Catheter-based Approach Research Articles

Characterisation and distribution of human coronary artery innervation.

A detailed understanding of the sympathetic innervation of coronary arteries is relevant to facilitate the development of novel treatment approaches. This study aimed to quantitatively examine periarterial innervation in human epicardial coronary arteries. Coronary arteries with adjacent epicardial adipose tissue were excised along the left main coronary artery (LMCA), left anterior descending artery (LAD), left circumflex artery (LCx), and right coronary artery (RCA) from 28 body donors and examined histologically. Immunofluorescence staining was performed to characterise sympathetic nerve fibres. A total of 42,573 nerve fibres surrounding 100 coronary arteries (LMCA: n=21, LAD: n=27, LCx: n=26, RCA: n=26) were analysed. The nerve fibre diameter decreased along the vessel course (median [interquartile range]): (proximal 46 μm [31-73], middle 38 μm [26-58], distal 31 μm [22-46]; p<0.001), with the largest nerve fibre diameter along the LMCA (50 μm [31-81]), followed by the LAD (42 μm [27-72]; p<0.001). The total nerve fibre density was highest along the RCA (123 nerves/cm² [82-194]). Circumferentially, nerve density was higher in the myocardial tissue area of the coronary arteries (132 nerves/cm² [76-225]) than in the epicardial tissue area (101 nerves/cm² [61-173]; p<0.001). The median lumen-nerve distance was smallest around the LMCA (2.2 mm [1.2-4.1]), followed by the LAD (2.5 mm [1.1-4.5]; p=0.005). Human coronary arteries are highly innervated with sympathetic nerve fibres, with significant variation in the distribution and density. Understanding these patterns informs pathophysiological understanding and, potentially, the development of catheter-based approaches for cardiac autonomic modulation.

Percutaneous Closure of Fistulous Tract from Right Coronary Artery to Right Atrium: A Case Report

The coronary artery fistula is a rare form of left to right shunt that can lead to significant hemodynamic consequences if left untreated. The patient, a 10-year-old female, presented with symptoms of increasing dyspnea and palpitations over the past year. Diagnostic imaging, including transthoracic echocardiography and cardiac computed axial tomography, confirmed the presence of a fistulous connection between the right coronary artery and the right atrium. Given the patient’s symptomatic presentation and the risk of complications, a decision was made to proceed with percutaneous closure. Using a catheter-based approach, the fistula was successfully occluded with a Amplatzer Vascular Plug II (AVP II), resulting in the resolution of symptoms and normalization of hemodynamic parameters. This case highlights the efficacy and safety of percutaneous intervention in managing coronary artery fistulas, particularly in pediatric patients, and underscores the importance of early diagnosis and treatment to prevent long-term sequelae.

Focused Ultrasound: Noninvasive Image-Guided Therapy.

Invasive open surgery used to be compulsory to access tumor mass to perform excision or resection. Development of minimally invasive laparoscopic procedures followed, as well as catheter-based approaches, such as stenting, endovascular surgery, chemoembolization, brachytherapy, which minimize side effects and reduce the risks to patients. Completely noninvasive procedures bring further benefits in terms of reducing risk, procedure time, recovery time, potential of infection, or other side effects. Focusing ultrasound waves from the outside of the body specifically at the disease site has proven to be a safe noninvasive approach to localized ablative hyperthermia, mechanical ablation, and targeted drug delivery. Focused ultrasound as a medical intervention was proposed decades ago, but it only became feasible to plan, guide, monitor, and control the treatment procedures with advanced radiological imaging capabilities. The purpose of this review is to describe the imaging capabilities and approaches to perform these tasks, with the emphasis on magnetic resonance imaging and ultrasound. Some procedures already are in clinical practice, with more at the clinical trial stage. Imaging is fully integrated in the workflow and includes the following: (1) planning, with definition of the target regions and adjacent organs at risk; (2) real-time treatment monitoring via thermometry imaging, cavitation feedback, and motion control, to assure targeting and safety to adjacent normal tissues; and (3) evaluation of treatment efficacy, via assessment of ablation and physiological parameters, such as blood supply. This review also focuses on sonosensitive microparticles and nanoparticles, such as microbubbles injected in the bloodstream. They enable ultrasound energy deposition down to the microvascular level, induce vascular inflammation and shutdown, accelerate clot dissolution, and perform targeted drug delivery interventions, including focal gene delivery. Especially exciting is the ability to perform noninvasive drug delivery via opening of the blood-brain barrier at the desired areas within the brain. Overall, focused ultrasound under image guidance is rapidly developing, to become a choice noninvasive interventional radiology tool to treat disease and cure patients.

Fibrin Clot Degradation by Polyaniline-Coated AuNP Using Laser Photolysis

Fibrin clots are crucial for hemostasis and the healing of wounds; nevertheless, excessive blood clotting plays an important role in many chronic diseases, including cardiovascular disease. In this study, we demonstrated the effect of the prepared AuNPs@PANI core/shell on the formed fibrin network. The synthesis of nanoparticles combining electrically conducting polymers polyaniline (PANI) and gold nanoparticles (AuNPs) is an appealing field of research currently because of their physical features and prospective applications in biochemistry. AuNPs showed surface plasmonic resonance (SPR) properties in the visible region at 520 nm then, after coating with PANI, there was a dramatic red shift to 610 nm. The morphological conformation was confirmed by characterization at the microscopic (TEM, SEM, EDX). The PANI shell plays a crucial role in this system, first enhances the stability of AuNPs core; also, the surface of the PANI shell has positive charges (zeta potential = +17.8 mV), leading to electrostatic interactions with fibrin clots that have negatively charged surfaces. The synthesized core/shell AuNPs@PANI showed good efficiency for degrading fibrin networks under 1:30 h of irradiation by an external source of laser light, which is a result of AuNPs’ ability to absorb light at 520 nm. The degradation of fibrin was observed using a scanning electron microscope (SEM), which showed a clear change in the shape of the network. The appearance of fibrous endings and gaping indicates the beginning of the degradation and melting of the fibrin network in different sites of the clot. Overall, this method could have a major influence on disease states, for example, deep vein thrombosis, through a localized, catheter-based approach.

Mortality and resource utilization in surgical versus transcatheter repeat mitral valve replacement: A national analysis.

Transcatheter mitral valve replacement (TMVR) has garnered interest as a viable alternative to the traditional surgical mitral valve replacement (SMVR) for high-risk patients requiring redo operations. This study aims to evaluate the association of TMVR with selected clinical and financial outcomes. Adults undergoing isolated redo mitral valve replacement were identified in the 2016-2020 Nationwide Readmissions Database and categorized into TMVR or SMVR cohorts. Various regression models were developed to assess the association between TMVR and in-hospital mortality, as well as additional secondary outcomes. Transseptal and transapical catheter-based approaches were also compared in relation to study endpoints. Of an estimated 7,725 patients, 2,941 (38.1%) underwent TMVR. During the study period, the proportion of TMVR for redo operations increased from 17.8% to 46.7% (nptrend<0.001). Following adjustment, TMVR was associated with similar odds of in-hospital mortality (AOR 0.82, p = 0.48), but lower odds of stroke (AOR 0.44, p = 0.001), prolonged ventilation (AOR 0.43, p<0.001), acute kidney injury (AOR 0.61, p<0.001), and reoperation (AOR 0.29, p = 0.02). TMVR was additionally correlated with shorter postoperative length of stay (pLOS; β -0.98, p<0.001) and reduced costs (β -$10,100, p = 0.002). Additional analysis demonstrated that the transseptal approach had lower adjusted mortality (AOR 0.44, p = 0.02), shorter adjusted pLOS (β -0.43, p<0.001), but higher overall costs (β $5,200, p = 0.04), compared to transapical. In this retrospective cohort study, we noted TMVR to yield similar odds of in-hospital mortality as SMVR, but fewer complications and reduced healthcare expenditures. Moreover, transseptal approaches were associated with lower adjusted mortality, shorter pLOS, but higher cost, relative to the transapical. Our findings suggest that TMVR represent a cost-effective and safe treatment modality for patients requiring redo mitral valve procedures. Nevertheless, future studies examining long-term outcomes associated with SMVR and TMVR in redo mitral valve operations, are needed.

Revolutionizing Atrial Fibrillation Treatment: The Robotic Convergent Plus Procedure.

Atrial fibrillation (AF) is widely accepted to be the most common sustained arrhythmia, with an increasing incidence over time. This is thought to be due to the aging population across the world. AF occurs when abnormal electrical foci result in disorganization of atrial depolarization, though the exact pathophysiology leading to these abnormal foci is not well understood. A range of interventions exist for AF - pharmacological therapies (anti-arrhythmic or negative chronotropic medications), cardioversion, or ablations to interrupt the abnormal conduction pathways. Ablation may be via a catheter-based approach, via a surgical approach using the "Maze" procedure (Cox-Maze IV), or more recently, via a hybrid approach. This first involves a surgical epicardial ablation, with catheter-based endocardial ablation following a few weeks later to ensure durable transmural lesion sets via the "Convergent" procedure. We describe the use of the Da Vinci Xi™ robotic platform to improve the procedure, allowing continuous and improved visualization of the anatomy without the need for potentially harmful retraction of the atrial appendage or the back of the left atrium, as well as increased precision with our mapping tools and more complete ablation. Here, we highlight the advantages over a non-robotic (subxiphoid) Convergent procedure, while outlining the key operative steps in undertaking the "Robotic Convergent Plus" procedure using the Da Vinci Xi™ robotic surgical system.

Rescue From Permanent Kidney Injury in Acute Thrombosis of Both Renal Veins, the Inferior Vena Cava, and Both Iliofemoral Veins by Catheter-Based Thrombectomy.

A 33-year-old man with previously diagnosed lupus membranous nephropathy presented with painful swelling in both legs. Laboratory tests revealed acute kidney injury, and imaging studies by duplex ultrasound and computed tomography scan showed acute thrombosis of both renal veins, the infrahepatic inferior vena cava, and both iliofemoral venous segments. Initially, pharmacomechanical thrombolysis led to an insufficient morphological result. The therapeutic breakthrough was achieved by catheter-based mechanical thrombectomy of the infrarenal vena cava and both renal veins, which successfully cleared all affected venous segments from thrombus, paralleled by improvement of the patient's condition. However, after 1 week, the patient experienced recurrent thrombosis of the right renal vein with hemorrhagic infarction of the right kidney. After further optimization of immunomodulatory and antithrombotic therapy, a repeated catheter-based mechanical thrombectomy resulted in sustained clinical improvement and preservation of renal venous drainage and kidney function. Extensive acute thrombosis of both renal veins, the inferior vena cava, and both iliofemoral venous segments is a rare emergency potentially threatening kidney function. Immediate effective thrombus removal is essential to preserve kidney function and can be achieved by catheter-based mechanical thrombectomy embedded in a comprehensive immunomodulatory and antithrombotic therapeutic concept. This case demonstrated the efficacy of a catheter-based therapeutic approach in patients with extensive thrombosis of the venous system. A catheter-based approach must be embedded in a comprehensive medical therapeutic concept, which is essential to achieve a sustainable result.

Distribution of insulin in primate brain following nose-to-brain transport.

Nose-to-brain (N2B) insulin delivery has potential for Alzheimer's disease (AD) therapy. However, clinical implementation has been challenging without methods to follow N2B delivery non-invasively. Positron emission tomography (PET) was applied to measure F-18-labeled insulin ([18F]FB-insulin) from intranasal dosing to brain uptake in non-human primates following N2B delivery. [18F]FB-insulin was prepared by reacting A1,B29-di(tert-butyloxycarbonyl)insulin with [18F]-N-succinimidyl-4-fluorobenzoate. Three methods of N2B delivery for [18F]FB-insulin were compared - delivery as aerosol via tubing (rhesus macaque, n = 2), as aerosol via preplaced catheter (rhesus macaque, n = 3), and as solution via preplaced catheter (cynomolgus macaque, n = 3). Following dosing, dynamic PET imaging (120 min) quantified delivery efficiency to the nasal cavity and whole brain. Area under the time-activity curve was calculated for 46 regions of the cynomolgus macaque brain to determine regional [18F]FB-insulin levels. Liquid instillation of [18F]FB-insulin by catheter outperformed aerosol methods for delivery to the subject (39.89% injected dose vs 10.03% for aerosol via tubing, 0.17% for aerosol by catheter) and subsequently to brain (0.34% injected dose vs 0.00020% for aerosol via tubing, 0.05% for aerosol by catheter). [18F]FB-insulin was rapidly transferred across the cribriform plate to limbic and frontotemporal areas responsible for emotional and memory processing. [18F]FB-insulin half-life was longer in olfactory nerve projection sites with high insulin receptor density compared to the whole brain. The catheter-based liquid delivery approach combined with PET imaging successfully tracked the fate of N2B [18F]FB-insulin and is thought to be broadly applicable for assessments of other therapeutic agents. This method can be rapidly applied in humans to advance clinical evaluation of N2B insulin as an AD therapeutic. [18F]FB-insulin passage across the cribriform plate was detected by PET.Intranasal [18F]FB-insulin reached the brain within 13 min.[18F]FB-insulin activity was highest in emotional and memory processing regions.Aerosol delivery was less efficient than liquid instillation by preplaced catheter.Insulin delivery to the cribriform plate was critical for arrival in the brain.

Novel laparoscopic renal denervation immediately reduces atrial fibrillation inducibility: a swine model study

Catheter-based approaches may have inherent limitations in achieving effective renal denervation (RDN) and treatment of atrial fibrillation (AF). This study aimed to investigate the acute effects of novel laparoscopic RDN on modulating AF inducibility using a swine model. Four and five swine were randomly allocated to the sham and RDN groups, respectively. Each swine underwent measurement of the atrial effective refractory period (AERP) and AF induction tests using burst atrial pacing before and immediately after sham or RDN procedures with and without vagal nerve stimulation (VNS). A laparoscopic RDN procedure circumferentially ablated the renal nerves round the renal arteries using radiofrequency energy. There was no significant difference in the baseline AERP between the two groups (p > 0.05). Under VNS, AERP was significantly increased by 20 ms after laparoscopic RDN (95% CI = 0–30, p = 0.004). Compared to the sham group, the RDN group showed significantly reduced AF inducibility [OR (95% CI) = 0.32 (0.13–0.76) and 0.24 (0.11–0.57) with and without VNS, respectively]. After laparoscopic RDN, the duration of inducible AF episodes was significantly shortened from 28 (10–77) s to 7 (3–11) s (p < 0.001). The novel laparoscopic RDN can immediately reduce AF inducibility in a swine model.

Transcatheter Interventions for Neonates with Congenital Heart Disease: A Review.

Newborns with congenital heart disease often require interventions linked to high morbidity and mortality rates. In the last few decades, many transcatheter interventions have become the first-line treatments for some critical conditions in the neonatal period. A catheter-based approach provides several advantages in terms of procedural time, length of hospitalization, repeatability and neurodevelopmental issues (usually related to cardiopulmonary bypass). The main transcatheter procedures will be reviewed, as they are now valid alternatives to conventional surgical management.

RECLAIMING THE MANAGEMENT OF COMMON DUCT STONES IN ACUTE CARE SURGERY.

Acute care surgery (ACS) is well positioned to manage choledocholithiasis at the time of laparoscopic cholecystectomy, but barriers to laparoscopic common bile duct exploration (LCBDE) include experience and the perceived need for specialized equipment. The technical complexity of this pathway is generally seen as challenging. As such, LCBDE is historically relegated to the "enthusiast." However, a simplified, effective LCBDE technique as part of a "surgery first" strategy could drive wider adoption in the specialty most often managing these patients. To determine efficacy and safety, we sought to compare our initial ACS-driven experience with a simple, fluoroscopy-guided, catheter-based LCBDE approach during laparoscopic cholecystectomy (LC) to LC with endoscopic retrograde cholangiopancreatography (ERCP). We reviewed ACS patients who underwent LCBDE or LC + ERCP (pre-/postoperative) at a tertiary care center in the four years since starting this surgery first approach. Demographics, outcomes, and length of stay (LOS) were compared on an intention to treat basis. LCBDE was performed via using wire/catheter Seldinger techniques under fluoroscopic guidance with flushing or balloon dilation of the sphincter as needed. Our primary outcomes were LOS and successful duct clearance. 180 patients were treated for choledocholithiasis with 71 undergoing LCBDE. The success rate of catheter-based LCBDE was 70.4%. LOS was significantly reduced for the LCBDE group compared to the LC + ERCP group (48.8 vs 84.3 hrs, p < 0.01). Of note there were no intra- or postoperative complications in the LCBDE group. A simplified catheter-based approach to LCBDE is safe and associated with decreased LOS when compared to LC + ERCP. This simplified step-up approach may help facilitate wider LCBDE utilization by ACS providers who are well positioned for a timely surgery first approach in the management of uncomplicated choledocholithiasis. Level III, Therapeutic/Care Management.

Hybrid Epicardial Ventricular Ablation for Arrhythmogenic Right Ventricular Cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) causes progressive fibro-fatty infiltration of the right ventricle (RV) and is associated with ventricular arrhythmias (VA). The disease progresses from the subepicardium to subendocardium; thus. epicardial ablation improves outcome in patients with recurrent VA. When percutaneous epicardial ablation is unsuccessful, a surgical approach may be required. Limited data are available for minimally invasive hybrid surgical-catheter techniques. Case: A 28-year-old man with ARVC presented with recurrent VA refractory to medical therapy following COVID-19 infection and underwent endocardial ablation with attempted epicardial ablation. He had nine or more different inducible VA morphologies at this study. Epicardial access was unsuccessful due to adhesions. Minimally invasive surgical access for epicardial ablation was scheduled as a multidisciplinary procedure in the electrophysiology suite. A left thoracoscopic approach provided intrapericardial access. Surgical ports were used to facilitate catheter placement and mapping. Relevant clinical arrhythmias were targeted, and substrate modification was performed. The patient was discharged the following morning. No subjective symptoms or implanted-device defibrillation has been required post procedure. Combined surgical and catheter-based approaches for ARVC ablation are safe and feasible. Multidisciplinary team collaboration is key for case planning and success.

Minimally Invasive Hematoma Evacuation Using the MindsEye Expandable Tubular Retractor: A Technical Note

Recent advances in intraoperative neuronavigation and cranial access devices have facilitated an increasing interest in the use of minimally invasive techniques (minimally invasive surgery) to safely treat subcortical lesions via a parafascicular approach. Newly developed expandable retractors, such as the MindsEye system further optimize such approaches. In this technical report, we describe the nuances in minimally invasive surgery parenchymal hematoma evacuation using the MindsEye device. After placement of the device, the inner stylet and inner obturator are removed, and the expandable sheath is left in place and secured into place with a Greenberg refractor. The sheath easily dilates to the surgeonss preference with a dial, and the walls of the sheath are composed of a thin, clear, membrane to allow easy visualization of the lesion. We additionally retrospectively reviewed clinical characteristics and outcomes across three patients treated at our facility with spontaneous multicompartment intracranial hematoma using the MindsEye system. We provide a video case demonstrating the use of the MindsEye retractor in a transfrontal parenchymal hematoma evacuation. Successful evacuation with achieved in less than 90 minutes with near total clot removal and resolution of mass effect for all reviewed cases with no patients experiencing procedure-related postoperative decline. Minimally invasive catheter-based and parafascicular approaches using tubular retractors are increasingly recognized as a viable option in the treatment of subcortical lesions. The MindsEye is the first expandable brain access port designed for removal of deep intracranial lesions. We believe it represents a recent addition in the armament of cranial surgeons.

Interventional therapies for pulmonary embolism.

Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate-high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discussfuture perspectives and unmet needs.

Intraoperative Sapien S3 Valve Placement in 2 Patients With Multi-Valvar Disease Operation: A Unique Hybrid Procedure.

There has been a paradigm shift in the management of patients with congenital heart disease with a move away from conventional surgical treatment in favor of a percutaneous catheter-based approach across the spectrum of valvular heart diseases. The Sapien S3 valve implantation in the pulmonary position has been previously reported using a conventional transcatheter approach in patients with pulmonary insufficiency due to an enlarged right ventricular outflow tract. In this report, we present 2 unique cases of intraoperative hybrid implantation of Sapien S3 valves in patients with complex pulmonic and tricuspid valvular disease.

Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain.

Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies. In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.

Massive Embolism: Knife versus PCI.

Pulmonary embolism is the third most common cardiovascular syndrome with an estimated up to 25% of patients presenting with sudden death. For those who survive, a mainstay of management for patients with hemodynamic stability is anticoagulation; however, recommendations and options are rapidly changing for patients with submassive or massive pulmonary embolism with hemodynamic instability. Catheter-based and surgical approaches offer efficacious management options for unstable patients or patients with contraindications to anticoagulation; however, both approaches have inherent benefits and risk. This article seeks to offer a brief review on the recommendations and options for management of pulmonary embolism from both surgical and catheter-based perspectives.

VR4EPCONSULT: REMOTE PROCEDURE CONSULTATION FOR ELECTROPHYSIOLOGY PROCEDURES USING VIRTUAL REALITY

BackgroundInvasive catheter-based approaches for challenging and complex cardiac arrhythmias requires expertise which is not readily available across various medical centers around the world. Due to overall limitation of expert proceduralists there can be suboptimal procedural outcome, avoidable procedural complications, re-do procedures, and a rise in cost across patient, payer, and healthcare utilization resources. Virtual Reality (VR) can minimize the above-mentioned concerns and facilitate anytime, anywhere procedure consultation.ObjectiveWe hypothesize that a Remote Procedural Consultant (RPC) can enhance patient safety, procedural success, and proceduralist satisfaction. In partnership with AirV Labs, we developed a VR4EPConsult framework that includes bi-directional communication and interactions to facilitate real-time procedural assistance between clinical sites.MethodsDeveloped using Unity3D™, and a proprietary collaboration platform AirVu™, VR4EPConsult (Figures 1 & 2) consists of the following modules to facilitate RPC between host and consultant sites: (i) synchronization to co-ordinate multi-modal interactions (audio, images, annotations, 3D models, live feeds of ultrasound, fluoroscopy, mapping system), (ii) visualization (scene composition including 360 live video, camera placement, rendering of modalities), and (iii) exploration (teleport, positioning and manipulation of multiple modalities) to strategize Electrophysiology (EP) procedure.ResultsVR4EPConsult proof-of-concept offers a real-time, interactive, procedural consultation anytime, anywhere by connecting a host with expert proceduralists. We report a case of complex ablation procedure which was analyzed and ablated using VR4EPConsult.ConclusionFigure 2: Snapshot of VR4EPConsult using Multiple modalities for Remote Procedural ConsultantView Large Image Figure ViewerDownload Hi-res image Download (PPT) BackgroundInvasive catheter-based approaches for challenging and complex cardiac arrhythmias requires expertise which is not readily available across various medical centers around the world. Due to overall limitation of expert proceduralists there can be suboptimal procedural outcome, avoidable procedural complications, re-do procedures, and a rise in cost across patient, payer, and healthcare utilization resources. Virtual Reality (VR) can minimize the above-mentioned concerns and facilitate anytime, anywhere procedure consultation. Invasive catheter-based approaches for challenging and complex cardiac arrhythmias requires expertise which is not readily available across various medical centers around the world. Due to overall limitation of expert proceduralists there can be suboptimal procedural outcome, avoidable procedural complications, re-do procedures, and a rise in cost across patient, payer, and healthcare utilization resources. Virtual Reality (VR) can minimize the above-mentioned concerns and facilitate anytime, anywhere procedure consultation. ObjectiveWe hypothesize that a Remote Procedural Consultant (RPC) can enhance patient safety, procedural success, and proceduralist satisfaction. In partnership with AirV Labs, we developed a VR4EPConsult framework that includes bi-directional communication and interactions to facilitate real-time procedural assistance between clinical sites. We hypothesize that a Remote Procedural Consultant (RPC) can enhance patient safety, procedural success, and proceduralist satisfaction. In partnership with AirV Labs, we developed a VR4EPConsult framework that includes bi-directional communication and interactions to facilitate real-time procedural assistance between clinical sites. MethodsDeveloped using Unity3D™, and a proprietary collaboration platform AirVu™, VR4EPConsult (Figures 1 & 2) consists of the following modules to facilitate RPC between host and consultant sites: (i) synchronization to co-ordinate multi-modal interactions (audio, images, annotations, 3D models, live feeds of ultrasound, fluoroscopy, mapping system), (ii) visualization (scene composition including 360 live video, camera placement, rendering of modalities), and (iii) exploration (teleport, positioning and manipulation of multiple modalities) to strategize Electrophysiology (EP) procedure. Developed using Unity3D™, and a proprietary collaboration platform AirVu™, VR4EPConsult (Figures 1 & 2) consists of the following modules to facilitate RPC between host and consultant sites: (i) synchronization to co-ordinate multi-modal interactions (audio, images, annotations, 3D models, live feeds of ultrasound, fluoroscopy, mapping system), (ii) visualization (scene composition including 360 live video, camera placement, rendering of modalities), and (iii) exploration (teleport, positioning and manipulation of multiple modalities) to strategize Electrophysiology (EP) procedure. ResultsVR4EPConsult proof-of-concept offers a real-time, interactive, procedural consultation anytime, anywhere by connecting a host with expert proceduralists. We report a case of complex ablation procedure which was analyzed and ablated using VR4EPConsult. VR4EPConsult proof-of-concept offers a real-time, interactive, procedural consultation anytime, anywhere by connecting a host with expert proceduralists. We report a case of complex ablation procedure which was analyzed and ablated using VR4EPConsult. Conclusion

Update on Renal Sympathetic Denervation for the Treatment of Hypertension.

Hypertension is a leading risk factor for all-cause mortality in adults; however, medication non-adherence and intolerance present an enormous treatment challenge. Given the critical role of renal sympathetic nerves in neurogenic control of blood pressure and pathophysiology of hypertension, renal sympathetic denervation (RDN) has been explored as a therapeutic strategy in hypertension treatment over the last 15years. In this review, we will discuss the role of renal sympathetic nerves in the pathophysiology of hypertension, provide an update on the available evidence regarding the short- and long-term safety and effectiveness of RDN in the treatment of hypertension, and consider its future perspectives. RDN is a percutaneous endovascular catheter-based neuromodulation approach that enables ablation of renal sympathetic nerve fibers within the adventitial layer of the renal arteries using radiofrequency (most extensively studied), ultrasound energy, or neurolytics (e.g., alcohol). In the last decade, advancements in procedural techniques and well-designed sham-controlled trials utilizing 24-h ambulatory blood pressure measurements have demonstrated that RDN has an excellent safety profile and results in a modest reduction of blood pressure, in a wide range of hypertensive phenotypes (mild to resistant), irrespective of antihypertensive drug use and this effect is sustained over a 3-year period. Superiority of a particular RDN modality has not been yet established. Despite strong evidence demonstrating efficacy and safety of RDN, current data does not support its use as a primary approach in the treatment of hypertension due to its modest treatment effect and concerns around long-term sustainability. Perhaps the best utility of RDN is in hypertensives intolerant to antihypertensive medications or as an adjunct to aldosterone antagonists in the management of resistant hypertension. Patient selection will be critical to demonstrate a meaningful benefit of RDN. Future well-designed studies are necessary to determine predictors and measures of response to RDN, long-term efficacy given question of renal nerve regeneration, comparison of available technologies, safety in patients with advanced kidney disease, and improvement in patient quality of life measures.

Ultrasound Guided Regional Anesthesia in Thoracic Surgery

Perioperative analgesia plays an important role in thoracic surgery, regarding not only patient satisfaction, but also in preventing postoperative complications such as pneumonia. Ultrasound-guided thoracic wall blocks close the gap between opiate based and neuraxial pain management concepts.The following article explores the different ultrasound-guided approaches to anesthetize the thoracic wall, ranging from the ventral blocks such as parasternal or PECS I/II, followed by the lateral blocks (i.e. serratus anterior), up to the dorsal approaches including the paravertebral, erector spinae plane, and retrolaminar block.In summary, the anterolateral blocks are supplementary blocks in an opiate sparing, multimodal anaesthesia concept, whereas the dorsal procedures, as they include visceral anaesthesia, are an alternative to neuraxial anaesthesia, as they have a comparable analgetic potency. For minimally invasive thoracic surgery, where due to risk-benefit considerations epidural anaesthesia is omitted, thoracic wall blocks can be utilized in a single shot or a continuous, catheter-based approach.