Interventional Electrophysiology Research Articles

2D and 3D TEE evaluation of an early reopening of the LARIAT epicardial left atrial appendage closure device

2D and 3D TEE evaluation of an early reopening of the LARIAT epicardial left atrial appendage closure device Luigi Di Biase, MD, PhD, FHRS, J. David Burkhardt, MD, FHRS, Douglas N. Gibson, MD, FHRS, Andrea Natale, MD, FHRS From the Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, Albert Einstein College of Medicine at Montefiore Hospital, New York, New York, Department of Biomedical Engineering, University of Texas, Austin, Texas, Department of Cardiology, University of Foggia, Foggia, Italy, and Interventional Electrophysiology, Scripps Clinic, San Diego, California.

Anatomical relationship of coronary sinus/great cardiac vein and left circumflex coronary artery along mitral annulus in atrial fibrillation before radiofrequency catheter ablation using 320-slice CT

PurposeWe evaluated anatomical relationships between the coronary sinus and great cardiac vein (CS/GCV) and left circumflex coronary artery (LCX) along the mitral annulus (MA) in patients with atrial fibrillation (AF) using 320-slice CT. MethodsFifty-three patients with AF (44 males; mean 63±11years; 28 paroxysmal, 10 persistent, and 15 permanent AF) underwent 320-slice CT. Double-oblique CT images perpendicular to the MA short axis were created every 10° for 36 circumferential sections. The angle of 0° corresponded to the 12 o'clock position. ResultsCS/GCV-MA distance was greatest in the posterolateral MA. CS/GCV diverged from the LCX more widely in the lateral through posterolateral MA than the anterior through anterolateral MA. CS/GCV crossed the LCX in 51 patients (96.2%) and left main coronary artery in 2 patients (3.8%). Median angle of the CS/GCV-LCX crossing point was at 40° but ranged widely (0° to 150°) and was more frequent in the anterior and anterolateral MA than in the lateral, posterolateral, and posterior MA (31.4%, 45.1%, 11.8%, 11.8%, and 0%, respectively; P<0.01). CS/GCV crossed over the LCX in 39 patients and under the LCX in 12 patients. Range of the CS/GCV-LCX overlapping course increased significantly as the CS/GCV-LCX crossing point neared the CS ostium. Correlation coefficient between the range of the overlapping course and crossing point angle was 0.78. ConclusionsAnatomical relationships between CS/GCV and LCX greatly varied in location and proximity among AF patients. Interventional electrophysiologists should know the potential risk for LCX injury when radiofrequency energy is delivered within the CS/GCV.

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Asymptomatic cerebral embolization in catheter ablation of atrial fibrillation—Can it be avoided?

Cerebral embolization in invasive cardiovascular procedures is a known problem that has seen some revived attention over the past several months. In interventional electrophysiology, left atrial ablation for the treatment of atrial fibrillation (AF) is the most commonly performed procedure that is known to be associated with this. Fortunately, the incidence of clinically manifest transient ischemic attack or cerebrovascular accidents in AF ablation is low.1 The issue of asymptomatic cerebral emboli (ACE) remains of significant concern, with magnetic resonance imaging studies showing a substantial burden of acutely asymptomatic brain lesions.

Quality of atrial fibrillation ablation:‬ “Success is not final, failure is not fatal; is it the score that matters?”

In the current issue of HeartRhythm, Chinitz et al present a novel scoring system (atrial fibrillation ablation [AFA] score) for evaluating the quality and success of catheter ablation for the treatment of paroxysmal atrial fibrillation (AF). We have paraphrased the words attributed to Sir Winston Churchill to give context to the transience of the wins and losses perceived in the greater battle against the formidable opponent of AF. We did this in order to shed light, and to pause and think of the direction AF ablation— the most prolific business in interventional electrophysiology —is taking. In their article, Chinitz et al underline the fact that a scoring system that incorporates quality and success has not been available for AF ablation and that the current use of AF recurrence as an outcome measure has limitations. The AFA score takes into account disparate factors such as lesion delivery, complications, and outcomes in order to evaluate the results and quality of AF ablation and allows for comparison of different techniques. This is achieved by incorporating 6 procedural features, half of which estimate efficacy and the other three reflect the relative acute safety of the procedure. A very strong emphasis is made on the total number of procedures performed, as seen in the relatively high score achieved by radiofrequency ablation in their article compared with emerging balloon techniques (cryo and laser), even though both redo and reconduction rates are quite similar among all methods, as seen in their Table 1. Although one would consider the novelty of this score may lie (if validated against meaningful outcomes) in its value in showing differences among manufacturers, operators, techniques, and institutions, the devil is always in the details. Like all creative concepts, this concept paper raises more questions than provides solutions to the problem at hand. What would this difference in score mean to the patient we hope to care for? The user of this score will not take into account the very premise for performing the procedure, that is, symptom relief. The score will only allow for comparison of nonpharmacologic treatment strategies that strictly target the pulmonary veins and does not permit comparison of AF

Recommendations for occupational radiation protection in interventional cardiology

The radiation dose received by cardiologists during percutaneous coronary interventions, electrophysiology procedures and other interventional cardiology procedures can vary by more than an order of magnitude for the same type of procedure and for similar patient doses. There is particular concern regarding occupational dose to the lens of the eye. This document provides recommendations for occupational radiation protection for physicians and other staff in the interventional suite. Simple methods for reducing or minimizing occupational radiation dose include: minimizing fluoroscopy time and the number of acquired images; using available patient dose reduction technologies; using good imaging-chain geometry; collimating; avoiding high-scatter areas; using protective shielding; using imaging equipment whose performance is controlled through a quality assurance programme; and wearing personal dosimeters so that you know your dose. Effective use of these methods requires both appropriate education and training in radiation protection for all interventional cardiology personnel, and the availability of appropriate protective tools and equipment. Regular review and investigation of personnel monitoring results, accompanied as appropriate by changes in how procedures are performed and equipment used, will ensure continual improvement in the practice of radiation protection in the interventional suite. These recommendations for occupational radiation protection in interventional cardiology and electrophysiology have been endorsed by the Asian Pacific Society of Interventional Cardiology, the European Association of Percutaneous Cardiovascular Interventions, the Latin American Society of Interventional Cardiology, and the Society for Cardiovascular Angiography and Interventions.

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.

Health technology assessment in interventional electrophysiology and device therapy: a position paper of the European Heart Rhythm Association

Healthcare systems face an increasing demand for costly medical interventions. The primary concern of a physician is centred around the best possible treatment for his or her patients, according to patients' requests and expectations. The healthcare system, in contrast, is ideally concerned with the assignment of resources in the best interest of society.1 Clinicians, public health physicians, economists, commissioners, managers, and politicians need to find ways to balance between what is best for the individual patient and what society can realistically afford.1–3 Appraisals of the clinical effectiveness, cost-effectiveness, cost-impact, and commissioning of emerging therapies can inform such judgements and decisions. Health technology assessments (HTAs) provide a means for assessing the clinical and cost-effectiveness of healthcare interventions.4 The aim of HTAs is to provide unbiased, rigorous, and transparent guidance in the application of emerging therapies, in the background of available resources.5,6 They are, in effect, a link between clinical evidence and policy-making, informing government agencies, healthcare professionals and administrators, private sector organizations, the healthcare industry, as well as patients, carers, and the general public. The past decade has witnessed relentless advances in interventional electrophysiology and device therapy. This has mainly been attributable to the development of cardiac resynchronization therapy (CRT),7 the widening indications for implantable cardioverter defibrillator therapy,8,9 and the emergence of ablation for atrial fibrillation (AF).10–12 Characteristically, these therapies involve initial costly equipment and procedures, delivered in a specific infrastructure, while their benefits are generally accrued over the long term. Not surprisingly, such therapies attract scrutiny from commissioners and policy-makers. In this position paper, we review a series of issues that are related to HTAs for catheter ablation and device therapy and that in our view deserve attention. The mission of a HTA is to …

National Registry on Cardiac Electrophysiology (2010 and 2011)

Based on a survey sent to Portuguese centers that perform diagnostic and interventional electrophysiology and/or implant cardioverter-defibrillators (ICDs), the authors analyze the number and type of procedures performed during 2010 and 2011 and compare these data with previous years.In 2011, a total of 2533 diagnostic electrophysiologic procedures were performed, which were followed by ablation in 2013 cases, a steady increase over previous years. The largest share of this increase compared to 2010 was in atrial fibrillation, which is now the second most frequent indication for ablation, after atrioventricular nodal reentrant tachycardia.The total number of ICDs implanted in 2011 was 1084, of which 339 were biventricular (BiV) cardiac resynchronization devices (BiV ICDs). This represents an increase in the total number relative to previous years, 2011 being the first year in which the rate of new ICD implantations in Portugal exceeded 100 per million population. However, compared to 2010, the number of BiV ICDs implanted decreased, despite the recent publication of updated European guidelines on device therapy in heart failure, which clarified and expanded the indications for implantation of these devices.Some comments are made on the current status of cardiac electrophysiology in Portugal and on factors that may influence its development in the coming years.

Registo Nacional de Eletrofisiologia Cardíaca (2010 e 2011)

Based on a survey sent to Portuguese centers that perform diagnostic and interventional electrophysiology and/or implant cardioverter-defibrillators (ICDs), the authors analyze the number and type of procedures performed during 2010 and 2011 and compare these data with previous years.In 2011, a total of 2533 diagnostic electrophysiologic procedures were performed, which were followed by ablation in 2013 cases, a steady increase over previous years. The largest share of this increase compared to 2010 was in atrial fibrillation, which is now the second most frequent indication for ablation, after atrioventricular nodal reentrant tachycardia.The total number of ICDs implanted in 2011 was 1084, of which 339 were biventricular (BiV) cardiac resynchronization devices (BiV ICDs). This represents an increase in the total number relative to previous years, 2011 being the first year in which the rate of new ICD implantations in Portugal exceeded 100 per million population. However, compared to 2010, the number of BiV ICDs implanted decreased, despite the recent publication of updated European guidelines on device therapy in heart failure, which clarified and expanded the indications for implantation of these devices.Some comments are made on the current status of cardiac electrophysiology in Portugal and on factors that may influence its development in the coming years.

Kardiales CT und Ablation von Vorhofflimmern

Both cardiac computed tomography (CT) and interventional electrophysiology (EP) have evolved considerably in recent years. Technical improvements in CT have significantly reduced the radiation dose in cardiac applications. This imaging technology plays an important role in preprocedural planning and guidance of the procedures in many EP centers worldwide. Furthermore, CT is the imaging modality of choice to diagnose relevant complications in ablation of atrial fibrillation, e.g. pulmonary vein stenosis or atrioesophageal fistula. In anatomically driven ablation procedures, such as balloon-based procedures in atrial fibrillation, detailed analysis of the relevant cardiac structures is absolutely crucial not only to reduce radiation exposure and procedure times but also to improve ablation success and to reduce the occurrence of complications. Current software applications enable 3-dimensional reconstruction of cardiac images and the integration into electroanatomical navigation systems. This article reviews the available evidence in this field and highlights recent developments in image guidance for ablation of atrial fibrillation.

Mapping and Ablation of the Pulmonary Veins and Cavo-Tricuspid Isthmus With a Magnetic Resonance Imaging–Compatible Externally Irrigated Ablation Catheter and Integrated Electrophysiology System

Background— Magnetic resonance imaging (MRI)–guided interventional electrophysiology (EP) has rapidly emerged as a promising alternative to x-ray–guided ablation. We aimed to evaluate an externally irrigated MRI-compatible ablation catheter and integrated EP pacing and recording system, testing the feasibility of pulmonary vein and cavo-tricuspid isthmus ablation. Methods and Results— Externally irrigated MRI-compatible ablation and diagnostic EP catheters and an integrated EP recording system (Imricor Medical Systems, Burnsville, MN) were tested in n=11 sheep in a 1.5-T MRI scanner. Power-controlled (40 W, 120-second duration) lesions were formed at the pulmonary vein and cavo-tricuspid isthmus. Real-time intracardiac electrograms were recorded during MRI. Steady-state free precession non–breath-hold images were repeatedly acquired to guide catheter navigation. Lesion visualization was performed using noncontrast (T2-weighted turbo spin echo pulse sequence) and gadolinium-diethylene triamine pentaacetic acid–enhanced T1-weighted imaging (inversion-recovery gradient echo pulse sequence). Catheters were able to be visualized and navigated under cardiovascular magnetic resonance guidance. In total, 8±2.5 lesions (radiofrequency time, 16±4.2 minutes) were formed at the pulmonary vein ostia, and 6.5±1.3 lesions (radiofrequency time, 13±2.2 minutes) were formed at the cavo-tricuspid isthmus, with the end point of bidirectional block. The mean procedure time was 150±55 minutes. Lesion visualization with both T2W imaging and contrast-enhanced imaging correlated with sites of injury at autopsy. Conclusions— These data demonstrate the feasibility of using multiple catheters, an integrated EP pacing and recording system, and externally irrigated ablation with cardiovascular magnetic resonance guidance to undertake clinically relevant biatrial mapping and ablation.

Invited Commentary

Invited Commentary

Nicht fluoroskopische Katheternavigation: das MediGuide™-System

Conventional fluoroscopy is the main technology for intracardiac device tracking in interventional cardiovascular procedures. For therapy delivery it carries the advantage of being able to instantaneously localize the device and its spatial relationship with respect to the moving target organ. However, besides the associated X-ray exposure, fluoroscopy only provides 2D orientation. For treatment of complex cardiac anatomies and substrates such as in interventional electrophysiology, 3-D mapping technologies have been introduced to facilitate spatial, anatomic, and electrical orientation. A new technological platform (MediGuide(™)) offers the option to continuously display the catheter tip on a prerecorded cine-loop allowing better anatomic understanding of the underlying substrate. We describe our initial experience using the system with diagnostic catheters only and the first procedures with the MediGuide(™) equipped ablation catheter (available since May 2012). We could show a significant decrease of fluoroscopy time in all types of procedures with comparable procedure times. No increase in complication rates was observed.

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.

A summary of recommendations for occupational radiation protection in interventional cardiology

The radiation dose received by cardiologists during percutaneous coronary interventions, electrophysiology procedures, and other interventional cardiology procedures can vary by more than an order of magnitude for the same type of procedure and for similar patient doses. There is particular concern regarding occupational dose to the lens of the eye. This document provides recommendations for occupational radiation protection for physicians and other staff in the interventional suite. Simple methods for reducing or minimizing occupational radiation dose include minimizing fluoroscopy time and the number of acquired images; using available patient dose reduction technologies; using good imaging-chain geometry; collimating; avoiding high-scatter areas; using protective shielding; using imaging equipment whose performance is controlled through a quality assurance program; and wearing personal dosimeters so that you know your dose. Effective use of these methods requires both appropriate education and training in radiation protection for all interventional cardiology personnel, and the availability of appropriate protective tools and equipment. Regular review and investigation of personnel monitoring results, accompanied as appropriate by changes in how procedures are performed and equipment used, will ensure continual improvement in the practice of radiation protection in the interventional suite. These recommendations for occupational radiation protection in interventional cardiology and electrophysiology have been endorsed by the Asian Pacific Society of Interventional Cardiology, the European Association of Percutaneous Cardiovascular Interventions, the Latin American Society of Interventional Cardiology, and the Society for Cardiovascular Angiography and Interventions.

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

Interventional Electrophysiology at the Crossroads: Cardiac Mapping, Ablation and Pacing Without Fluoroscopy

Interventional Electrophysiology at the Crossroads: Cardiac Mapping, Ablation and Pacing Without Fluoroscopy

Initial experience in ablation of typical atrial flutter using a novel three-dimensional catheter tracking system

Three-dimensional (3D) mapping has been established for clinical routine in an interventional electrophysiology (EP). Recently, a novel sensor-based 3D catheter tracking system has been introduced integrating 3D non-fluoroscopic catheter navigation into the environment of pre-recorded 2D fluoroscopy [MediGuide™ Technology (MG)]. We are reporting on the first clinical experience for ablation of typical atrial flutter. First we aimed to demonstrate safety and feasibility of this new technique. Secondly, procedural aspects such as effectiveness, procedure, and fluoroscopy time should be evaluated. Ten consecutive patients (100% male, age 68 ± 8 years) were ablated using MG technology. Two steerable diagnostic EP catheters (MediGuide Enabled Livewire™ Catheter, SJM) were used for coronary sinus cannulation and anatomical cavo-tricuspidal isthmus (CTI) reconstruction within the EnSite NavX™ System (NavX). Ablation was performed with a conventional 8 mm tip ablation catheter (IBI, SJM). In all 10 patients both sensor-equipped MG catheters could be tracked non-fluoroscopically. Successful anatomical CTI reconstruction was performed and complete isthmus block was documented after the ablation. Total procedure duration was comparable with conventional procedures (55 ± 8 min). Usage of the MG tracking system resulted in a fluoroscopy time of 2.5 ± 2 min. No adverse events occurred during the procedures. For the first clinical application of the MG technology in an interventional electrophysiology we found a stable system enabling excellent 3D orientation for spatial catheter positioning on the basis of underlying pre-recorded cine loops. Clinically, the MG technology allowed successful procedures with short fluoroscopy times, even though a sensor-equipped ablation catheter was not yet available for use in the study.

Anesthetic management of electrophysiology procedures

Cardiac arrhythmias are a major source of morbidity and mortality. Many of these patients require diagnostic or therapeutic intervention in an electrophysiology laboratory with involvement of an anesthesiologist. The goal of this review is to provide the anesthesiologist with a comprehensive understanding of the mechanisms underlying various arrhythmias; specific procedures performed for diagnosis and treatment, and associated risks. With the introduction of new interventional electrophysiology techniques, anesthesiologists are facing new challenges during perioperative management of these complex procedures and patients. By reviewing the current literature regarding electrophysiology procedures, this review will provide information essential to the anesthesiologist to safely care for this unique patient population.