Ablation Procedures Research Articles

Mortality and postinterventional complications after ablative treatment of liver malignancies: A cohort study of 4374 patients

PurposeAblative therapies for primary and secondary liver malignancies are increasingly adopted in current guidelines. Nevertheless, surgical resection remains the gold standard in most curative therapy settings.Extensive studies on mortality and morbidity after ablative treatment of the liver are missing. We investigated complications and mortality after ablative treatment in a large, unselected study cohort. Materials and MethodsStandardized patient and treatment data in 4374 percutaneous and angiographic ablative procedures of the liver from the DRG-based hospital reimbursement system (diagnosis-related groups) of an academic hospital in Germany were retrospectively evaluated. We analyzed descriptive patient data, length of stay (LOS), pre-existing medical conditions, previous gastrointestinal surgeries, severe complications, and occurrence of death. ResultsTreatment of secondary liver malignancies constituted over two-thirds of all procedures (71%, n = 3053). The mean LOS was 4.1 ± 3.5 days. Severe complications were documented in 1.4% and in-house death in 0.2% of cases, significantly more often after treatment with chemoembolization of primary liver malignancies (p = 0.003; p = 0.000).Previous partial liver resection, partial bowel resection, and chronic renal failure were independent risk factors for the occurrence of severe complications. ConclusionSevere complications and in-hospital death are rare in the treatment of primary and secondary liver malignancies with percutaneous and angiographic procedures.They are a viable alternative or addition to a surgical approach in treating liver lesions.

The anticoagulation one year after ablation of atrial fibrillation in patients with atrial fibrillation (ALONE-AF) trial: Study protocol

BackgroundThe ideal long-term antithrombotic strategy for patients after successful catheter-based atrial fibrillation (AF) ablation is still uncertain. Presently, practices vary, and the advantages of oral anticoagulation (OAC) for the post-ablation population are not clearly established. To date, no randomized trials have addressed this therapeutic question. This study aimed to evaluate whether no OAC therapy is superior to apixaban in reducing the risk of stroke, systemic embolism, or major bleeding among patients without apparent recurrent atrial arrhythmias for at least 1 year after their AF ablation procedure. MethodsThe ALONE-AF trial is a prospective, multicenter, open-label, randomized study with blinded outcome assessment. Patients with AF who have at least one non-gender stroke risk factor (as determined by the CHA2DS2-VASc score) and no documented recurrences of atrial arrhythmia for at least 12 months post-ablation will be randomly assigned to apixaban 5 mg b.i.d. or no OAC therapy. The primary endpoint is a composite outcome of stroke, systemic embolism, and major bleeding. Key secondary outcomes include clinically relevant non-major bleeding, all-cause mortality, myocardial infarction, transient ischemic attack, quality of life, and frailty analysis. Participants will be followed for a period of 2 years. The estimated total sample size is 840 subjects, with 420 subjects in each arm. ConclusionThe ALONE-AF trial aims to provide robust evidence for the optimal anticoagulation strategy for patients with stroke risk factors following successful AF ablation.

The role of MRgFUS in the treatment of neuropsychiatric disorders: a state of the art.

Magnetic resonance-guided focused ultrasound (MRgFUS) is a contemporary non-invasive ablative procedure that utilizes high- or low-intensity ultrasound, guided and monitored by magnetic resonance imaging (MRI). While MRgFUS has been established as an effective treatment for conditions like essential tremor and tremor-dominant Parkinson's disease, it has recently emerged as a safe and promising ablative minimally invasive procedure for the management of treatment-resistant psychiatric disorders. Indeed, despite the availability of various pharmacological and behavioral therapies, a subset of psychiatric patients remains refractory to conventional treatments. To assess the feasibility and safety of MRgFUS in psychiatric disorders, a comprehensive literature search in PubMed and Scopus databases was conducted, resulting in the inclusion of five relevant articles in this review. While data on this innovative procedure are still limited, MRgFUS demonstrates potential as a safer and less invasive surgical technique for treating these disorders. Continued research efforts and data validation are imperative to establish MRgFUS as an additional, minimally invasive procedure for treatment-resistant psychiatric patients in the near future.

Cardiac-gated spectroscopic photoacoustic imaging for ablation-induced necrotic lesion visualization.

Radiofrequency (RF) ablation is a minimally invasive therapy for atrial fibrillation. Conventional RF procedures lack intraoperative monitoring of ablation-induced necrosis, complicating assessment of completeness. While spectroscopic photoacoustic (sPA) imaging shows promise in distinguishing ablated tissue, multi-spectral imaging is challenging in vivo due to low imaging quality caused by motion. Here, we introduce a cardiac-gated sPA imaging (CG-sPA) framework to enhance image quality using a motion-gated averaging filter, relying on image similarity. Necrotic extent was calculated based on the ratio between spectral unmixed ablated tissue contrast and total tissue contrast, visualizing as a continuous color map to highlight necrotic area. The validation of the concept was conducted in both ex vivo and in vivo swine models. The ablation-induced necrotic lesion was successfully detected throughout the cardiac cycle through CG-sPA imaging. The results suggest the CG-sPA imaging framework has great potential to be incorporated into clinical workflow to guide ablation procedures intraoperatively.

Selective complex fractionated atrial electrogram ablation based on the number-of-fractionation for persistent atrial fibrillation refractory to pulmonary vein isolation.

Previous studies have suggested that the prolonged or highly fractionated electrograms during atrial fibrillation (AF) are closely related to the reentrant driver regions. We hypothesized that exploration and ablation of these critical complex atrial fractionated electrograms (CFAE) may improve the outcome of persistent AF (PeAF) refractory to conventional PVI. A total of 73 PeAF patients with residual inducibility or failed cardioversions of AF after PVI were enrolled and underwent number-of-fractionation mapping (NFM) by counting the number of fractionations in 2.5s at each of the points using the CARTO3 (ICL mode) and EnSite (fractionation map) systems. After NFM, selective CFAE ablation (NFM-CA) targeting the sites of the upper 40% of the counted fraction number (NF40) was performed as an additional procedure for refractory PeAF. We investigated the prognosis of these patients within 24months after the index ablation procedure and the relationship between changes in activation patterns during the ablation procedure and their prognosis. We also performed a propensity score-matched analysis comparing these patients with historical controls (HC) to identify the optimal indications for NFM-CA. The AF/AT free survival rate was 79.1% at 12months and 56.7% at 24months. Patients with AF termination or AF cycle length prolongation > 21ms during the procedure had significantly better AF/AT-free survival rates than those without notable activation changes (87.7% vs. 69.0%, logrank p = 0.028). After propensity-matched analysis, AF/AT-free survival showed comparable results between the two groups (1year; NFM 72.1% vs. HC 77.1%, logrank p = 0.649). NFM-CA is a versatile and less invasive adjunctive procedure for patients with PVI-refractory PeAF who showed a comparable prognosis to patients with PVI-compliant PeAF. In particular, remarkable activation changes during the procedure (AFCL prolongation > 21ms or acute termination) suggest a favorable prognosis.

An artificial intelligence-enabled electrocardiogram algorithm for the prediction of left atrial low-voltage areas in persistent atrial fibrillation.

We aimed to construct an artificial intelligence-enabled electrocardiogram (ECG) algorithm that can accurately predict the presence of left atrial low-voltage areas (LVAs) in patients with persistent atrial fibrillation. The study included 587 patients with persistent atrial fibrillation who underwent catheter ablation procedures between March 2012 and December 2023 and 942 scanned images of 12-lead ECGs obtained before the ablation procedures were performed. Artificial intelligence-based algorithms were used to construct models for predicting the presence of LVAs. The DR-FLASH and APPLE clinical scores for LVA prediction were calculated. We used a receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis to evaluate model performance. The data obtained from the participants were split into training (n = 469), validation (n = 58), and test sets (n = 60). LVAs were detected in 53.7% of all participants. Using ECG alone, the deep learning algorithm achieved an area under the ROC curve (AUROC) of 0.752, outperforming both the DR-FLASH score (AUROC = 0.610) and the APPLE score (AUROC = 0.510). The random forest classification model, which integrated a probabilistic deep learning model and clinical features, showed a maximum AUROC of 0.759. Moreover, the ECG-based deep learning algorithm for predicting extensive LVAs achieved an AUROC of 0.775, with a sensitivity of 0.816 and a specificity of 0.896. The random forest classification model for predicting extensive LVAs achieved an AUROC of 0.897, with a sensitivity of 0.862, and a specificity of 0.935. The deep learning model based exclusively on ECG data and the machine learning model that combined a probabilistic deep learning model and clinical features both predicted the presence of LVAs with a higher degree of accuracy than the DR-FLASH and the APPLE risk scores.

Management of complications associated with percutaneous left atrial appendage closure with or without ablation: experience from 512 cases over a 4-year period.

Percutaneous left atrial appendage closure (LAAC) serves as an alternative prophylactic strategy for patients with non-valvular atrial fibrillation (AF) who cannot undergo anti-coagulation therapy. Proper management of associated complications is crucial to enhancing the procedure's success rate and mitigating perioperative risks and adverse events during follow-up. This study aims to summarize our center's experience and strategies in managing procedural-related complications encountered in 512 cases of LAAC with or without ablation for AF conducted from January 2020 to December 2023. We identified 11 significant intervention-requiring complications associated with LAAC with or without Ablation procedure. These included three cases of intraoperative thrombosis, three instances of pericardial effusion or tamponade, one case of device-related thrombosis, one peri-device leak, one systemic embolism, one bleeding episode, and one additional device-related complication. The categorization of intraoperative thrombosis was as follows: one patient exhibited heparin resistance; one experienced thrombosis due to prolonged device implantation during the LAAC with ablation procedure; and one had unexplained intraoperative thrombosis. The pericardial effusion or tamponade likely resulted from damage to the atrial appendage during LAAC device insertion. Two patients encountered device-related thrombosis and systemic embolism events possibly caused by non-standard postoperative antithrombotic medication use; one patient's peri-device leak may have resulted from incomplete endothelialization of the occluder post-surgery; one patient experienced postoperative bladder bleeding; and one patient's device-related complications occurred due to a dislodged strut frame that damaged the left atrial appendage, leading to pericardial effusion. Our proactive interventions enabled all patients with these surgical-related complications to be safely discharged, with subsequent follow-ups showing no adverse events. Implementing targeted interventions for immediate procedural-related complications during the LAAC with or without ablation procedures enhances procedural success rates, diminishes postoperative mortality and patient disability, and bolsters stroke prevention efforts. This approach underscores the importance of a strategic response to complications, affirming the procedure's viability and safety in managing non-valvular AF in patients contraindicated for anticoagulation.

A nationwide neurosurgical inter-disciplinary service for cancer-related refractory pain

PurposeNeurosurgical ablative procedures, such as cordotomy and cingulotomy, are often considered irreversible and destructive but can provide an effective and individualized solution for cancer-related refractory pain, when all other approaches have been unsuccessful. This paper provides an in-depth exploration of a novel approach to managing refractory cancer pain. It involves an interdisciplinary team led by a neurosurgeon at a renowned national referral center.Methodsa retrospective analysis of the medical records of all sequential patients who underwent their initial evaluation at our interdisciplinary refractory cancer pain clinic from February 2017 to January 2023.ResultsA total of 207 patients were examined in the clinic for a first visit during the study period. All patients were referred to the clinic due to severe pain that was deemed refractory by the referring physician. The mean age was 61 ± 12.3 years, with no significant sex difference (P = 0.58). The mean ECOG Performance Status score was 2.35. Conservative measures had not yet been exhausted in 28 patients (14%) and 9 patients were well controlled (4%). Neurosurgical ablative procedures were recommended for 151 (73%) of the patients. Sixty-six patients (32%) eventually underwent the procedure. 91 patients (44%) received a negative recommendation for surgery. Thirty-five patients (17%) were referred for further invasive procedures at the pain clinic.ConclusionAn Interdisciplinary cooperation between palliative care specialists, pain specialists, and neurosurgeons ensures optimal patient selection and provides safe and effective neurosurgery for the treatment of refractory cancer-related pain.

Surgical Profile of Osteosarcoma Patients in a Tertiary Referral Hospital in Surabaya, Indonesia

Osteosarcoma is a rare malignant bone disease with unclear etiology. It is primarily a disease of childhood with rapid bone growth in periods of rapid bone proliferation [such as in puberty]. Before the 1970s, prognosis for this malignancy is very grim with the only available form of treatment are limb ablation [amputation]. The advent of modern chemotherapy, in addition to the development of modern limb salvage surgery [LSS] techniques, mortality has decreased and quality of life of surviors have increased. Indonesia is a developing country with unequal distribution of adequate health facilities. Studies have shown that unlike western countries, most osteosarcoma patients in Indonesia are still treated with limb ablation procedures. A retrospective descriptive study is done on Dr. Soetomo General Hospital to discover the surgical profile of patients undergoing chemotherapy during the period of 2014-2020. Results have shown that the majority [26] underwent amputation, 17 underwent no surgical treatment, and the rest [9] LSS. The results of this research shows that the clinical reality of developing nations like Indonesia is still far from the ideal clinical situation in developed western nations where these studies originate.

Past, present, and future perspectives of ultrasound-guided ablation of liver tumors: Where could artificial intelligence lead interventional oncology?

The first ablation procedures for small hepatocellular carcinomas were percutaneous ethanol injection under ultrasound (US) guidance. Later, radiofrequency ablation was shown to achieve larger coagulation areas than percutaneous ethanol injection and became the most used ablation technique worldwide. In the past decade, microwave ablation systems have achieved larger ablation areas than radiofrequency ablation, suggesting that the 3-cm barrier could be broken in the treatment of liver tumors. Likewise, US techniques to guide percutaneous ablation have seen important progress. Contrast-enhanced US (CEUS) can define and target the tumor better than US and can assess the size of the ablation area after the procedure, which allows immediate retreatment of the residual tumor foci. Furthermore, fusion imaging fuses real-time US images with computed tomography or magnetic resonance imaging with significant improvements in detecting and targeting lesions with low conspicuity on CEUS. Recently, software powered by artificial intelligence has been developed to allow three-dimensional segmentation and reconstruction of the anatomical structures, aiding in procedure planning, assessing ablation completeness, and targeting the residual viable foci with greater precision than CEUS. Hopefully, this could lead to the ablation of tumors up to 5-7 cm in size.

Nutritional Risk Screening 2002 score is a predictor of prolonged hospitalizations after cardiac ablation procedures

Abstract Background Nutritional risk is a recognized factor of mortality, complications, and length of stay at a hospital in various medical conditions. This relationship was already proven in surgery, oncology, and selected cardiovascular diseases. Purpose This study aimed to analyze, if the Nutritional Risk Screening 2002 (NRS 2002) score is a predictor of the hospitalization length and in-hospital convalescence period defined as the time from the procedure to discharge among patients undergoing cardiac ablations. Methods 265 patients who underwent cardiac ablation in 2023 were included in this retrospective study. The analyzed parameters included the overall length of stay and the time of the in-hospital convalescence after the ablation procedure. They were combined with the nutritional risk assessed with NRS 2002, body mass, and body mass index. The analysis was also performed in subgroups regarding the type of arrhythmia. Results The regression analysis revealed a significant impact of the NRS 2002 score on the overall length of stay (B=0.89, p=0.003) and the in-hospital convalescence time (B=0.57, p=0.02). Subgroup analysis revealed that this relationship was particularly strong in the atrial fibrillation patients (B=1.10, p=0.001 and (B=0.91, p=0.002 respectively), and in atrial arrhythmias for the overall length of stay (B=0.92, p=0.001), and ventricular arrhythmias for the convalescence time (B=0.76, p=0.002). Lower body mass index impacted the prolonged convalescence time (B= -0.05, p=0.03), mainly in the atrial fibrillation subgroup (B= -0.08, p=0.04) and atrial arrhythmias (B= -0.05, p=0.04). Conclusions Nutritional risk is a factor that impacts the length of stay and in-hospital convalescence in patients undergoing cardiac ablations, particularly in atrial fibrillation patients.

Novel Domain Knowledge-Encoding Algorithm Enables Label-Efficient Deep Learning for Cardiac CT Segmentation to Guide Atrial Fibrillation Treatment in a Pilot Dataset.

Background: Segmenting computed tomography (CT) is crucial in various clinical applications, such as tailoring personalized cardiac ablation for managing cardiac arrhythmias. Automating segmentation through machine learning (ML) is hindered by the necessity for large, labeled training data, which can be challenging to obtain. This article proposes a novel approach for automated, robust labeling using domain knowledge to achieve high-performance segmentation by ML from a small training set. The approach, the domain knowledge-encoding (DOKEN) algorithm, reduces the reliance on large training datasets by encoding cardiac geometry while automatically labeling the training set. The method was validated in a hold-out dataset of CT results from an atrial fibrillation (AF) ablation study. Methods: The DOKEN algorithm parses left atrial (LA) structures, extracts "anatomical knowledge" by leveraging digital LA models (available publicly), and then applies this knowledge to achieve high ML segmentation performance with a small number of training samples. The DOKEN-labeled training set was used to train a nnU-Net deep neural network (DNN) model for segmenting cardiac CT in N = 20 patients. Subsequently, the method was tested in a hold-out set with N = 100 patients (five times larger than training set) who underwent AF ablation. Results: The DOKEN algorithm integrated with the nn-Unet model achieved high segmentation performance with few training samples, with a training to test ratio of 1:5. The Dice score of the DOKEN-enhanced model was 96.7% (IQR: 95.3% to 97.7%), with a median error in surface distance of boundaries of 1.51 mm (IQR: 0.72 to 3.12) and a mean centroid-boundary distance of 1.16 mm (95% CI: -4.57 to 6.89), similar to expert results (r = 0.99; p < 0.001). In digital hearts, the novel DOKEN approach segmented the LA structures with a mean difference for the centroid-boundary distances of -0.27 mm (95% CI: -3.87 to 3.33; r = 0.99; p < 0.0001). Conclusions: The proposed novel domain knowledge-encoding algorithm was able to perform the segmentation of six substructures of the LA, reducing the need for large training data sets. The combination of domain knowledge encoding and a machine learning approach could reduce the dependence of ML on large training datasets and could potentially be applied to AF ablation procedures and extended in the future to other imaging, 3D printing, and data science applications.

A danish healthcare-focused economic evaluation of first-line cryoballoon ablation versus antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation

IntroductionThree randomised controlled trials (RCTs) have demonstrated that first-line cryoballoon pulmonary vein isolation decreases atrial tachycardia in patients with symptomatic paroxysmal atrial fibrillation (PAF) compared with antiarrhythmic drugs (AADs). The aim of this study was to develop a cost-effectiveness model (CEM) for first-line cryoablation compared with first-line AADs for the treatment of PAF. The model used a Danish healthcare perspective.MethodsIndividual patient-level data from the Cryo-FIRST, STOP AF and EARLY-AF RCTs were used to parameterise the CEM. The model structure consisted of a hybrid decision tree (one-year time horizon) and a Markov model (40-year time horizon, with a three-month cycle length). Health-related quality of life was expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3% per year. Model outcomes were produced using probabilistic sensitivity analysis.ResultsFirst-line cryoablation is dominant, meaning it results in lower costs (-€2,663) and more QALYs (0.18) when compared to first-line AADs. First-line cryoablation also has a 99.96% probability of being cost-effective, at a cost-effectiveness threshold of €23,200 per QALY gained. Regardless of initial treatment, patients were expected to receive ∼ 1.2 ablation procedures over a lifetime horizon.ConclusionFirst-line cryoablation is both more effective and less costly (i.e. dominant), when compared with AADs for patients with symptomatic PAF in a Danish healthcare system.

Feasibility of targeting the cingulate gyrus using high-intensity focused ultrasound on a cadaveric specimen: illustrative case.

Cancer is commonly associated with pain. For patients with advanced cancer and intractable pain, ablative neurosurgical procedures can significantly improve pain and transition patients out of inpatient settings. These procedures are normally invasive, and this poses an important risk in this population. Cingulotomy has been reported to improve pain perception and contribute substantially to the quality of life of cancer patients with refractory pain. One fresh human cadaver specimen was used for the setup. The cingulate gyrus was targeted using intraoperative magnetic resonance images, and osseous aberrations were corrected after coregistration with the preoperative head computed tomography. After accounting for sinuses, membrane folds, and calcifications, a total of 737 elements were available for thermal ultrasound ablation. On high-power sonications, the total energy delivered reached a peak temperature of 57°C (15,050 J, 350 W, 45 seconds) in the right cingulate and 52°C (13,000 J, 405 W, 46 seconds) in the left cingulate. Despite the limitations of using a cadaver model (temperature, vascularization), cingulotomy appears to be feasible using high-intensity focused ultrasound. https://thejns.org/doi/10.3171/CASE2459.

Initial experience with zero-fluoroscopy pulmonary vein isolation in patients with atrial fibrillation: single-center observational trial

Pulmonary vein isolation (PVI) stands as a widely practiced cardiac ablation procedure on a global scale, conventionally guided by fluoroscopy. The concurrent application of electroanatomical mapping systems (EAMS) and intracardiac echocardiography offers a means to curtail radiation exposure. This study aimed to compare procedural outcomes between conventional and our initial zero-fluoroscopy cases in patients with paroxysmal or persistent atrial fibrillation (AF), undergoing point-by-point PVI. Our prospective observational study included 100 consecutive patients with AF who underwent point-by-point radiofrequency PVI. The standard technique was used in the first 50 cases (Standard group), while the fluoroless technique was used in the subsequent 50 patients (Zero group). The zero-fluoroscopy approach exhibited significantly shorter procedural time (59.6 ± 10.7 min vs. 74.6 ± 13.2 min, p < 0.0001), attributed to a reduced access time (17 [16; 20] min vs. 31 [23; 34.5] min, p < 0.001). Comparable results were found for the number of RF applications, total ablation energy, and left atrial dwelling time. In the Zero group, all procedures were achieved without fluoroscopy, resulting in significantly lower fluoroscopy time (0 [0; 0] sec vs. 132 [100; 160] sec, p < 0.0001) and dose (0 [0; 0] mGy vs. 4.8 [4.1; 8.2] mGy, p < 0.0001). The acute success rate was 100%, with no major complications. Zero-fluoroscopy PVI is feasible, safe, and associated with shorter procedure times compared to the standard approach, even in cases without prior experience in zero-fluoroscopy PVI.

Safety and feasibility of pulmonary vein isolation utilizing pulsed field ablation in patients with symptomatic atrial fibrillation and implanted Watchman devices.

Pulsed field ablation (PFA) is a novel method of non-thermal cardiac ablation for atrial fibrillation (AF). Its use on patients with pre-existing Watchman devices has not been studied. Pulmonary vein isolation (PVI) utilizing PFA was performed in 7 patients with symptomatic AF and implanted Watchman devices. All cases were conducted at a single academic center. Successful PVI in patients with Watchman devices implanted at a median time of 534days prior to the index ablation procedure (IQR 365days) was achieved in all cases. No major adverse events (intraprocedural CVA, post-procedural CVA, major or minor bleeding events, device embolization, or cardiac tamponade) were observed. In 6 of 7 patients, a low-dose direct oral anticoagulant (DOAC) strategy was implemented post-PFA. We present the first reported case series of PFA in patients with AF and implanted Watchman devices. This study highlights the safety and feasibility of the FARAPULSE PFA system in this patient population.

Ablation apprentices and their first experience of pulmonary vein isolation procedure on paroxysmal atrial fibrillation with different sheaths

ObjectivesThis study aimed at exploring how using different kinds of sheaths will affect the very first ablation procedure of apprentices.Methods15 patients with paroxysmal atrial fibrillation were randomized to used fixed-curve, conventional steerable or visualized steerable sheath, and received complete isolation of pulmonary veins. All ablations were the very first procedure performed by 15 ablation apprentices. The use of fluoroscopy and catheter stability during the PVI were analyzed.ResultsProcedure duration was much longer in the fixed-curve group (116.8 ± 27 vs. 62.2 ± 17 vs. 60.4 ± 17, p < 0.001). X-ray exposure was lowest with visualized sheath (17.6 ± 5 vs. 18.6 ± 6 vs. 5.2 ± 6, p < 0.001). CF SD differed significantly, especially at the anterior aspect of LSPV (7.90 ± 2.90 vs. 5.04 ± 2.18 vs. 4.52 ± 2.40, p < 0.001) and posterior aspect of RSPV (6.84 ± 2.79 vs. 3.42 ± 2.04 vs. 3.50 ± 2.30, p < 0.001) in the fixed-curve group. Impedance drop was significantly smaller in the fixed-curve group at the anterior aspect of LSPV (8.74 ± 3.02 vs. 11.49 ± 5.48 vs. 12.57 ± 5.96, p = 0.005).ConclusionEven for the very first ablation procedure of an ablation apprentice, the use of steerable sheaths will significantly reduce the procedure duration and improve the catheter stability, but only visualized steerable sheath can reduce fluoroscopic time.

Septal late enhancement by cardiac CT is associated with repeat ablation in nonischemic cardiomyopathy patients.

Scar substrate in nonischemic cardiomyopathy (NICM) patients is often difficult to identify. Advances in cardiac imaging, especially using late iodine-enhanced computed tomography (LIE-CT), allow better characterization of scars giving rise to ventricular tachycardia (VT). Currently, there are limited data on clinical correlates of CT-derived scar substrates in NICM. We sought assess the relationship between scar location on LIE-CT and outcomes after radiofrequency catheter ablation (RFCA) in NICM patients with VT. From 2020 to 2022, consecutive patients with NICM undergoing VT RFCA with integration of cardiac CT scar modeling (inHeart, Pessac, France) were included at two US tertiary care centers. The CT protocol included both arterial-enhanced imaging for anatomical modeling and LIE-CT for scar assessment. The distribution of substrate on CT was analyzed in relation to patient outcomes, with primary endpoints being VT recurrence and the need for repeat ablation procedure. Sixty patients were included (age 64 ± 12 years, 90% men). Over a median follow-up of 120 days (interquartile range [IQR]: 41-365), repeat ablation procedures were required in 32 (53%). VT recurrence occurred in 46 (77%), with a median time to recurrence of 40 days (IQR: 8-65). CT-derived total scar volume positively correlated with intrinsic QRS duration (r = .34, p = 0.008). Septal scar was found on CT in 34 (57%), and lateral scar in 40 (7%). On univariate logistic regression, septal scar was associated with increased odds of repeat ablation (odds ratio [OR]: 2.9 [1.0-8.4]; p = 0.046), while lateral scar was not (OR: 0.9 [0.3-2.7]; p = 0.855). Septal scar better predicted VT recurrence when compared to lateral scar, but neither were statistically significant (septal scar OR: 3.0 [0.9-10.7]; p = 0.078; lateral scar OR: 1.7 [0.5-5.9]; p = 0.391). In this tertiary care referral population, patients with NICM undergoing VT catheter ablation with septal LIE-CT have nearly threefold increased risk of need for repeat ablation.

Influence of cryoablation versus operation on circulating lymphocyte subsets in patients with early-stage renal cell carcinoma

Immune response is known to play an important role in local tumor control especially in renal cell carcinoma (RCC), which is considered highly immunogenic. For localized tumors, operative resection or local ablative procedures such as cryoablation are common therapeutical options. For thermal ablative procedures such as cryoablation, additional immunological anti-tumor effects have been described.The purpose of this prospective study was to determine changes in peripheral blood circulating lymphocytes and various of their subsets in RCC patients treated with cryoablation or surgery in a longitudinal approach using extensive flow cytometry. Additionally, lymphocytes of RCC patients were compared to a healthy control group.We included 25 patients with RCC. Eight underwent cryoablation and 17 underwent surgery. Univariate and multivariable analysis revealed significantly lower values of B cells, CD4 and CD8 T cells, and various of their subsets in the treatment groups versus the healthy control group. Comparing the two different therapeutical approaches, a significant decline of various lymphocyte subsets with a consecutive normalization after three months was seen for the surgery group, whereas cryoablation led to increased values of CD69 + CD4 + and CD69 + CD8 + cell counts as well as memory CD8 + cells after three months.Treatment-naïve RCC patients showed lower peripheral blood lymphocyte counts compared to healthy controls. The post-treatment course revealed different developments of lymphocytes in the surgery versus cryoablation group, and only cryoablation seems to induce a sustained immunological response after three months.

Adjunctive left atrial posterior wall isolation for atrial fibrillation: An updated systematic review and meta-analysis.

Posterior left atrial wall isolation (PWI) plus traditional pulmonary vein isolation (PVI) has been proposed as a promising intervention to decrease atrial fibrillation (AF) recurrence. We aim to investigate the efficacy and safety of adding PWI to the traditional PVI in patients with AF. A systematic review and meta-analysis was conducted using synthesizing randomized controlled trials (RCTs) retrieved by systematically searching PubMed, Web of Science, SCOPUS, EMBASE, and Cochrane through June 14, 2023. We used Stata version 17 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI) (PROSPERO ID: CRD42023446227). We included 11 RCTs with a total number of 1534 patients. Combined ablation with PWI + PVI was not associated with any significant difference over PVI only regarding the recurrence of clinical AF (RR: 0.86 with 95% CI [0.70-1.06]), all atrial arrhythmia (RR: 0.93 with 95% CI [0.82-1.07]), nonatrial fibrillation arrhythmia (RR: 1.22 with 95% CI [0.97-1.53]), early AF (RR: 0.89 with 95% CI [0.62-1.27]), and antiarrhythmic drugs at discharge (RR: 0.83 with 95% CI [0.67-1.04]). However, it was associated with increased total ablation duration (minutes) (MD: 12.58 with 95% CI [6.80-18.37]) and total procedure duration (minutes) (MD: 16.77 with 95% CI [9.63-23.91]), without any significant difference regarding adverse events (RR: 1.05 with 95% CI [0.63-1.74]). While the pooled data from PWI + PVI using point-by-point radiofrequency did not suggest a benefit in the recurrence of various atrial arrhythmias compared to PVI alone, PWI+PVI using direct posterior wall ablation, especially with cryoballoon, demonstrated a significant reduction in recurrence of AF/atrial arrhythmias. Also, PWI + PVI significantly increased the ablation and total procedure durations.