system of 2 commercially 640
573 641
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610 Figure 4 Contact surface percentage with the tissue according to contact force (CF) for each catheter tip shape (spherical in blue, cylindrical in orange) and 678
611 comparison of the corresponding lesions generated with a 30-W/30-second ablation protocol. Blood flow and irrigation rate were kept at 0.5 m/s and 17 mL/min, 679
612 respectively. In all plots, blood flows from left to right. 680

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 6 Heart Rhythm O2, Vol -, No -, - 2022

681 Table 2 Lesion characteristics for the 2 tip shapes applying different blood flows and saline irrigation rates 749
682 750
683 Electrode tip protocol 751
684 752
Spherical (40 W, 10g) Cylindrical (35 W, 10g)
685 753
Blood flow (m/s) HBF LBF HBF LBF
686 754
0.5 0.1 0.5 0.1
687 Q6 755
Saline irrigation rate (mL/min) 30 17 30 17 30 17 30 17
688 756
D (mm) 5.48 5.49 5.53 5.50 5.64 5.64 5.68 5.66
689 757
W(mm) 8.21 8.29 8.48 8.32 8.66 8.72 8.77 8.79
690 758
DW (mm) 2.33 2.34 2.28 2.35 2.24 2.23 2.18 2.36
691 759
V(mm3) 176.6 185.3 200.3 186.7 207.7 213.8 222.8 217.9
692 760
Tmax ( C) 96.2 96.2 98.0 97.1 98.2 98.0 99.9 99.0
693 761
694 HBF 5 high blood flow; LBF 5 low blood flow; other abbreviations as in Table 1. 762
695 763
696 764
697 765
698 available catheters (Ablation Index for CARTO3, Biosense the spherical catheter, the only observed pop was at a greater 766
699 767
Webster, Inc., Diamond Bar, CA; Lesion Size Index [LSI] CF (20g).
700 768
701 for Ensite Precision, Abbott Laboratories, Abbott, IL), Our observations suggest the need for a tailored power 769
702 similar to those considered in our study.4 Lozano Granero setting based on the anatomic region and the catheter tip 770
703 et al4 also observed an inversion in lesion size according to design. Use of a spherical tip with low power may be suitable 771
704 CF and attributed to a suboptimal prediction ability of the for the atrial wall where abrupt changes in CF are foreseeable, 772
705 773
LSI when using a spherical catheter in a low-CF setting. thus avoiding the risk of pop or perforation. In contrast, use of
706 15 774
707 Our results suggest that, in line with previous publications, cylindrical tips may be appropriate for reaching deeper ven- 775
708 lesion size indicators should account for reliable estimators of tricular arrhythmogenic substrates, allowing greater heat 776
709 contact surface between the tip and the tissue, beyond the CF. transfer and larger lesions. 777
710 778
711 779
712 Impact of blood flow and catheter irrigation 780
713 We observed no significant influence on tissue temperature 781
714
Safety 782
715 Both electrode tips show an increasing risk of steam pop from variations in blood flow or irrigation rate for the elec- 783
716 occurrence with increased CF and power. However, for the trode tips used in our study. Available clinical and experi- 784
717 cylindrical tip the risk of pop depends more on power than mental data also support that the type of irrigation (ie, 785
718 on CF, whereas for the spherical tip both CF and power are discrete number of pores or surround flow designs) has no 786
719 significant impact on lesion size.2,3,10,18–20 787
720
equally important. Thus, greater powers can be applied 788
721 with the spherical tip if the CF is kept low, and vice versa. Our study also suggests that the incidence of steam pops is 789
722 In contrast, for the cylindrical tip, setting the power up to not directly related to the amount of irrigation. Whether the 790
723 30 W will be mostly safe, independent of CF. Because power type of irrigation (discrete vs surround flow) has an impact 791
724 is a selected parameter in contrast to CF, which may vary on pop occurrence remains unclear. Although clinical studies 792
725 have not reported significant differences,21 in vitro results 793
726
abruptly during the ablation, the behavior of the cylindrical 794
727 tip seems overall more predictable than that of the spherical have shown discrepancies.2,3,18,19 795
728 tip. 796
729 Knecht et al16 described differences in 2 catheters having 797
730 Clinical implications 798
different tip shapes and irrigation in terms of safety. In their
731 Electrode tip shape plays a crucial role in terms of safety and 799
732
study, the spherical tip shape showed a higher risk of pop, 800
efficacy. The cylindrical tip shape has a more predictable
733 and they related the difference to a more efficient irrigation 801
behavior at a wide range of CF values, although it seems to
734 system that, by underestimating tissue temperature feedback, 802
be more prone to steam pop generation at higher powers.
735 would enable higher power delivery. Iles et al17 observed an 803
736 However, its low sensitivity to CF favors the generation of 804
increase in pop occurrence at power .40 W delivered by a
737 more homogeneous lesions, thus helping to standardize the 805
738
spherical tip on a reanimated porcine cardiac model. 806
ablation procedures.
739 Although they group did not consider CF, they did consider 807
740 .50% of the electrode tip surface to be in contact with the 808
741 endocardium, which is more than twice the maximal percent- Study limitations 809
742 age we studied. In other studies comparing many catheter tip Our calculations are based on ablations performed on a 810
743 811
744
designs, a trend toward more frequent pops with spherical porcine slab of tissue representing an in vitro setting because 812
745 tips also was found.2,18 Although in a recent study by Lozano that was the setting used to validate the computational 813
746 et al4 more pops were observed with lesions performed by a model10; therefore, as in the case of in vitro experiments on 814
747 cylindrical tip, the main factor for the occurrence was the animal models, direct extrapolation of the results to the hu- 815
748 applied power (from 30 to 60 W at 10g). In contrast, for man clinical setting should be taken with care. However, 816

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817 the aim of the present work was not to directly provide guide- References 885
818 lines for clinical settings to be used. 886
1. Haines DE. Determinants of lesion size during radiofrequency catheter ablation:
819 887
820
Our model considers only a perpendicular orientation of the role of electrode-tissue contact pressure and duration of energy delivery. J
888
Cardiovasc Electrophysiol 1991;2:509–515.
821 the catheter with respect to the tissue. Different orientations 2. Guerra JM, Jorge E, Raga S, et al. Effects of open-irrigated radiofrequency abla- 889
822 may have a considerable impact on the contact surface and, tion catheter design on lesion formation and complications: in vitro comparison of 890
823 therefore, on the lesion geometry and the risk of pop. Our pre- 6 different devices. J Cardiovasc Electrophysiol 2013;24:1157–1162. 891
824 liminary data suggest that for orientations ranging from
3. Winterfield JR, Jensen J, Gilbert T, et al. Lesion size and safety comparison be- 892
825 tween the novel flex tip on the FlexAbility ablation catheter and the solid tips on 893
826
perpendicular to 45 of inclination, the cylindrical tip would the ThermoCool and ThermoCool SF ablation catheters: flex tip comparative
894
827 exhibit a significantly larger loss of contact surface in com- ablation. J Cardiovasc Electrophysiol 2016;27:102–109.
895
parison to the spherical tip. From 45 to the parallel position,
4. Lozano Granero C, Franco E, Matía Francés R, et al. Impact of power and contact
828 force on index-guided radiofrequency lesions in an ex vivo porcine heart model. J 896
829 the contact surface is expected to increase for both catheter Interv Card Electrophysiol 2022;63:687–697. 897
830 tips. The actual trend for each catheter tip also would depend 5. Singh S, Melnik R. Thermal ablation of biological tissues in disease treatment: a 898
831 review of computational models and future directions. Electromagn Biol Med 899
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on CF. This particular aspect could be of great clinical impor- 2020;39:49–88. 900
833 tance and requires extensive further investigation. Our results 6. Gonzalez-Suarez A, Pérez JJ, Irastorza RM, D’Avila A, Berjano E. Computer 901
834 set the basis for such future research. modeling of radiofrequency cardiac ablation: 30 years of bioengineering research. 902
Comput Methods Programs Biomed 2022;214:106546.
835 In our study, a power-controlled ablation mode without 903
7. Verma A, Schmidt MM, Lalonde J-P, Ramirez DA, Getman MK. Assessing the
836 temperature cutoff was simulated. This may limit direct 904
relationship of applied force and ablation duration on lesion size using a diamond
837 905
838
extrapolation of the results to the clinical setting, as current tip catheter ablation system. Circ Arrhythm Electrophysiol 2021;14:e009541.
906
8. Petras A, Moreno Weidmann Z, Leoni M, Gerardo-Giorda L, Guerra JM. System-
839 technology allows for power down-regulation upon reaching atic characterization of high-power short-duration ablation: insight from an 907
840 an upper limit temperature. However, because the aim of this advanced virtual model. Front Med Technol 2021;3:747609. 908
841 study was to better understand the mechanisms behind the 9. Petras A, Leoni M, Guerra JM, Jansson J, Gerardo-Giorda L. A computational 909
842 impact of tip shape on RF ablation, we consider this aspect
model of open-irrigated radiofrequency catheter ablation accounting for mechan- 910
843 ical properties of the cardiac tissue. Int J Numer Method Biomed Eng 2019; 911
844
to have little impact on the conclusions of the study. 35:e3232.
912
10. Masnok K, Watanabe N. Catheter contact area strongly correlates with lesion area
845 913
in radiofrequency cardiac ablation: an ex-vivo porcine heart study. J Interv Card
846 Conclusion Electrophysiol Int J Arrhythm Pacing 2022;63:561–572. 914
847 915
Our findings from this in silico study demonstrate that cath- 11. Liu S, Chiu YT, Shyu JJ, et al. Hypertrophic cardiomyopathy in pigs: quantitative
848 pathologic features in 55 cases. Cardiovasc Pathol 1994;3:261–268. 916
849 eter tip shape plays a critical role in the safety and efficacy 12. Wittkampf FHM, Nakagawa H. RF catheter ablation: lessons on lesions. Pacing 917
850 of cardiac RF ablations. Lesion size and complications are Clin Electrophysiol 2006;29:1285–1297. 918
851 determined mostly by the power for the cylindrical tip and 13. Thompson N, Lustgarten D, Mason B, et al. The relationship between surface 919
852 by the combination of power and CF for the spherical tip.
temperature, tissue temperature, microbubble formation, and steam pops. Pacing 920
Clin Electrophysiol 2009;32:833–841.
853 921
Pop occurrence is minimally affected by saline irrigation 14. Ikeda A, Nakagawa H, Lambert H, et al. Relationship between catheter contact
854 922
855 rate and blood flow for both shapes. Our results should force and radiofrequency lesion size and incidence of steam pop in the beating
923
canine heart: electrogram amplitude, impedance, and electrode temperature are
856 help in designing new catheters and safe ablation protocols poor predictors of electrode-tissue contact force and lesion size. Circ Arrhythm 924
857 in the future. Electrophysiol 2014;7:1174–1180. 925
858 15. Shah D, Namdar M. Real-time contact force measurement: a key parameter for 926
859 Q5 Funding Sources: Part of this work was performed when Drs Gerardo- controlling lesion creation with radiofrequency energy. Circ Arrhythm Electro- 927
860 Giorda, Petras, and Leoni were with BCAM, Bilbao, Spain. Dr Ferrero physiol 2015;8:713–721. 928
861 was supported by the Basque Government (BERC 2018-2021) and the 16. Knecht S, Sacher F, Forclaz A, et al. Is there a potential benefit to increased irri- 929
Spanish State Research Agency (BCAM Severo Ochoa Excellence gation channels during radiofrequency ablation? Results from a two-center pro-
862 930
Accreditation SEV-2017-0718). Drs Gerardo-Giorda, Petras, and Leoni are spective randomized study. J Cardiovasc Electrophysiol 2011;22:516–520.
863 931
partially supported by the State of Upper Austria. 17. Iles TL, Quallich SG, Iaizzo PA. Identification of radiofrequency ablation cath-
864 eter parameters that may induce intracardiac steam pops: direct visualization of 932
865 Disclosures: Dr Guerra has served as a consultant for Biosense Webster, elicitation in reanimated swine hearts. J Cardiovasc Transl Res 2019; 933
866 Boston Scientific, and Abbott; received speaker fees from Boston 12:250–256. 934
867 Scientific and Abbott; and received research grants from Abbott, 18. Moreno J, Quintanilla JG, Molina-Morua R, et al. Morphological and thermody- 935
868 namic comparison of the lesions created by 4 open-irrigated catheters in 2 exper- 936
Q7 Medtronic, and Biosense Webster. All other authors have no conflicts to
869 disclose.
imental models: thermodynamic evaluation of 4 open-irrigated catheters. J 937
870 Cardiovasc Electrophysiol 2014;25:1391–1399. 938
19. Mehta N, Morgaenko K, Sauer W, Stevenson W, Haines D. Impact of variable
871 Authorship: All authors attest they meet the current ICMJE criteria for 939
orientation and flow rates on radiofrequency ablation lesions created by externally
872 authorship. 940
irrigated catheters: an ex-vivo study. J Atr Fibrillation 2020;13:2353.
873 20. Larsen T, Du-Fay-de-Lavallaz JM, Winterfield J, et al. Comparison of ablation 941
Ethics Statement: No patient data or animals were used in this study. The
874 index versus time-guided radiofrequency energy dosing using normal and half- 942
computer model was validated in a previous study by the authors.
875 normal saline irrigation in a porcine left ventricular model. J Cardiovasc Electro- 943
876 physiol 2022;33:698–712. 944
877 Appendix 21. Theis C, Rostock T, Mollnau H, et al. The incidence of audible steam pops is 945
878 increased and unpredictable with the thermocoolÒ surround flow catheter dur- 946
879
Supplementary data ing left atrial catheter ablation: a prospective observational study: audible steam 947
880 Supplementary data associated with this article can be found pops during left atrial catheter ablation. J Cardiovasc Electrophysiol 2015;
948
26:956–962.
881 in the online version at 10.1016/j.hroo.2022.07.014. 949
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