Interventional Cardiac Electrophysiology Research Articles

The head of invasive cardiologists as a target of professional exposure to ionizing radiation

Exposure to ionizing radiation has recognized detrimental cancer and non-cancer health effects. These effects are now well-proven not only for high doses > 1,000 millisieverts (mSv) associated with head radiotherapy but also for moderate (100–1,000 mSv) and even low (< 100 mSv) doses, of interest for professionally exposed cardiologists. The head of interventional cardiologists is highly exposed to ionizing radiation, with possible damage to the eye and brain. Unprotected interventional cardiologists experience head radiation doses up to ten times greater than chest doses below lead aprons, with marked exposure to the left hemisphere of the brain reaching up to 2 Sv—equivalent to 10,000 chest X-rays over a professional lifetime. This narrative review aims to provide an overview of the background of radioprotection, the biological mechanisms involved, and the epidemiological evidence regarding the health effects of head exposure to ionizing radiation in invasive cardiologists. These health effects include cataracts, brain cancer, cerebrovascular diseases, neurodegeneration, and mood disorders. The evidence gathered from other exposed populations, which experienced similar eye and brain doses, has also been reviewed. This is important because the doses, risks, and effects are consistent in cases of repeated exposures, which occur more frequently for patients, and in situations involving chronic low doses, as seen with interventional cardiologists. Despite these risks, effective protective measures—such as suspended lead ceilings, curtains, and specialized eyewear—can reduce radiation exposure to near-zero levels. In some fields, like interventional cardiac electrophysiology, a groundbreaking near-zero radiation approach using non-fluoroscopic methods has been created, eliminating radiation exposure and alleviating orthopedic stress and operational discomfort. The race to zero radiation in interventional cardiology is ongoing.

Bacteria and the growing threat of multidrug resistance for invasive cardiac interventions.

Invasive cardiovascular procedures which include heart transplantations, congenital heart surgery, coronary artery bypass grafts, cardiac valve repair and replacement, and interventional cardiac electrophysiology procedures represent common mechanisms to treat a variety of cardiovascular diseases across the globe. The majority of these invasive approaches employ antibiotics as a regular and obligatory feature of the invasive procedure. Although the growing incidence of bacterial resistance to currently used antibiotics threatens to curtail the use of all interventional surgical techniques, it remains an underappreciated threat within the arsenal of cardiovascular therapies. It is reasonable to expect that the continued overuse of antibiotics and the frequent management of coronavirus disease 2019 (COVID-19) infected patients with high doses of antibiotics will inevitably accentuate the rise of multidrug resistance. The purpose of this article is to heighten awareness of the role of bacterial infections in cardiovascular disease, the use of antibiotics in today's cardiovascular surgical theaters, the threat facing cardiovascular surgery should multidrug resistance continue to rise unabated, and the development of new antibiotic platforms to solve this problem.

Canadian national electrophysiology ablation registry report 2011\u20132016

Background/purpose: Interventional cardiac electrophysiology (EP) is a rapidly evolving field in Canada; a nationwide registry was established in 2011 to conduct a periodic review of resource allocation.MethodsThe registry collects annual data on EP lab infrastructure, imaging, tools, human resources, procedural volumes, success rates, and wait times. Leading physicians from each EP lab were contacted electronically; participation was voluntary.ResultsAll Canadian EP centres were identified (n = 30); 50 and 45 % of active centres participated in the last 2 instalments of the registry. A mean of 508 ± 270 standard and complex catheter ablation procedures were reported annually for 2015–2016 by all responding centres. The most frequently performed ablation targets atrial fibrillation (PVI) arrhythmia accounting for 36 % of all procedures (mean = 164 ± 85). The number of full time physicians ranges between 1 and 7 per centre, (mean = 4). The mean wait time to see an electrophysiologist for an initial non-urgent consult is 23 weeks. The wait time between an EP consult and ablation date is 17.8 weeks for simple ablation, and 30.1 weeks for AF ablation. On average centres have 2 (range: 1–4) rooms equipped for ablations; each centre uses the EP lab an average of 7 shifts per week. While diagnostic studies and radiofrequency ablations are performed in all centres, point-by-point cryoablation is available in 85 % centres; 38 % of the respondents use circular ablation techniques.ConclusionsThis initiative provides contemporary data on invasive electrophysiology lab practices. The EP registry provides activity benchmarks on national trends and practices.

Cardiac electrophysiology and pacing educational and training needs among early-career cardiologists: a national survey of the Young Committee of the Italian Association of Arrhythmology and Cardiac Pacing.

Over the past three decades, cardiac electrophysiology and pacing, including device therapy and catheter ablation of arrhythmias, has rapidly developed as a subspecialty in cardiology. Currently, there is no clear perception about the needs in cardiac electrophysiology and pacing among early-career cardiologists. To address these concerns, the Young Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) carried out a survey among those under the age of 40 years to obtain detailed information on practical activities and formal lessons during the fellowship in cardiology and their satisfaction and proficiency level at the end of the fellowship. We obtained 334 answers to the survey. In invasive cardiac electrophysiology and pacing, the percentage of participants attending the activity for a longer time (3-6 months) is lower compared with those in noninvasive subspecialties. About 40% of participants did not receive lessons on interventional cardiology, cardiac electrophysiology and pacing. On the contrary, 71% of participants received an adequate number of lessons on clinical arrhythmology. The vast majority of the participants expressed satisfaction for the education received in the echocardiographic, cardiac interventional laboratories and clinical arrhythmology, but about half of the participants were unsatisfied with the education received in cardiac electrophysiology and pacing. In interventional arrhythmology, the majority of the participants declare their lack of proficiency with two peaks for more complex procedures, namely interventional electrophysiology procedures (82%) and cardiac resynchronization therapy (CRT) procedures (76%). The present survey among Italian early-career cardiologists suggests that the majority of participants consider themselves not confident in performing cardiac electrophysiology and pacing procedures. Due to the complexity of the treatment for heart rhythm disorders and the long learning curve, structured additional training in cardiac electrophysiology and pacing procedures is required after cardiology fellowship.

Position paper concerning the competence, performance and environment required for the practice of ablation in children and in congenital heart disease

The population of patients with congenital heart disease (CHD) is continuously increasing, and a significant proportion of these patients will experience arrhythmias because of the underlying congenital heart defect itself or as a consequence of interventional or surgical treatment. Arrhythmias are a leading cause of mortality, morbidity and impaired quality of life in adults with CHD. Arrhythmias may also occur in children with or without CHD. In light of the unique issues, challenges and considerations involved in managing arrhythmias in this growing, ageing and heterogeneous patient population and in children, it appears both timely and essential to critically appraise and synthesize optimal treatment strategies. The introduction of catheter ablation techniques has greatly improved the treatment of cardiac arrhythmias. However, catheter ablation in adults or children with CHD and in children without CHD is more technically demanding, potentially causing various complications, and thus requires a high level of expertise to maximize success rates and minimize complication rates. As French recommendations regarding required technical competence and equipment are lacking in this situation, the Working Group of Pacing and Electrophysiology of the French Society of Cardiology and the Affiliate Group of Paediatric and Adult Congenital Cardiology have decided to produce a common position paper compiled from expert opinions from cardiac electrophysiology and paediatric cardiology. The paper details the features of an interventional cardiac electrophysiology centre that are required for ablation procedures in adults with CHD and in children, the importance of being able to diagnose, monitor and manage complications associated with ablations in these patients and the supplemental hospital-based resources required, such as anaesthesia, surgical back-up, intensive care, haemodynamic assistance and imaging. Lastly, the need for quality evaluations and French registries of ablations in these populations is discussed. The purpose of this consensus statement is therefore to define optimal conditions for the delivery of invasive care regarding ablation of arrhythmias in adults with CHD and in children, and to provide expert and - when possible - evidence-based recommendations on best practice for catheter-based ablation procedures in these specific populations.

Evaluating Eye Lens Dose of Neurovascular and Cardiac Electrophysiology Interventional Physician

The International Commission on Radiological Protection recommended that interventional radiologies (IRs) have high radiation doses and that staff may also be exposed to high doses. In the present study, we measured the radiation exposure dose [3 mm dose equivalent, Hp (3) ] in the eye using an appropriate dosimeter placed next to the physician' s eye during neurovascular intervention procedure (Neuro-IR) and interventional cardiac electrophysiology procedure (EP-IR). Physicians wore a direct eye dosemeter just lateral to the left eye and an additional direct eye dosemeter outside the radiation protective glasses close to their left eye. Additionally, a neck badge [0.07 mm dose equivalent, Hp (0.07) ] was worn outside the protective apron to the left of the neck, to compare the direct eye dosimeter estimated doses. The occupational eye lens dose was evaluated over a period of 6-month. The maximum Hp (3) of the Neuro-IR physician was estimated 5.1 mSv without the radiation protective glasses and 1.6 mSv with the radiation protective glasses. On the other hand, the maximum Hp (3) of the EP-IR physician was estimated 29 mSv without the radiation protective glasses and 15 mSv with the radiation protective glasses. Physicians eye lens dose [Hp (3) ] tended to be overestimated by the neck badge measurements [Hp (0.07)]. A correct evaluation of the lens dose [Hp (3) ] using the direct eye dosimeter is recommended. Although we found a positive correlation between Hp (0.07) and Hp (3), the value of R2 in the regression equation is low, we recommended that the eye lens dose estimated carefully from Hp (0.07).

Gender differences in cardiac interventions

Differences in pathophysiology, clinical presentation, and outcomes of cardiovascular disease in men and women have been known for decades, but are not fully understood; women are underrepresented in most cardiovascular trials. Furthermore, women remain a minority in interventional cardiology and clinical cardiac electrophysiology.

Acknowledgment and tribute to Dr. Sanjeev Saksena, Editor-in-Chief of the Journal of Interventional Cardiac Electrophysiology (JICE).

Acknowledgment and tribute to Dr. Sanjeev Saksena, Editor-in-Chief of the Journal of Interventional Cardiac Electrophysiology (JICE).

Current status of interventional cardiac electrophysiology training in ESC member countries: an EHRA Young EP Report

Current status of interventional cardiac electrophysiology training in ESC member countries: an EHRA Young EP Report

CANADIAN ELECTROPHYSIOLOGY LABS REGISTRY REPORT UPDATE 2011-2018

Interventional cardiac electrophysiology (EP) is a rapidly evolving field; a nationwide registry was established and re-administered since 2011 to conduct a periodic review of resource allocation across Canada. A retrospective questionnaire was designed to collect data regarding EP laboratory infrastructure, imaging, human resources, procedural volumes, and wait times. Leading physicians from each EP lab were contacted electronically; participation was voluntary. Each survey collected data over two calendar years. All existing Canadian EP centres were identified (29 in 2011, 31 in 2018); 50% and 45% of active centres participated in the last two instalments of the registry. Since the registry’s inception in 2011, data has been consistently obtained from 11 centres. All eleven centres are university-affiliated. The number of full time physicians ranges between one and seven, (mean of 4 per centre). Table 1 reports trends in procedural volumes and operators. The mean wait time to see an electrophysiologist for an initial non-urgent consult is 23 weeks. The wait time between an EP consult and ablation date is 17.8 weeks for a simple ablation, 15.9 weeks for a VT ablation, and 30.1 weeks for an AF ablation. On average centres have two (range: 1-4) rooms equipped for ablations; each centre uses facilities an average of seven daily shifts per week. While diagnostic studies and radiofrequency ablations are performed in all centres, point-by-point cryoablation is available in 85% and cryoballoon in 77% of the centres; 23% and 15% of the respondents use PVAC and NMARQ technology respectively. Two centres actively use remote magnetic navigation systems. CARTO and intracardiac echo are the most commonly utilized 3D mapping systems in 11 (85%) centres, followed by EnSite-NavX Velocity in nine (69%), EnSite-NavX Precision in 7 (54%), Mediguide in two (15%) centres, Rhythmia and LocaLisa are used in one centre each. Philips is the most widely used imaging system in 85% of centres, followed by Siemens in 54% centres. Non-3D tracing systems were operated by technicians in 23% of the centers in 2016, up from 50% in 2011. Industry representatives are increasingly operating 23% of the tracing systems up from 11% in 2011. This initiative provides contemporary information on invasive electrophysiology lab practices. The results show a feasibility in ongoing data collection which will serve as a reference for decisions regarding the needs of laboratories and research planning. This data provides basic benchmarks of national resources and may assist local resource planning.

Irreversible electroporation ablation for atrial fibrillation.

Atrial fibrillation (AF) is one of the most important problems in modern cardiology. Thermal ablation therapies, especially radiofrequency ablation (RF), are currently "gold standard" to treat symptomatic AF by localized tissue necrosis. Despite the improvements in reestablishing sinus rhythm using available methods, both success rate and safety are limited by the thermal nature of procedures. Thus, while keeping the technique in clinical practice, safer and more versatile methods of removing abnormal tissue are being investigated. This review focuses on irreversible electroporation (IRE), a nonthermal ablation method, which is based on the unrecoverable permeabilization of cell membranes caused by short pulses of high voltage/current. While still in its preclinical steps for what concerns interventional cardiac electrophysiology, multiple studies have shown the efficacy of this method on animal models. The observed remodeling process shows this technique as tissue specific, triggering apoptosis rather than necrosis, and safer for the structures adjacent the myocardium. So far, proposed IRE methodologies are heterogeneous. The number of devices (both generators and applicators), techniques, and therapeutic goals impair the comparability of performed studies. More questions regarding systemic safety and optimal processes for AF treatment remain to be answered. This work provides an overview of the electroporation process, and presents different results obtained by cardiology-oriented research groups that employ IRE ablation, with focus of AF-related targets. This contribution on the topic aspires to be a practical guide to approach IRE ablation for cardiac arrhythmias, and to highlight controversial features and existing knowledge, to provide background for future improved experimentation with IRE in arrhythmology.

Utility and Safety of Combined Interventional Catheterization and Electrophysiology Procedures in a Children's Hospital.

Interventional cardiac catheterization (cath) and electrophysiology (EP) procedures are not routinely performed together. There are several perceived barriers affecting this practice, though there are also advantages for both the patient and practitioner to a combined approach. This was a single-center retrospective study reviewing combined cath and EP procedures with a preprocedural intention to intervene at Texas Children's Hospital from 2001 to 2014. We excluded procedures in which the intended procedure was purely diagnostic in nature. A total of 121 patients requiring 125 procedures were identified, of which 61 patients underwent 62 procedures that met our inclusion criteria. Potential subgroups of interest included adult congenital heart disease patients (26% of cohort), single ventricle anatomy (34%), and heterotaxy (19%) and collectively 58% of procedures involved a patient in one of these groups. The combined nature of the procedure did not preclude a cath or EP intervention in any patient. There were no mortalities. There were three adverse events, affecting 4.8% of procedures. Combined interventional cardiac cath and EP procedures in pediatric patients and those with congenital heart disease can be performed safely in a high-volume center. These combined procedures save patients the risk and inconvenience of multiple procedures, and further investigation into cost savings is warranted.

The establishment of comprehensive cardiac care centre

Salman Abdulla Aldabbous Cardiac Centre in Aladan hospital was inaugurated in February 2010. Constructed with generous grant from Mr. Salman Abdulla Aldabbous, the centre was a progression for the cardiology division services at Aladan hospital which till then was part of the internal medicine department. The centre serves a population of 1.3 million in the Governorates of Ahmadi and Mubarak Alkabeer in the State of Kuwait. The centre includes of 20 bed coronary care unit, 40 beds for inpatients, 2 catheterization suites, 2 operating room suites and 3 bed cardiac surgical intensive care unit. Tremendous amount of work went into staffing it before and after its opening in 2010. Our vision was to equip it in a way to become a standalone centre of excellence in the country to be able to provide all types of cardiac services including diagnostic and interventional cardiac catheterization procedures, electrophysiology procedures and cardiac surgery. This was a huge challenge that involved employing trained human resources from nurses, technicians and doctors as well as …

Snapshot of adult invasive cardiac electrophysiology in Canada: results of the web-based registry.

Interventional cardiac electrophysiology (EP) has experienced a significant growth in Canada. Our aim is to establish a periodic registry as a nationwide initiative. The registry is designed to collect information regarding EP laboratory infrastructure, human resources, and the spectrum and volumes of EP procedures. Respective administrative staff were contacted electronically. Out of 25 identified Canadian EP centers, 19 centers (76%) have participated in the registry. Responding centers have access on average to 5.3 lab days per week to perform EP studies/ablations; average lab time per full- and part-time (prorated to 0.5) EP physician is 0.8 day per week. Diagnostic EP studies and radio-frequency ablations are performed in all (19) centers; cryoablation is available in 83% of centers. Two centers have remote magnetic navigation systems. EnSite NavX is the most widely available 3D mapping system utilized in 15 (83%) centers, followed by CARTO and intracardiac echo which are each available in 14 (78%) centers; LocaLisa is actively used in one center. The number of full-time physicians ranges between 0 and 7, with a mean of 3.5 full-time physicians per center. The ratio of staff to trainees is 1.6:1. A total of 8,041 EP procedures are performed in the 19 centers per annum. On an annual average, 104 procedures per one operator and 159 procedures per trainee are performed. This registry provides contemporary information on invasive EP lab resources and procedures in Canada. It also demonstrates that Canadian EP procedural intensities of practice and training are comparable to international standards.

Objective quality assessment of atrial fibrillation ablation: A novel scoring system

health-care processes and overall patient outcomes. 1 However, these critical evaluations have been lacking in the field of interventional cardiac electrophysiology and in the assessment of catheter ablation for atrial fibrillation (CAAF) in particular. The clinical success of CAAF, the most common ablation procedure performed worldwide, is currently reported in terms of atrial fibrillation (AF) recurrence rates, an assessment strategy with considerable limitations. Since recognition of AF recurrence is largely based on the presence of symptoms and as recurrences are frequently asymptomatic, 2 this strategy can substantially underestimate the true incidence of postablation AF. Even when noninvasive monitoring is routinely used after ablation, the sensitivity for the detection of asymptomatic AF recurrences depends on the protocol used, with more aggressive arrhythmia surveillance certain to identify higher rates of recurrence. 3 Furthermore, the definition of AF burden (symptomatic and asymptomatic) used to define recurrence varies and there are discrepancies as to whether a requirement for antiarrhythmic drugs is considered separately from maintenance of sinus rhythm without adjuvant pharmacotherapy. 4 As a result, there are wide variations in reported recurrence rates after CAAF among centers and the factors accounting for these differences have not been systematically delineated. In addition, and perhaps most importantly, reported success rates do not account for procedural safety, precluding meaningful comparisons between different techniques. The appraisal of CAAF requires a more objective evaluation that combines data on the quality of lesion delivery, complication rates, and clinical outcomes. To develop a more comprehensive, less biased criterion to assess the quality of CAAF and standardize comparisons between ablation strategies, we devised a novel quantitative scoring system based on more objective measures of the ablation procedure and a weighted assessment of procedurerelated complications, which we have termed the AF ablation (AFA) score.

Endovascular brain intervention and mapping in a dog experimental model using magnetically-guided micro-catheter technology

Despite the substantial progress that has been achieved in interventional cardiology and cardiac electrophysiology, endovascular intervention for the diagnosis and treatment of central nervous system (CNS) disorders such as stroke, epilepsy and CNS malignancy is still limited, particularly due to highly tortuous nature of the cerebral arterial and venous system. Existing interventional devices and techniques enable only limited and complicated access especially into intra-cerebral vessels. The aim of this study was to develop a micro-catheter magnetically-guided technology specifically designed for endovascular intervention and mapping in deep CNS vascular structures. Mapping of electrical brain activity was performed via the venous system on an animal dog model with the support of the NIOBE II system. A novel micro-catheter specially designed for endovascular interventions in the CNS, with the support of the NIOBE II technology, was able to reach safely deep intra-cerebral venous structures and map the electrical activity there. Such structures are not currently accessible using standard catheters. This is the first study demonstrating successful use of a new micro-catheter in combination with NIOBE II technology for endovascular intervention in the brain.

N001 Demystifying the Electrophysiology Laboratory: An Introduction to Interventional Cardiac Electrophysiology for Cardiac Nurses

N001 Demystifying the Electrophysiology Laboratory: An Introduction to Interventional Cardiac Electrophysiology for Cardiac Nurses

JICE goes “social”

Social media is transforming health care. The Journal of Interventional Cardiac Electrophysiology (JICE) has launched its own social media presence and is now on Facebook. JICE will post each issue's table of contents, special articles, online-first publications to allow real-time notifications to JICE's readers and fans of our Facebook page. We encourage you to take the plunge and connect to our Facebook page.

Twenty years of interventional cardiac electrophysiology: Meeting future challenges with continuing innovations

The “Sixth International Symposium on Interventional Elec-trophysiology in the Management of Cardiac Arrhythmias”was held in Newport, Rhode Island on September 24–26,2010. This symposium commemorated a special landmark inclinical cardiac electrophysiology. Twenty years had elapsedsince the first in this series of symposia recognized interven-tional electrophysiology as a distinct scientific discipline. In1990,thissymposiumwastheveryfirst internationalmeetingdevoted exclusively to the fundamentals of science andclinical practice of interventional electrophysiology. Theumbrella of “interventional electrophysiology” gathered suchdiverse but fundamentally linked sciences of experimentalelectrophysiology, epidemiology, pharmacotherapy, cardiacpacing, defibrillation, catheter and surgical ablation, imaging,and clinical trials as applied to the management of cardiacarrhythmias. The crystallization of this discipline and thebreadthanddepthofscienceinthisfieldledtotheevolutionofa committed scientific journal devoted to it, the Journal ofInterventional Cardiac Electrophysiology. The meeting con-tinues a longstanding tradition of providing a scientificforum for experts from Europe and North America to presentfrontiers in research as well as critically evaluate develop-ments in interventional cardiac electrophysiology in ascientific forum. The presentations at this meeting are thebasisforaseriesofreviewarticlesthathavebeencriticallyacclaimed in past years and memorialized in print, initially intextbook form and more recently as special issues of theJournal of Interventional Cardiac Electrophysiology.This symposium’s scientific program was restructured tofocus on translational science, new technology, and therestructuring of clinical practice based on clinical trials inour field. Regenerative medicine, genomics, and molecularbiologic research into inherited or acquired heart rhythmdisorders assumed center stage in basic science presentations.Innovations in technology bought imaging methods in clinicalelectrophysiology into focus. New catheter navigation tech-nology, computed tomographic and magnetic resonanceimaging methods, intracardiac and three-dimensional echocar-diography, and essentials of clinical interpretation of theseimagingdatafortheinterventionalistboughtanewfrontierintoview, the “integrated” electrophysiologic laboratory. Newdevelopments in device and ablation therapy were reviewedin the context of evidence-based practice. The rise ofperformance standards and metrics for arrhythmia programs,impact of clinical trials, and registries on interventionalelectrophysiologic practice and outcomes research in clinicalelectrophysiologyfocusedthediscussionsonthepathaheadforthe interventional electrophysiologist.TheNewportsymposiumhasnowbeenmemorializedwiththe authors preparing state-of-the-art review articles for twospecial issues of the journal. The first issue encompassesadvances in basic and translation science, imaging, newtechnology and developing standards for patient follow-upand management, catheter and surgical ablation, and clinicaltrials in drug, device, and ablation therapies. Special issueslikethisonearenot possiblewithout the enormoussupport ofour authors and our editorial staff. We are grateful to theauthors for this serious effort to critically assess our current

Ectopic Focus in an Accessory Left Atrial Appendage

A 65-year-old man with symptomatic atrial fibrillation refractory to medical therapy was referred for repeat pulmonary vein (PV) isolation. Clinical symptoms included paroxysmal palpitations once to twice per week with associated light-headedness and chest pain. Initial PV isolation had been performed 6 months earlier without cessation of atrial fibrillation despite combined medical therapy with oral flecainide and bisoprolol. His past medical history was significant for hypertension, and in his family history, 1 brother had experienced a stroke at the age of 57 years. Physical examination, ECG, chest radiography, and coronary angiography were normal. Holter 24-hour ECG recordings revealed occasional atrial premature beats and paroxysmal atrial tachycardia. A magnetic resonance imaging study of the patient’s PVs and left atrium (LA) was performed before the repeat radiofrequency ablation. Images were acquired with a 1.5-T whole-body magnetic resonance system (Siemens Avanti, Siemens Medical Solutions, Forcheim, Germany) with an 8-element cardiac synergy coil for radiofrequency signal reception. First-pass breath-hold 3-dimensional contrast-enhanced magnetic resonance angiography of the PV was obtained after pump injection (3 mL/s) of 15 mmol of …