Fluoroscopy Exposure Research Articles

DETERMINATION OF LOCAL DIAGNOSTIC REFERENCE LEVEL (DRL) ON CONVENTIONAL RADIOTHERAPY SIMULATOR WITH BRAIN METASTASIS CASES AT DR. ADHYATMA, MPH HOSPITAL

Conventional simulators in 2-dimensional (2D) radiotherapy procedures can be done with fluoroscopy and single exposure features. The most significant percentage of 2D patients in the radiotherapy installation of Dr. Adhyatma MPH Hospital, are patients with brain metastasis cases, with a percentage of 65% of all 2D patients. Therefore, this study focuses on brain metastasis cases. The feature used in the Radiotherapy Installation of Dr. Adhyatma MPH Hospital is the single exposure feature, which is identical to conventional diagnostic radiology examinations. Radiation in diagnostic radiology requires a local Diagnostic Reference Level (DRL) on a conventional radiotherapy simulator as a guideline for optimizing radiation protection for medical exposure. This study aims to determine the local DRL value of a conventional radiotherapy simulator in cases of brain metastasis and compare it with the national DRL in lateral head examinations. The local DRL value obtained is then used as a guideline in improving services to increase the quality of service to patients. The data collection method is carried out in 2 (two) ways, namely calculating the local DRL value from the ESAK value and interviews related to the quality of the resulting image. The exposure factors used in this study followed the same routine exposure factors with a tube voltage of 72 kV and a tube current of 25 mAs. The local DRL value obtained was 0.586 mGy, with a percentage difference of 51% lower than the national DRL. With this value, the quality of the resulting image is classified as optimal and easy to assess. Thus, the exposure factors in the conventional radiotherapy simulation process in cases of brain metastasis can be used as a guideline for clinical practice at RSUD dr. Adhyatma, MPH. Keywords: conventional radiotherapy simulator, 2-dimensional radiotherapy, local DRL, diagnostic patients, radiation dose.

Outcomes of Radiation Dose Reduction Protocol in Electrophysiologic and Cardiac Device Procedures

Background: Exposure to radiation has been demonstrated to be associated with adverse short- and long-term health outcomes. Objective: To presented outcomes before and after the implementation of a radiation dose reduction protocol in electrophysiologic (EP) and cardiac device procedures. Materials and Methods: The present study was a retrospective comparative study, conducted at Chiang Mai University Hospital in Thailand using 2017 and 2019 data, including all patients who underwent EP and cardiac implantable electronic device (CIED) procedures. Exclusion criteria involved patients with incomplete radiation dose records. The authors compared fluoroscopic time, radiation exposure, and complication rates before and after the protocol. Results: Among the 458 cases, with 214 Eps and 244 devices, the mean age was 58 years. For device implantation procedures, there was no significant change in fluoroscopic time as median (P₂₅, P₇₅) before and after protocol implementation were 3.1 (0.4, 5.8) versus 4.4 (1.2,7.6) minutes, respectively (p=0.117). However, there was a decreasing trend in dose area product (DAP) at 242.0 (119.2, 766.0) versus 197.9 (71.5, 494.5) cGy.cm² (p=0.073). The reduction in DAP was more pronounced in cardiac resynchronization therapy (CRT) implantation when comparing 2017 to 2019 were 1,933.6 (1,039.4, 7,683.8) versus 1,074.6 (427.2, 2,890.7) cGy.cm² (p=0.020). In EP procedures, fluoroscopic time significantly decreased from 8.1 (3.0, 14.3) minutes in 2017 to 1.0 (0.0, 3.6) minute in 2019 (p<0.001), accompanied by a significant reduction in exposure dose of 45.0 (10.8, 153.3) versus 1.7 (0.0, 31.6) mGy (p<0.001) and DAP of 1,022.9 (247.2, 2,660.3) versus 38.5 (0.0, 566.9) cGy.cm² (p<0.001). There was no difference in the complication rate between the two periods. Conclusion: The implementation of the radiation dose reduction protocol resulted in a significant decrease in radiation exposure during EP procedures and showed a trend towards reduction in CIED procedures.

Comparing Low-to-Zero Fluoroscopic Navigation Systems for AVNRT Catheter Ablation: A Network Meta-Analysis.

Low-to-zero fluoroscopic navigation systems lower radiation exposure which improves health outcomes. Conventional x-ray fluoroscopy (CF) has long been the standard to guide to catheter location for cardiac ablation. With advancements in technology, alternative safety navigation systems have been developed. Three primary modalities commonly utilized are three-dimensional electroanatomic mapping (3D-EAM), magnetic navigation system (MNS), and intracardiac echocardiography (ICE), all of which can reduce radiation exposure during the procedure. We aim to compare the efficacy and safety among ICE, EAM, MNS, and CF in ablation of atrioventricular nodal reentrant tachycardia (AVNRT). This is a meta-analysis consisting of observational studies and randomized controlled trials, which evaluated the performance of navigation systems of catheter ablation in AVNRT patients. Primary endpoint was to access the AVNRT recurrence after the procedure during follow-up periods. Secondary endpoints were technical success, fluoroscopic time, fluoroscopic dose area product, radiofrequency ablation time, and adverse events. Random-effect model was applied for pooled estimated effects of included studies. A total of 21 studies (21 CF, 2 ICE, 9 EAM, 11 MNS) including 1716 patients who underwent catheter ablation for AVNRT treatment were analyzed. Of these, 16 were observational studies and 5 were randomized controlled trials. Point estimation of AVNRT recurrence showed ICE exhibited a pooled odds ratio (ORs) of 1.06 (95% confidence interval [CI]: 0.064-17.322), MNS with ORs of 0.51 (95% CI: 0.214-1.219], and EAM with ORs of 0.394 (95% CI: 0.119-1.305) when compared to CF. EAM had significant higher technical success with ORs of 2.781 (95% CI: 1.317-5.872) when compared to CF. Regarding fluoroscopy time, EAM showed the lowest time with mean differences (MD) of -10.348 min (95% CI: -13.385 to -7.3101) and P-score of 0.998. It was followed by MNS with MD of -3.712 min (95% CI: -7.128 to -0.295) and P-score of 0.586, ICE with MD of -1.150 min (95% CI: -6.963 to 4.662) with a P-score of 0.294 compared to CF, which has a P-score of 0.122. There were insignificant adverse events across the procedures. AVNRT ablation navigated by low-to-zero fluoroscopic navigation systems achieves higher efficacy and comparable safety to conventional fluoroscopywhile also reducing risk of radiation exposure time.

Pulsed Field Ablation to Treat Paroxysmal Atrial Fibrillation: Safety and Effectiveness in the AdmIRE Pivotal Trial.

Evidence from clinical trials of early pulsed field ablation (PFA) systems in treating atrial fibrillation has demonstrated their promising potential to reduce complications associated with conventional thermal modalities while maintaining efficacy. However, the lack of a fully integrated mapping system, a staple technology of most modern electrophysiology procedures, poses limitations in lesion creation and workflow options. A novel variable-loop PFA catheter integrated with an electroanatomic mapping system has been developed that allows for real-time nonfluoroscopic procedural guidance and lesion indexing as well as feedback of tissue-to-catheter proximity. AdmIRE (Assessment of Safety and Effectiveness in Treatment Management of Atrial Fibrillation With the Bosense-Webster Irreversible Electroporation Ablation System), a multicenter, single-arm, Food and Drug Administration investigational device exemption study, evaluated the long-term safety and effectiveness of this integrated PFA system in a large United States-based drug-refractory symptomatic paroxysmal atrial fibrillation patient population. Using the PFA catheter with a compatible electroanatomic mapping system, patients with drug-refractory symptomatic paroxysmal atrial fibrillation underwent pulmonary vein isolation. The primary safety end point was primary adverse event within 7 days of ablation. The primary effectiveness end point was a composite end point that included 12-month freedom from documented atrial tachyarrhythmia (ie, atrial fibrillation, atrial tachycardia, atrial flutter) episodes, failure to achieve pulmonary vein isolation, use of a nonstudy catheter for pulmonary vein isolation, repeat procedure (except for one redo during blanking), taking a new or previously failed class I or III antiarrhythmic drug at higher dose after blanking, or direct current cardioversion after blanking. At 30 centers, 277 patients with paroxysmal atrial fibrillation (61.5±10.3 years of age; 64.3% male) in the pivotal cohort underwent PFA. More than 25% of the procedures were performed without fluoroscopy. Median (Q1, Q3) pulmonary vein isolation procedure, fluoroscopy, and transpired PFA application times were 81.0 (61.0, 112.0), 7.1 (0.00, 14.3), and 31.0 (24.8, 40.9) minutes, respectively. The primary adverse event rate was 2.9% (8 of 272), with the most common complication being pericardial tamponade. The 12-month primary effectiveness end point was 74.6%. The 1-year freedom from atrial fibrillation, atrial tachycardia, or atrial flutter recurrence rate after blanking was 75.4%. Substantial improvements in quality of life were observed as early as 3 months after the procedure, concurrent with a reduction in multiple health care use measures. AdmIRE confirmed the safety and effectiveness of the variable-loop PFA catheter, with short procedure and PFA application times and low fluoroscopy exposure. URL: https://www.clinicaltrials.gov; Unique identifier: NCT05293639.

Open Surgical Implantation of Lumbosacral Dorsal Root Ganglion Stimulators for Chronic Pain: Analysis of Patient Outcomes and Operative Technique

ObjectiveDorsal root ganglion (DRG) stimulator leads were designed to be placed percutaneously, yet open surgical placement via laminectomy is an option. We present the largest series to date of surgically-placed DRG stimulators and the first series where open surgical implantation was the chosen technique and not a salvage procedure. MethodsA retrospective review of a prospective database of DRG implants identified 17 patients who had open lumbosacral DRG lead placement performed by a single surgeon (NDT) between October 2021 and April 2023. Descriptive statistics, fluoroscopy exposure times, and complications were reported. The window of data collection was 1 month pre-operatively to 12 months post-operatively. Phone interviews were conducted to collect information on pain outcomes and patient satisfaction. ResultsWe identified 17 patients (12 women, 5 men) who had lumbosacral DRG placement. Phone interviews were conducted for 10/17 patients, with mean follow-up of 11.9 months. 53% reduction in mean pain score was achieved (n=10, p<0.001). There were no infections, hematomas, or symptomatic lead migrations. 1/17 experienced a superficial dehiscence and 2/17 had an intra-operative repairable durotomy with no post-operative sequelae. Mean fluoroscopy time per lead was 15.4±9.9s (n=10). ConclusionOpen DRG lead placement via laminotomy/laminectomy is reported as a salvage procedure but may have comparable safety and efficacy profile to percutaneous implantation when utilized as the primary implantation method. Before establishing open DRG as an alternative permanent implantation method, more studies are needed to determine whether such benefits as less migration outweigh the risks of a more invasive implantation procedure.

Ablation of Supraventricular Arrhythmias With as Low as Reasonably Achievable X-Ray exposure (AALARA): Results of Prospective, Observational, Multicenter, Multinational, Open-Label Registry Study on Real World Data Using Routine Ensite 3D Mapping During SVT Ablation.

The reduction of fluoroscopic exposure during catheter ablation of supraventricular arrhythmias is widely adopted by experienced electrophysiology physicians with a relatively short learning curve and is becoming the standard of care in many parts of the world. While observational studies in the United States and some parts of Western Europe have evaluated the minimal fluoroscopic approach, there are scarce real-world data for this technique and the generalizability of outcomes in other economic regions. The AALARA study is a prospective, observational, multicenter, and multinational open-label study. Patients were recruited from 13 countries across Central Eastern Europe, North and South Africa, the Middle East, and the CIS (Commonwealth of Independent States), with different levels of operator expertise using minimal fluoroscopic exposure techniques. Data on radiation exposure, procedural success, complications, recurrence, and quality of life changes were collected and analyzed. A total of 680 patients were enrolled and followed for 6 months. The majority were ablation naïve with the commonest arrhythmia ablated being typical AVNRT (58%) followed by Atrial Flutter (23%). Zero fluoroscopy exposure was observed in almost 90% of the cases. Fluoroscopy was most commonly used during the ablation phase of the procedure. We observed a high acute success rate (99%), a low complication rate (0.4%), and a 6-month recurrence rate of 3.8%. There was a significant improvement in the patient's symptoms and quality of life as measured by patient global assessment. The routine use of a 3D mapping system during right-sided ablation was associated with low radiation exposure and associated with high acute success rate, low complications, and recurrence rate along with significant improvement in quality of life. The data confirm the reproducibility of this approach in real-world settings across different healthcare systems, and operator experience supporting this approach to minimize radiation exposure without compromising efficacy and safety. NCT04716270.

Ultrathin semirigid retrograde ureteroscopy versus antegrade flexible ureteroscopy in treating proximal ureteric stones 1-2cm, a prospective randomized multicenter study.

To compare the outcomes of using Ultrathin semirigid retrograde ureteroscopy and antegrade flexible ureteroscopy to treat proximal ureteric stones of sizes 1-2cm. A prospective randomized multicenter study included patients who had proximal ureteric stones 1-2cm, amenable for ureteroscopy and laser lithotripsy between August 2023 and February 2024. Two hundred thirty patients were divided evenly into two treatment groups. Group I included patients treated with antegrade flexible ureteroscopy and holmium laser stone fragmentation, and Group II included patients treated with retrograde ultrathin semirigid ureteroscopy. The study groups were compared in terms of patient demographics, stone access success, operation time, reoperation rates, peri-operative complications, and stone-free status. Group I included 114 patients, while Group II included 111. The mean age of the patients was 33.92 ± 10.37years, and the size of the stones was 15.88 ± 3mm. The study groups had comparable demographics and stone characteristics. The mean operative time was significantly longer in group I than in group II (102.55 ± 72.46min vs. 60.98 ± 14.84min, respectively, P < 0.001). Most reported complications were MCCS grades I and II, with no significant difference between the study groups. The stone-free rate after four weeks was 92.1% and 81.1% for groups I and II, respectively, which increased to 94.7% and 85.6% after eight weeks (P > 0.05). Antegrade flexible ureteroscopy is equivalent to retrograde ultrathin semirigid ureteroscopy in treating proximal ureteric stones regarding stone-free status and procedure-related morbidity. However, the antegrade approach has a longer operative time, greater fluoroscopy exposure, and longer hospital stays.

Shortened radiofrequency delivery time to optimize efficiency and safety of pulmonary vein isolation with the radiofrequency balloon: insights from the COLLABORATE registry.

Previous clinical studies on pulmonary vein isolation (PVI) with a radiofrequency balloon (RFB) reported safe and effective procedures using conventional ablation settings with 20/60 s RF delivery via posterior/anterior (PST/ANT) electrodes. The latest evidence suggests that reducing the application time to 15 s (s) on the posterior wall when facing the oesophageal region is as effective as applying 20 s. To prospectively assess whether reducing RF time on PST/ANT segments to 15/45 s can ensure sufficient quality of lesion metrics and compare the new shortened ablation settings with the conventional one in terms of safety, and effectiveness at 1-year. A total of 641 patients from seven European centres were enrolled in a collaborative registry, with 374 in the conventional RF delivery group and 267 in the shortened RF delivery group. Procedural outcomes, lesion metrics, and safety profiles were assessed and compared between the groups. Freedom of any atrial tachycarrythmias at one year was 85.4% and 88.2% in the SHRT and CONV groups, respectively. The shortened RF delivery strategy was associated with significantly shorter procedure times (median 63.5 vs. 96.5 min, P < 0.001) and shortened fluoroscopy exposure (median 10.0 vs. 14.0 min, P < 0.001) compared to conventional delivery. Efficacy metrics, including first-pass isolation rates and time to isolation, were comparable between groups. Shortened RF delivery was associated with a lower incidence of procedural complications (1.4% vs. 5.3%, P = 0.04) and optimized thermal characteristics. Analyses from the COLLABORATE registry demonstrate that shortening RF energy delivery times to 15/45 s (PST/ANT) during PVI with the RFB resulted in comparable freedom from recurrent atrial tachyarrhythmia compared to conventional delivery times with comparable efficiency and safety.

Pediatric distal both-bone forearm fractures treated with percutaneous pinning with or without ulna fixation: a retrospective cohort study from two centres

PurposeThis study investigated the clinical and functional outcomes of children with distal both-bone forearm fractures treated by fixation of the radius only compared to fixation of both the radius and ulna.MethodsA total of 71 patients from two centres with distal both-bone forearm fractures (30 in the ulna-yes group, 41 in the ulna-no group) who underwent closed reduction and percutaneous pinning treatment were retrospectively analysed. Operation duration, number of fluoroscopic exposures, loss of reduction rate and angulation based on radiographic assessment were compared between the two groups. Evaluation of wrist function including Gartland-Werley Score and Mayo Wrist Score were compared at the last follow-up.ResultsUlna angulation upon bone healing on the posteroanterior and the lateral plane of ulna-no group (6.11 ± 1.56°; 6.51 ± 1.69°) was significantly greater than that of ulna-yes group (4.49 ± 1.30°; 5.05 ± 2.18°) (p < 0.05). No significant difference was found in the loss of reduction rate between ulna-yes group (6.67%, 2/30) and the ulna-no group (4.88%, 2/41) (p > 0.05). At last follow-up, no significant difference was found between the Gartland-Werley Scores of the ulna-yes group (1.83 ± 3.25, range: 0–16) and ulna-no group (1.85 ± 2.72, range: 0-11.5) (p > 0.05). No significant difference was found between the Mayo Wrist Scores of the ulna-yes group (92.60 ± 6.20) and ulna-no group (92.15 ± 7.58) (p > 0.05).ConclusionsFor distal both-bone forearm fractures in children, fixation of only the radius appears to be a viable method with equivalent clinical outcomes compared to fixation of both the radius and ulna.

Three-dimensional-printing-guided preoperative planning of upper and lower extremity pediatric orthopedic surgeries: A systematic review of surgical outcomes.

Three-dimensional printing has evolved into a cost-effective and accessible tool. In orthopedic surgery, creating patient-specific anatomical models and instrumentation improves visualization and surgical accuracy. In pediatric orthopedics, three-dimensional printing reduces operating time, radiation exposure, and blood loss by enhancing surgical efficacy. This review compares outcomes of three-dimensional printing-assisted surgeries with conventional surgeries for upper and lower extremity pediatric surgeries. A complete search of medical literature up to August 2023, using Ovid Medline, EMBASE, Scopus, Web of Science, and Cochrane Library was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Broad search terms included "pediatrics," "orthopedic," and "3D-printing." Eligible studies were assessed for intraoperative time, blood loss, and fluoroscopy exposure. Out of 3299 initially identified articles, 14 articles met inclusion criteria. These studies included 409 pediatric patients, with ages averaging 9.51 years. The majority were retrospective studies (nine), with four prospective and one experimental study. Studies primarily utilized three-dimensional printing for navigation templates and implants. Results showed significant reductions in operative time, blood loss, and radiation exposure with three-dimensional printing. Complication occurrences were generally lower in three-dimensional printing surgeries, but there was no statistical significance. Three-dimensional printing is an emerging technology in the field of orthopedics, and it is primarily used for preoperative planning. For pediatric upper and lower extremity surgeries, three-dimensional printing leads to decreased operating room time, decreased intraoperative blood loss, and reduced radiation exposure. Other uses for three-dimensional printing include education, patient communication, the creation of patient-specific instrumentation and implants. Level III.

SHORT TERM FUNCTIONAL OUTCOME OF CLOSED REDUCTION AND FIXATION OF TIBIA SHAFT FRACTURES USING UNREAMED ENDERS NAIL IN ADULT POPULATION - A PROSPECTIVE STUDY

Most of the tibial shaft fractures are the result of high energy trauma. There are various non surgical and surgical methods for managing tibial shaft fractures ranging from conservative casting, tubular external fixator, ring external fixator, open reduction and plating, reamed intramedullary interlocking nailing and unreamed intramedullary nailing. Aim of the study was to evaluate the functional outcomes of closed reduction with unreamed enders nailing as a definitive treatment option for closed tibial shaft fractures in adult population. In the study we included 150 adult patients who had sustained closed tibial fractures and underwent closed reduction and fixation with unreamed enders nailing within 12 hours of the injury. Eye of the nail, present at the distal end of the nails was locked. Total surgical time was averaged to 27.6 minutes. Evaluation was done by the time of clinical union, time of radiological union and VAS score. Ten patients had a delayed union. Two patients developed infection which was managed with oral antibiotics. In the conclusion, we found out that unreamed enders nailing procedure preserves the periosteum and its blood supply due to minimal exposure and improves the healing of fracture and decreases the incidence of infection. This method reduces the operative time, has a relatively less learning curve, reduces fluoroscopic exposure, reduces blood loss, reduces infection rate, doesnt expose the joint thus maintaining its congruity, reduces the cost of implant, reduces patient hospital stay, reduces the antibiotic usage and the implant removal at a later stage can be done as a day care procedure.

Procedural efficiency is enhanced combining the pentaspline pulsed field ablation catheter with three-dimensional electroanatomical mapping system for pulmonary vein isolation

Abstract Background Pulsed field ablation (PFA) offers a safe, non-thermal alternative for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Currently, the pentaspline PFA-system relies heavily on fluoroscopy for catheter manipulation, which poses challenges due to the complexity of left atrium anatomy. Incorporating three-dimensional electroanatomical mapping (3D-EAM) could improve procedural efficiency reducing dependency on fluoroscopy guidance. This study aims to evaluate the effects of integration of 3D-EAM with PFA during PVI. Methods Between September 2022 and December 2023, we retrospectively enrolled 248 patients with paroxysmal or persistent AF undergoing PVI at our center using the pentaspline PFA catheter. The control group (n = 104) received conventional PFA with fluoroscopic guidance alone, while the intervention group (n = 144) underwent PVI with PFA with 3D-EAM integration. Primary outcomes were procedural time, fluoroscopy time (FT), and dose area product (DAP). Secondary endpoints included acute procedural success and incidence of periprocedural complications. Results In the 3D-EAM-PFA group, procedural time was 63.3 ± 14.3 min, compared to 65.6 ± 14.9 min in the control group (p = 0.22). The 3D-EAM group experienced significantly reduced FT (9.7 ± 4.4 min vs. 16.7 ± 5.2 min) and DAP (119.2 ± 121.7 cGycm2 vs. 338.7 ± 229.9 cGycm2) compared to the control group, respectively (p &lt; 0.001). Acute procedural success was achieved in all cases. No major complications were observed in either group. Conclusion Integration of 3D-EAM with the pentaspline PFA catheter for PVI in AF treatment offers a promising approach, with significantly reduced fluoroscopy exposure without compromising procedural time and efficacy. Graphical abstract

Nailing precision: a systematic review and meta-analysis of randomized controlled trials comparing piriformis and trochanteric entry points for femoral antegrade nailing.

Entry point selection, a crucial aspect of femoral antegrade nailing, can impact nail fit and consequently fracture reduction. In adults, the standard entry portals used are the piriformis fossa and the tip of the greater trochanter. Previous systematic reviews comparing the two techniques have not been limited to Randomized Controlled Trials (RCTs) and have not consistently included the same available RCTs. A systematic search of comparative studies regarding entry portal selection in femoral antegrade nailing was conducted on seven databases. Only Prospective RCTs comparing trochanteric and piriformis entry in the management of trochanteric or diaphyseal femur fractures were eligible for inclusion. Ultimately, only 6 RCTs were found eligible for inclusion. Five of the six included studies reported on operative time. The resulting mean difference (MD) illustrated a significant decrease in operative time by approximately 21.26min (95% CI - 28.60 to - 13.92, p < 0.001) using trochanteric entry. Fluoroscopy exposure was reported on by four studies, however, only two studies were included in the analysis due to different reporting methods. Trochanteric entry used significantly less fluoroscopy than piriformis entry (MD -50.33s, 95% CI - 84.441 to - 16.22, p = 0. 004). No significant difference in malalignment rates, delayed union rates, nonunion rates, pain scores, or complication rates was found. The significant differences found in operating time and fluoroscopy time align with those in other studies. While we were not able to pool the data on functional outcome scores, none of the included studies found a significant difference in scores by their last follow-up. Both approaches demonstrate comparable functional outcomes and safety profiles, indicating the choice of entry point should be at the discretion of the surgeon based on technique familiarity and fracture characteristics.

Differences in Intraoperative Fluoroscopic Radiation Exposure During Ankle Fracture Open Reduction and Internal Fixation Between Orthopaedic Surgery and Podiatry.

Surgical ankle fractures pose a unique situation because both podiatrists and orthopaedic surgeons manage these injuries. Intraoperative fluoroscopy is routinely used; however, excessive radiation can be harmful to both the patient and the surgical team. The primary goal of this study was to determine whether there is a difference in the amount of intraoperative radiation exposure during ankle fracture open reduction and internal fixation (ORIF) when performed by orthopaedic surgeons versus podiatrists. This is a retrospective review of patients who underwent ankle fracture ORIF at an urban level I trauma center between January 1st, 2018, and April 1st, 2023. The electronic health record was queried using International Classification of Diseases nine and 10 codes associated with ankle fractures. Patients aged older than 18 years with an ankle fracture managed surgically were included. Subjects were then stratified by procedure. The mean total radiation dose (mRad) and mean total fluoroscopic time (seconds) were then compared between those performed by orthopaedic surgeons and podiatrists. Of the 333 included procedures, 186 were done by orthopaedic surgeons and 147 were done by podiatrists. Using multiple linear regression analysis to control for age, sex, race, ethnicity, and body mass index, patients undergoing isolated malleolus ORIF with syndesmosis repair performed by orthopaedic surgery were found to have a significantly lower mean fluoroscopic time compared with those performed by podiatry (68.4 s versus 104.8 s; P = 0.028). In addition, trimalleolar ORIF with syndesmotic repair performed by orthopaedic surgery had a significantly lower mean total radiation dose compared with those performed by podiatry (244.6 mRad v 565.6 mRad; P = 0.009). Patients and surgical teams are exposed to markedly less radiation in isolated malleolar and trimalleolar fracture ORIF with syndesmosis repair when performed by an orthopaedic surgeon as compared with those performed by a podiatrist.

Endoscopic combined intrarenal surgery versus percutaneuos nephrolithotomy for complex pediatric stone disease: A comparative analysis of efficacy and safety

INTRODUCTIONDecision-making for complex pediatric urinary system stone disease is still a challenge for pediatric urologists. The interest in supine percutaneous nephrolithotomy (PCNL) is increasing among centers to achieve high surgical success rates with less morbidity. Despite advanced retrograde intrarenal surgery armamentarium, percutaneous approaches remain the first-line surgical treatment modality for >2 cm and complex renal stones. There are no comparative studies yet in the literature for pediatric endoscopic combined intrarenal surgery (ECIRS) OBJECTIVEIn this study, we aimed to contribute to the literature by evaluating the safety and efficacy of ECIRS by comparing it with PCNL. STUDY DESIGNPatients under 18 years of age who underwent PCNL and ECIRS for urinary tract stone disease at our Pediatric Urology department between 2012 and 2024 were included. Preoperative (demographic characteristics, stone characteristics, biochemical parameters), perioperative (duration of surgery, number of accesses, lasing and fluoroscopy times, endoscopic and fluoroscopic stone-free rates) and postoperative (hospital stay, urinary tract infection, complication and radiological stone-free rates) parameters were retrospectively evaluated. RESULTSA total of 68 children [28 (41%) girls and 40 (59%) boys] aged 5 (0-17) years were included in the study. ECIRS was performed in 19 (28%), supine in 28 (41%) and prone PCNL in 21 (30%) patients. Age (p = 0.029), Guy's stone score (p<0.001), S.T.O.N.E. (p<0.001), and Seoul National University Renal Stone Complexity (S-ReSC) scores (p=0.001) for preoperative parameters were found to be higher in ECIRS group over both PCNL methods (Summary Table). However, Clinical Research Office of the Endourological Society (CROES) score was seen lower for ECIRS group patients compared to other groups (p=0.028).Surgery time (in favor of supine over prone PCNL), fluoroscopy time (in favor of ECIRS and Supine PCNL over Prone PCNL), preferred laser type (prone PCNL group was mostly performed with holmium laser, whereas other groups were balanced between Holmium and Thulium Fiber Laser) and exit strategy (the preferred exit strategy was DJ Stent in most of the ECIRS patients, whereas nephrostomy tube was used in some of the PCNL group) showed significant difference among the groups as perioperative parameters (p=0.042, <0.001, <0.001, <0.001, respectively). Surgery time was lower for supine PCNL compared to prone PCNL. For postoperative parameters, stone-free rates, complication rates and urinary tract infections were similar between the 3 groups, while a difference was detected in terms of length of hospital stay in favor of ECIRS over both supine and prone PCNL (p = 0.006). DISCUSSIONThe current trial suggests that stone-free and complication rates of ECIRS and supine PCNL were similar in the pediatric complex stone patients. Although, the stones in the ECIRS group we found to be more complex. Also, ECIRS was superior to PCNL in terms of fluoroscopy exposure and hospital stay. CONCLUSIONWith the widespread use of new generation ureteral access sheaths and flexible ureterorenoscopes, ECIRS may have an important role in treatment of complex pediatric kidney stones.

Pulsed field vs very high-power short-duration radiofrequency ablation for atrial fibrillation: Results of a multicenter, real-world experience

BackgroundPulsed field ablation (PFA) and very high-power short-duration (vHPSD) radiofrequency ablation are the most recently introduced technologies for atrial fibrillation (AF) ablation. The procedural performance, safety, and effectiveness of PFA vs vHPSD are currently unknown. ObjectiveThe study aimed to compare PFA with vHPSD for the treatment of paroxysmal or persistent AF. MethodsWe conducted an observational, multicenter study enrolling 534 consecutive patients (63 ± 9 years; 36% female) with paroxysmal (n = 368 [69%]) or persistent (n = 166 [31%]) AF undergoing ablation by either PFA (Farapulse; n = 192) or vHPSD (90 W/4 seconds; QDOT Micro; n = 342) between 2020 and 2023. Atrial tachyarrhythmia recurrence after a 1-month blanking period was the primary efficacy end point and was assessed both overall and in propensity score–matched patients. The primary safety end point was a composite of procedure-related complications. ResultsSuccessful pulmonary vein isolation was achieved in all patients, with shorter procedure duration (PFA,70 minutes; vHPSD, 100 minutes; P < .001) but longer fluoroscopy time (PFA, 15 minutes; vHPSD, 7 minutes; P < .001) in the PFA group. PFA was associated with more frequent use of general anesthesia (P < .001). Primary safety outcome events occurred in 19 patients (3.5%), with similar prevalence in both groups (PFA, 4%; vHPSD, 3%; P = .745). After a median follow-up of 12 (9–12) months, survival free from recurrent atrial tachyarrhythmia was similar between the PFA and vHPSD groups, both overall (12-month estimate: PFA, 75%; vHPSD, 76%; log-rank P = .73) and in propensity score–matched patients (n = 342; 12-month estimate: PFA, 75%; vHPSD, 77%; log-rank P = .980). ConclusionIn a large, multicenter experience, PFA was associated with more common use of general anesthesia, shorter procedural times, and longer fluoroscopy exposure compared with vHPSD ablation, with both techniques displaying superimposable safety and efficacy.

Safety and feasibility of zero-fluoroscopy technique in ablation-index guided pulmonary vein isolation: a prospective, single center trial

Abstract Introduction Pulmonary vein isolation (PVI) represents the cornerstone of catheter ablation procedures in patients with symptomatic paroxysmal/persistent atrial fibrillation (AF). Conventionally, PVI is performed using fluoroscopy, but it can also be performed using the zero-fluoroscopy (ZF) technique with the assistance of electroanatomical mapping systems and intracardiac ultrasound, achieving fluoroscopy-free procedures. Purpose Our study aimed to compare procedural data of ablation-index guided point-by-point radiofrequency (RF) PVI performed with non-zero-fluoroscopy (NZF) vs. ZF approaches. Methods We enrolled 100 consecutive patients undergoing PVI for antiarrhythmic drug- refractory AF in our prospective observational study. In the first 50 cases, PVI was performed using the NZF technique, and in the other 50 cases, the ZF technique was applied. Procedural time, fluoroscopy exposure, ablation parameters, and the occurrence of complications were compared between the two groups. Results Compared to the NZF group, procedural time (59.6±10.7 min vs. 74.6±13.2 min, p&amp;lt;0.0001) was significantly shorter in the ZF group. This difference was mainly driven by the time from puncture to the beginning of left atrial mapping, which was significantly longer in the NZF group (17 [16; 20] min vs. 31 [23; 34.5] min, p&amp;lt;0.001). No differences were found between the two approaches in the number of RF applications (81 [73; 103] vs. 83 [71; 91], p=0.67), total ablation energy (54986 ± 13093 Ws vs. 55500 ± 11907 Ws, p=0.48), and the left atrial dwelling time (41.5 [36; 52.5] min vs. 40.5 [35; 46], p=0.14). No complications occurred in either group. In the ZF group, complete elimination of fluoroscopy was achieved in all cases, resulting in significant differences in fluoroscopy time (0 [0; 0] sec vs. 132 [100; 160] sec, p&amp;lt;0.0001] and dose (0 [0; 0] mGy vs. 4.8 [4.1; 8.2] mGy, p&amp;lt;0.0001) compared to the NZF technique. The acute success rate was 100% in the study population, and no complications occurred during the study period. Conclusion Ablation-index guided ZF PVI is feasible and safe. Using this technique, the procedure time can be shortened besides achieving a similar acute success rate without increasing complications.

Posterior wall isolation in patients with persistent atrial fibrillation: a single center comparative study between ablation index and very high power short duration radiofrequency ablation protocol

Abstract Background Circumferential pulmonary veins ablation (CPVA) with posterior wall isolation (PWI) using radiofrequency catheter ablation (RFCA) is gaining increasing interest in terms of safety and efficacy. Purpose To compare procedural data and efficacy between two radiofrequency ablation protocols for the treatment of persistent atrial fibrillation (PersAF): very high power-short duration (vHPSD) ablation using a novel temperature-controlled ablation catheter and Ablation Index (AI) guided RFCA using traditional contact-force catheter. Methods This single center prospective study enrolled 75 consecutive patients (Group 1) with symptomatic PersAF undergoing RFCA using a novel contact-force catheter optimized for temperature-controlled ablation with microelectrodes and 6 thermocouples for real-time temperature monitoring during ablation. The vHPSD algorithm modulates power to maintain target temperature during these lesions (90 Watts, 4 s) in the posterior wall. RF delivery in anterior regions was performed in a temperature guided setting (1-45W, 45°C) to achieve a 500-550 AI. These patients were compared to 75 propensity matched patients (Group 2) undergoing PersAF ablation with traditional AI-guided ablation. Procedural data were compared between the two groups (Table 1). Procedural outcome was considered as loop recorder documented atrial arrhythmias recurrences and compared between the two groups. Results Seventy-five patients (69% male, 63.1±11.2 years old) underwent ablation with vHPSD protocol (Group 1). CPVA and PWI was achieved in all patients with total procedure and fluoroscopy times of 67.5±28.8 min and 4.5±2.8 min, respectively. After 12-month median follow-up, 57/75 patients (76%) were free from AF. Seventy-five propensity matched patients (69% male, 60.7±9.9 years old) have undergone ablation with standard contact-force catheter. CPVA and PWI was achieved in all patients with total procedure and fluoroscopy times of 81.99±20.5 min and 5.7±2.1 min, respectively. After 12-month median follow-up, 55/75 patients (73%) were free from AF. Procedural and fluoroscopy times were significantly lower in in Group 1 than in Group 2 (Table 1). AF recurrencies were comparable between the two groups as assessed with survival analysis (Figure 1, log-rank 0.509). There were no deaths or other severe periprocedural complications. Conclusions PWI on top of CPVA is effective in limiting arrhythmic recurrences following RFCA of PersAF. Compared to standard AI guided ablation, vHPSD protocol significantly reduces procedural time and fluoroscopy exposure. Clinical outcomes between the two protocols are similar.Figure 1

Optimizing outcomes in catheter ablation for typical atrial flutter: a comparative study of intracardiac echocardiography versus fluoroscopy guidance

Abstract Background Catheter ablation is a standard intervention for typical atrial flutters, specifically targeting the cavotricuspidal isthmus (CTI). Intracardiac echocardiography (ICE) plays a pivotal role in providing real-time visualization of anatomical structures during the electrophysiology procedure, thereby enhancing safety and potentially reducing reliance on fluoroscopy, leading to improved procedural outcomes. We aimed to conduct a comparative analysis of procedural and follow-up outcomes between ICE-guided and fluoroscopy-only guided catheter ablations for CTI in patients undergoing treatment for typical atrial flutter. Methods A retrospective analysis was conducted at our university center, encompassing 376 consecutive patients in a single-center study. Of these, 158 underwent procedures guided solely by fluoroscopy, while 218 received ICE-guided CTI ablation. Results ICE-guidance demonstrated a statistically significant reduction in fluoroscopy time (72 [36; 170] s vs. 888 [578; 1184] s; p&amp;lt;0.01), total procedure time (70 [52; 90] min vs. 90 [60; 105] min; p&amp;lt;0.01), total ablation time (692 [435; 998] s vs. 920 [629; 1373] s; p&amp;lt;0.01), and the duration from the first to last ablation (20.5 [12; 37] min vs. 41.0 [26.8; 59.3] min; p&amp;lt;0.01). Both groups achieved a 100% acute success rate without major complications. The ICE-guided group exhibited a significantly superior long-term success rate (ICE-guided group: 95.74%, fluoroscopy-only group: 89.26%; p=0.048) compared to the fluoroscopy-only group at an average follow-up length of 34 months. Conclusion The utilization of ICE-guidance for CTI ablation significantly reduces fluoroscopy exposure, procedure time, and ablation time, ultimately contributing to enhanced long-term success rates when compared to the conventional fluoroscopy-only approach.

Remote magnetic navigation for catheter ablation of complex arrhythmias in congenital heart disease: an initial experience using a transnational telerobotic approach

Abstract Background The field of congenital electrophysiology (EP) is still in its relative infacncy with a limited number of electrophysiologists capable of performing catheter ablation in patients with congenital heart disease (CHD). As a result, patients or physicians are often required to travel great distances to performed specialised ablation procedures, something made near impossible during the COVID-19 pandemic. Objective We aimed to explore the feasibility and safety of a telerobotic approach to catheter ablation where the remote operator was situated approximately 1200km away from the patient and local team. Methods A 3D-printed 'phantom' heart was used in a pilot experiment in which no significant difference was seen between the local and remote operators in electroanatomic (EAM) mapping of the phantom heart using remote magnetic navigation (RMN). Catheter ablation was subsequently performed in patients with severe CHD using a transnational telerobotic approach to catheter ablation where the remote operator was able to view the dedicated console with live fluoroscopy, EAM and EP signals, as well as control the mapping and ablation catheters from 1200km away. As a safety precaution, radiofrequency (RF) could only be delivered by the local team. Results In total, 10 procedures were performed in 9 patients with severe CHD (mean age 38) between April and December 2021. All patients underwent an atrial ablation and one additional non-CHD patient underwent denervation of the pulmonary arteries. Median procedure duration was 335 (minutes) (IWR 230-349) with 11.5 minutes (QRS 3-15.4) of fluoroscopy exposure and 752 (IQR 674-905) seconds of RF delivery. There were no acute procedural complications. At one-year follow-up, one patient died as a result of heart failure and there were two arrhythmia recurrences. Conclusions Telerobotic catheter ablation is feasible and effective and creates the possibility of exciting new approaches to remote ablation and its use in the tele-proctoring of international fellows.