Circumferential Approach Research Articles

Esophageal Temperature Monitoring During Radiofrequency Ablation of Atrial Fibrillation

Ablative strategies for atrial fibrillation have centered on the left atrium, in particular the pulmonary veins. An emphasis on ablating outside the ostia of the pulmonary veins appears to have reduced the risk of pulmonary vein stenosis. Unfortunately, ablation in the posterior left atrium has been reported to result in fatal atrio-esophageal fistula. We monitored esophageal temperatures in 16 consecutive patients undergoing atrial fibrillation ablation. There were 14 men and 2 women; average age 54.7 +/- 10.6 years. Eight patients had a lasso-guided pulmonary isolation procedure, eight an electroanatomically guided left-atrial circumferential approach. A commercially available esophageal temperature probe (Mallinckrodt Mon-a-therm 12F Esophageal Stethoscope with Temperature Sensor, Thermistor 400 Series) was positioned under general anesthesia. Temperature changes were noted and related to the relative location of the ablation catheter and the temperature probe during the temperature change. The esophagus was midline in three, right sided in three, and left sided in the remaining patients. Temperature rises could be recorded at the posterior aspect of any pulmonary vein. Detailed analysis of six patient maps revealed heating occurred with lesions created within 1 cm of the esophagus. The location of the esophagus relative to the back of the left atrium displays considerable variability. It is rarely midline and most often lies in close proximity to the left-sided veins. Ablation in close radiographic proximity (approximately 1 cm) to the esophagus as defined by a radio-opaque temperature probe can result in heating at the esophageal lumen.

Incidence and predictors of pulmonary vein stenosis following catheter ablation of atrial fibrillation using the circumferential approach: Results from paired magnetic resonance angiography

II vs. no MB or type I MB.) Tissue heating of 21 to 40°C was associated with a lesser magnitude of impedance decrease, but excess tissue temperatures were noted across the spectrum of impedance decreases. Conclusion: Impedance monitoring during cooled-tip ablation is more useful than microbubble monitoring. A decrease 20 ohms heralds impending aggressive microbubble formation. Target tissue heating was associated with lesser, rather than greater, magnitudes of impedance decreases.

Adult Low-Grade Acquired Spondylolytic Spondylolisthesis

Literature review. To discuss the presentation and evaluation of adult patients with acquired spondylolytic spondylolisthesis of low-grade severity and to review surgical treatment options. Low-grade adult acquired spondylolytic spondylolisthesis is one of the most common forms of spondylolisthesis. Literature review. Adults with symptomatic low-grade spondylolytic spondylolisthesis are treated predominantly nonoperatively, with activity modification, physiotherapy, nonsteroidal anti-inflammatory agents, and local injections. Surgical treatment is reserved for individuals with intractable back pain and/or radicular symptoms. A number of surgical options exist, including direct pars repair, and fusion with or without decompression. Fusion can be achieved by providing anterior column support alone, posterior support alone, or a combined circumferential approach; the optimal method by which fusion should be achieved has not been established. The management of low-grade acquired spondylolytic spondylolisthesis requires a thoughtful and individualized approach, recognizing the frequently benign natural history of the deformity and the potentially good clinical outcomes from surgery in those select patients with intolerable back and leg pain. While fusion is the mainstay of surgical management, a prospective randomized study would be extremely useful to delineate the optimal fusion technique.

Pulmonary vein occlusion: An unanticipated complication of catheter ablation of atrial fibrillation using the anatomic circumferential approach

Favorable results of circumferential pulmonary vein (PV) ostial ablation guided by electroanatomic mapping (Carto) have fueled great enthusiasm for this technique. The lesion set for this ablation procedure as described by Pappone et al. 1,2 involves a figure of 8 lesions encompassing the 2 right and 2 left PV ostia with 2 additional linear lesions. Pulmonary vein stenosis/or occlusion has not previously been reported as a complication of this procedure. We describe PV occlusion after this procedure. Based on the occurrence of this previously unreported complication, we no longer create a figure ‘8’ lesion around the right superior and inferior PVs. We anticipate that this complication can be avoided by creating a circular lesion encompassing the 2 PV ostia, while avoiding the linear lesion between the 2 PV ostia.

Circumferential approach to contouring of the trunk

Background: Body contouring usually involves the lower and upper abdomen, flanks, hips, and back. Several techniques are available with which to achieve suitable simultaneous correction of all these aesthetic units. Objective: We review the techniques available for contouring of the trunk. Excisional procedures are abdominoplasty, abdominohemiflankplasty or extended abdominoplasty, abdominoflankplasty, and flankplasty. Indications for excisional surgery and its combination with ultrasound-assisted lipoplasty and conventional lipoplasty with excisional surgery are discussed. Methods: A series of 102 consecutive patients underwent contouring surgery of the trunk between 1998 and 2003. Detailed preoperative evaluation of the entire trunk area was performed to determine the most appropriate surgical procedure for each patient. The key surgical principles defining the technique used included high lateral tension with minimal central tension, direct limited undermining to a central triangle, discontinuous cannula undermining, and anchoring of the scar so as to avoid migration. Results: A circumferential approach to contouring of the trunk area offered excellent outcomes and a high level of patient satisfaction. Significant improvement in body contour was achieved, with a low rate of complications. Conclusions: Excisional techniques for body contouring involve major surgery that results in a relatively large scar. Carried out with maximal preoperative, intraoperative, and postoperative care, it offers a safe way to achieve significant improvement in body contour with minimal risk to the patient.

Summary statement: fusion technologies.

Summary statement: fusion technologies.

4:04 Circumferential reconstruction of the cervical spine

Purpose of study: A significant number of adults have pain, cosmetic deformity or neurologic injury related to cervical malalignment. The majority of such cases involve sagittal plane malalignment with loss of lordosis, kyphosis or double curve (swan-neck) deformity of the subaxial spine. A smaller number of patients have coronal plane malalignment or scoliosis in the subaxial spine or various anomalies of the occipitoatlantoaxial complex. In the following, we describe 50 cases within the past 5 years in which circumferential approaches have been applied for the correction of cervical deformities.Methods used: At our institution, more than 50 cases of multisegmental cervical or occipitocervical deformity corrections have been performed since 1995. Thirty cases have at least 24 months of follow-up. Causative pathologies include rheumatoid arthritis, congenital dysplasias, late posttraumatic deformity, iatrogenic postsurgical deformity, severe degenerative disease, tumors, vascular malformations and infections. All subaxial cases involved sagittal plane restoration. One in four also required coronal or axial realignment. Two thirds of occipitoatlantoaxial cases involved sagittal corrections; half with axial or coronal restoration as well. Two thirds of all cases, including 540 degree reconstructions, could be completed in a single day with a single anesthetic.of findings: An aggressive approach to anterior and posterior osteotomy followed by anterior distraction and posterior compression allowed correction of kyphotic deformity in all subaxial cases. Partial loss of correction occurred in one third of cases secondary to cage or strut settling or telescoping, despite rigid fixation. Intraoperative correction of coronal or axial deformities was maintained with little, if any, subsequent loss. Rigid screw fixation to the suboccipital keel and to the C1–C2 region with long C2 pars screws or C1–C2 transarticular screws allowed maintenance of intraoperative correction with no apparent late loss. There were no deaths and no spinal cord or nerve root injuries in this series. Two vertebral artery injuries related to C1–C2 transarticular screw placement occurred; one resulted in a delayed Wallenburg's syndrome. Two next-segment failures occurred, requiring reoperation for extension of fusion. There was a measurable loss of anterior distractive height restoration in one third of cases over time. In no case was this clinically significant. Anterior cage or strut settling occurred with both rigid and dynamic anterior buttresses and in the face of rigid anterior and posterior hardware.Relationship between findings and existing knowledge: The literature on spinal deformity is largely concerned with thoracic and thoracolumbar pathology. Traditional surgical approaches to cervical deformity using nonrigid internal fixation with wire or cable and/or semirigid external fixation in halo vests or Minerva casts were of limited use in the correction of deformity in any plane either above or below C2.Overall significance of findings: Modern reconstructive techniques allow for clinically significant correction of cervical and occipitocervical deformities associated with chronic pain, cosmetic deformity and neurologic deficit. An aggressive circumferential approach to decompression and osteotomy allows near-anatomic correction of geometric deformity in any plane.Disclosures: No disclosures.Conflict of interest: No conflicts.

Surgical Treatment of Peyronie’s Disease Using Penile Implants: Survey of 69 Patients

Implantation of bilateral prostheses was used to treat Peyronie’s disease in 69 patients. A circumferential approach was used in 46 patients and, more recently, a prepubic approach was used in 23. In addition, plaque removal was performed by a transcavemous route in 29 patients. Penile lengthening was performed in 49 patients and the glans was repositioned in 14. In 4 patients it became necessary to remove the implants. The best results without complications were observed when the prepubic approach was used for implants and lengthening of the penis, without removal of the plaque. This technique provides a penile length gain of about 3cm. and generally does not obviate additional normal erection.

Foucault & the history of classification theory

Radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) originating from the left ventricular (LV) papillary muscles (PMs) is challenging.We enrolled 16 consecutive patients who received RFCA for VAs from LV PMs. Three-dimensional electroanatomical mapping was used to construct activation and/or pace maps. RFCA was performed first at the earliest activation site or at the best matched site in the pace maps. When an acceleration or reduction in the incidence of VAs was observed during the first few seconds of the application, the ablation energy was delivered continuously for 60–120 s. Additional ablation was then circumferentially delivered at the base of the PMs.RFCA was successfully performed in all 16 patients with no cases of recurrence of VAs after a mean follow-up of 20 ± 12 months. VAs originated from the anterior (n = 8) and posterior (n = 8) PMs. Purkinje potentials were identified at the target sites in seven patients. All VAs were temporarily suppressed by one to two long-duration shots of RFCA at the initial targeted site, but recurrence was subsequently noted. In six patients, the QRS morphologies of the VAs changed after the initial RFCA. A subsequent circumferential approach with multiple ablations applied to the base of the PMs completely eliminated all VAs. In all but one patient, successful RFCA was achieved using an open-irrigated ablation catheter.Circumferential RFCA at the base of the PMs overcame anatomical limitations, leading to a high success rate of RFCA for VAs from LV PMs.