Total Fluoroscopy Time Research Articles

Reduction in Radiation Exposure in Minimally Invasive Pedicle Screw Placement Using a Tubular Retractor: A Pilot Study

Percutaneous pedicle screw (PPS) placement is a minimally invasive spinal procedure that has been rapidly adopted over the last decade. However, PPS placement has elicited fear of increased radiation exposure from some surgeons, medical staff, and patients. This is because PPS placement is performed using a K-wire, and the operator must perform K-wire insertion into the pedicle under fluoroscopy. In order to prevent erroneous insertion, there are many occasions when direct insertion is required during radiation exposure, and the amount of radiation exposure to hands and fingers in particular increases. Although these problems are being addressed by navigation systems, these systems are still expensive and not widely available. Attempts have been made to address this situation using instrumentation commonly used in spinal surgery. First, it was considered to visualize anatomical bone markers using a tubular retractor and a microscope. In addition, the use of a self-drilling pin was adopted to locate the pedicle in a narrower field of view. Based on these considerations, a minimally invasive and highly accurate pedicle screw placement technique was developed while avoiding direct radiation exposure. This study evaluated radiation exposure and accuracy of pedicle screw placement using this new procedure in one-level, minimally invasive, transforaminal lumbar interbody fusion (MIS-TLIF). Data were collected retrospectively to review pedicle screw placement in single-level MIS TLIFs using a tubular retractor under a microscope. The total fluoroscopy time, radiation dose, and screw placement accuracy were reviewed. Extension of operating time was also evaluated. Twenty-four patients underwent single-level MIS TLIFs, with placement of 96 pedicle screws. There were 15 females and 9 males, with an average age of 64.8 years and a mean body mass index of 25.5 kg/m2. The mean operating time was 201.8 min. The mean fluoroscopic time was 26.8 s. The mean radiation dose of the area dose product was 0.0706 mGy∗m2. The mean radiation dose of air kerma was 6.0 mGy. The mean radiation dose of the entrance skin dose was 11.31 mGy. Postoperative computed tomography scans demonstrated 93 pedicle screws confined to the pedicle (97%) and three pedicle screw breaches (3.2%; two lateral, one medial). A patient with screw deviation of the medial pedicle wall developed right-foot numbness necessitating reoperation. There were no complications after reoperation. The average added time with this combined procedure was 39 min (range 16-69 min) per patient. This novel pedicle screw insertion technique compares favorably with other reports in terms of radiation exposure reduction and accuracy and is also useful from the viewpoint of avoiding direct radiation exposure to hands and fingers. It is economical because it uses existing spinal surgical instrumentation.

1049 PREVALENCE OF ATRIAL FIBRILLATION AND FEASIBILITY OF PULMONARY VEIN ISOLATION AFTER PATENT FORAMEN OVALE CLOSURE

Abstract Background Data about prevalence and the risk of atrial fibrillation, stroke, and need for pulmonary vein isolation (PVI) after device closure of a patent foramen ovale (PFO) are still lacking. We aim to investigate the prevalence and the risk of atrial fibrillation after PFO closure and the feasibility of PVI in a PFO closure cohort compared to contemporary PVI without PFO closure. Methods retrospective observational study of consecutive patients undergoing PFO closure enrolled from February 2013 to September 2020. Patients were divided into 3 groups: i) patients without AF before and after the procedure (n=132), ii) patients with paroxysmal AF prior to the procedure (n=21), iii) patients with documented AF after the procedure (n=13). All patients with AF occurrence were treated with adequate anticoagulation therapy according to the current ESC Guidelines. We compared the procedural data of these patients to a matched contemporary cohort without previous PFO closure undergoing PVI in our center. AF and stroke prevalence and PVI feasibility after PFO closure were assessed at follow up. Results one-hundred and sixty-six consecutive PFO closure patients were enrolled; the mean age was 54 ± 13 years. Median follow-up was 3.5 + 2.5 years. During the study period, 21 patients had AF before or after the PFO closure (group 2) and 13 (7.8%) new onset AF (group 3). Stroke after the PFO closure occurred in 8 patients (4.8%), of which 4 in the group with new onset AF (30% of the group 3). Among the 34 patients with AF, 10 patients (6%) underwent a PVI. Compared to a contemporary matched PVI cohort, total procedural times and fluoroscopy times were significantly higher in the patients with previous PFO closure (108±15 vs 75±29, p=0.002 and 3±1.5 vs 8±7, p<0.001). Similar rate of AF relapses (p=0.198) was observed between the two groups, with a trend for higher rate of complication (pericardial effusion) for the cohort with previous PFO closure (p=0.06). Conclusion This study shows that a more accurate screening and treatment of AF is needed in patients with cryptogenic stroke despite the presence of a PFO, possibly a bystander. In our study, 30% of patients with new onset AF after PFO closure, experienced a further stroke after the procedure. In case of AF, the indication for PVI should be considered prior to the PFO closure since it turns out to be more difficult in terms of procedural and fluoroscopy times and risks of complications after PFO closure.

Local diagnostic reference levels in diagnostic and therapeutic pediatric cardiology at a specialist pediatric hospital in South Africa

Abstract Introduction: Children may be at a higher risk of experiencing the detrimental effects of ionizing radiation arising from medical radiation imaging. Dose optimisation is therefore recommended to provide assurance that their exposure is as low as reasonably achievable. To this end, periodic assessment of dose levels and establishment of Local Diagnostic Reference Levels (LDRLs) in medical facilities is necessary. There is a general paucity in the literature of data pertaining to dose levels in pediatric interventional radiology. This study establishes LDRLs in diagnostic and therapeutic heart catheterization procedures at a specialist pediatric hospital in a resource constrained country. Material and methods: Dose indicators from actual patient procedures were collected from the archive and analyzed retrospectively to determine the median, 25th, and 75th percentiles of the total Air Kerma Area Product (KAP), Cumulative Air Kerma (CAK), total Fluoroscopy Time (FT), and a total number of Cine Images (CI) of selected interventional procedures. The dose indicators were also age-stratified into five age groups defined by the International Commission on Radiation Protection publication 135. The results were compared to values available from similar studies in the literature to benchmark our dose levels. Local Dose Reference Levels were set as the 75th percentile values. Results: For diagnostic procedures (n = 80), the 75th percentiles of KAP, CAK, FT, and CI were 4.0 Gy·cm2, 31.5 mGy, 14.3 min, and 315 frames, respectively and 3.2 Gy·cm2, 30.5 mGy, 17.5 min, and 606 frames, respectively for therapeutic procedures (n = 143). Conclusions: The LDRLs from this study did not vary significantly from those published in the literature, suggesting that practices at our center were comparable to international norms. Regular reviews of the LDRLs must be conducted to check that the dose levels do not deviate considerably.

Comparison of Safety and Efficacy in Endoscopic Combined Intrarenal Surgery Performed in the Lateral Decubitus and Galdakao-modified Supine Valdivia Positions

To examine the safety and efficacy of Endoscopic combined intrarenal surgery (ECIRS) between the lateral decubitus (LD) and Galdakao-modified supine Valdivia (GMSV) position. We retrospectively reviewed the records of 226 patients with renal stones who underwent ECIRS in the LD and GMSV positions between 2018 and 2022. Surgeries early in the study period were mainly performed in the GMSV position, while later surgeries were mainly performed in the LD position. The number of patients in the LD and GMSV groups was 119 and 107, respectively. The proportion of patients who had no residual stone fragments >2 mm detected on radiography the day after surgery did not significantly differ between the LD group (91.6%) and the GMSV group (97.2%). Operation time was significantly shorter in the LD group (72 vs 81 minutes; P=.02). Total fluoroscopy time was significantly shorter in the LD group (92 vs 189 seconds; P<.001). Complication rates did not significantly differ between the groups. Among the variables analyzed, the patient position was independently impact on the fluoroscopy time (OR 0.309; 95% CI, 0.167-0.571; P<.001). ECIRS in the LD position is safe and effective and associated with shorter fluoroscopy than the GSMV position.

Pulsed field ablation in patients with complex consecutive atrial tachycardia in conjunction with ultra-high density mapping: Proof of concept.

Catheter-ablation (CA) of consecutive left atrial tachycardias (LAT) can be challenging. Pulsed field ablation (PFA) yields a novel nonthermal CA technology for treatment of atrial fibrillation (AF). There is no data regarding PFA of LAT. This study sought to investigate PFA of consecutive LAT following prior CA of AF. Consecutive patients with LAT underwent ultrahigh-density (UHDx) mapping. Subsequent to identification of the AT mechanism, PFA was performed at the assumed critical sites for LAT maintenance. Continuous ablation lines were performed if required and evaluated with pre- and post-PFA HDx-mapping. Fifteen patients (age 70 ± 10, male 73%) who underwent 3.6 ± 2 prior AF-CA procedures were included. The total mean procedure and fluoroscopy times were 141 ± 43 and 18 ± 10 min, respectively. All 19 of 19 (100%) LAT were successfully ablated with PFA. Two AT located at the right atria required RF-ablation. LAT were identified as localized reentry (n = 1) and macro-reentry LAT (n = 18) and targeted with PFA. All LAT terminated with PFA either to sinus rhythm (9/15) or a secondary AT (6/15 and subsequently to SR); 63% (12/19) terminated with the first PFA-application. All lines (13 roof, 11 anterior, 1 mitral) were blocked. LA-posterior-wall isolation (LAPWI) was successfully achieved when performed (10/10). AF/AT free survival was 80% (12/15) after 153 [88-207] days of follow-up. No procedure-related complications occurred. PFA of consecutive LAT is feasible and safe. Successful creation of ablation lines and LAPWI can be achieved in a short time. PFA may offer the opportunity for effective ablation of atrial arrhythmias beyond AF.

Clinical Comparison between Three Single-Use Flexible Ureteroscope Models: A Real-World Experience

Introduction: Studies comparing different single-use flexible ureteroscope (su-fURS) models are lacking. The objective was to compare three types of su-fURS: the Uscope 3022 (PUSEN), LithoVue (Boston Scientific), and EU-scope (Innovex). Methods: This was a retrospective study comparing the clinical outcomes from patients undergoing flexible ureteroscopy with one of the three su-fURS for upper urinary tract stone treatment between September 2019 and 2021. Analysis included total surgery and fluoroscopy time, post-procedure ureteral catheter, stone-free rate (SFR), and complications. Results: There were 104 cases with the Uscope 3022, 141 with LithoVue, and 80 with EU-scope. Groups were comparable in terms of stone size, location and density, and prior double-J stent presence. Multivariate analysis showed no difference in terms of SFR: 79% (Uscope 3022), 77.5% (LithoVue), and 81% (EU-scope); p = 0.38. Significant differences were found for total surgery and fluoroscopy time, as well as ureteral access sheath use (p < 0.001), favoring the EU-scope group. Discussion/Conclusion: The three devices evaluated are highly effective in treatment of kidney stones. Reasons for difference in total surgery and fluoroscopy time and access sheath use are not clear. However, this could be explained by technical aspects of these devices, such as external diameter, optical resolution, and field of view.

A novel wide-band dielectric imaging system to guide radiofrequency ablation for pulmonary vein isolation.

Recently, the wide-band dielectric mapping system Kodex-EPD was introduced. This study reports the first clinical experience using a novel system to guide pulmonary vein isolation (PVI) with radiofrequency (RF)ablation. METHODSAND RESULTS: The study included 20 consecutive patients undergoing de-novo PVI for symptomatic paroxysmal or persistent atrial fibrillation guided by Kodex-EPD. The primary efficacy endpoint was successful PVI. Secondary endpoints included procedural parameters and complications. In all 20 patients (mean age 68 ± 8 years, 12 male patients, paroxysmal fibrillation in 14/20 [70%] patients), PVI was successfully completed. One patient underwent additional cavo-tricuspid isthmus ablation for concomitant typical atrial flutter and one patient required additional ablation of a focal atrial tachycardia. A conventional three-dimensional image of the left atrium as well as the innovative endocardial panoramic view were used to guide catheter manipulation and ablation. Median procedure time was 115 [1st; 3rd quartile 93,75; 140] min and median total fluoroscopy time was 9.9 [9.7; 11.2] min, of which a median of 0.8 [0.6; 0.9] min was required to create left atrial maps. Complete left atrial imaging using Kodex-EPD was achieved within a median of 7.1 [5.7; 8.3] min. Median RFablation time was 45.1 [34.6; 58.7] min. No major complications were observed. RF ablation PVI guided by Kodex-EPD seems safe and feasible. The system provides effective three-dimensionalguidance for PVI.

Pulsed field ablation for atrial fibrillation: acute procedural efficacy and safety of an initial German multicenter experience

Abstract Background Pulsed field ablation (PFA) is a novel non-thermal energy source to conduct catheter ablation of atrial fibrillation (AF). However, real-world multi-center data regarding acute procedural efficacy and safety is sparse. Purpose To study acute procedural success and safety in patients undergoing PFA for catheter ablation of AF in a multicenter registry. Methods Consecutive paroxysmal and persistent AF patients undergoing PFA-based catheter ablation using a multispline catheter were enrolled. The cohort included first and repeat ablation procedures. Procedural parameters, acute success and in-hospital safety were evaluated. A follow-up of all patients was conducted. Results Five German centers enrolled a total of 154 patients undergoing PFA in this study. Mean age was 68±12 years, median CHA2DS2-VASc Score was 3 (Q1-Q3: 2–4). Patients suffered from paroxysmal AF (n=55; 36%), persistent AF (n=93; 60%) and consecutive atrial tachycardias (AT) due to previous CA (n=6; 4%). The median left atrial (LA) PFA and total procedure times were 33 (Q1-Q3: 24–53) and 90 (Q1-Q3: 73–116) minutes, respectively. Mean LA PFA fluoroscopy and total fluoroscopy times were 12.1±5.5 and 20.2±8.7 minutes. Of all 154 procedures, 130 (84%) were index ablation procedures with isolation of pulmonary veins (PVI) only and 24 (16%) were repeat procedures (including re-PVI and ablation of consecutive AT). Acute PV reconnection following primary PVI and the initial set of PFA-applications was found in 20/130 (15%) patients, necessitating additional PFA ablation. Finally, successful PFA-guided PVI was achieved in all patients. Additional PFA lesion sets (including LA posterior wall isolation, anterior ablation, mitral isthmus ablation) were applied in 17/154 (11%) patients. Complications occurred in a total of 6/154 (3.8%) patients (including three groin site complications, two pericardial tamponades, one transient coronary spasm without sequela). The follow up data is still being assessed and will be provided by the time of the ESC 2022 meeting. Conclusion PFA performed in patients with atrial fibrillation demonstrates high acute procedural success rates and a favorable safety profile in this first real-world multicenter registry. Funding Acknowledgement Type of funding sources: None.

Almost zero-fluoroscopy LBBP-procedure using a 3D-mapping system

Abstract Introduction Cardiac device therapy has recently been extended by the option of Conduction System Pacing, CSP (HIS Bundle Pacing, HBP; Left Bundle Branch Area Pacing, LBBAP). Similar to cardiac resynchronization therapy (CRT), complex procedures can result in long fluoroscopy-duration and considerable radiation exposure for the patient and the implanting team. According to the principle ALARA (As Low As Reasonably Achievable), measures should be taken to reduce radiation, wherever possible. We report the almost fluoroscopy-free implantation of a LBBAP-system using a 3D electroanatomical mapping system (EAMS). The patient was indicated for a pace &amp; ablate concept due to recurrent, highly symptomatic, persistent atrial fibrillation (AF), a history of mitral valve repair and a severely dilated left atrium. ESC guidelines suggest choosing a RV-lead (indication IIa), alternatively either a CRT system or HBP (both IIb). LBBAP as new option for physiological pacing was chosen in this patient because it usually provides excellent stimulation thresholds and the lead – in contrast to HBP – is distant from Koch's triangle, so that AV-nodal-ablation can be performed safely. Methods Surgery was performed under deep sedation. After accessing the cephalic vein, a quick 3D map of relevant structures was acquired (right atrium; coronary sinus; HIS; interventricular septum, IVS). Then a preformed sheath and a stylet-driven pacemaker-lead were advanced. The lead-tip was visualized within the EAMS and maneuvered without fluoroscopy. After approaching the proximal IVS, the implantation site was confirmed by unipolar stimulation and the lead was advanced into the IVS under close monitoring of impedance and signals. Final position was confirmed by sheath-angiography [Fig. 1]. Results During lead fixation, LBBAP-typical ECG-changes (progression to rSR morphology, fixation beats) could be observed. A left bundle branch potential (poLBB) could be documented. The left ventricular activation time (LVAT) as a marker of rapid LV-excitation was shortened from 108 ms to 68 ms. Thresholds for non-selective and selective LBBP were 3 V @ 1 ms and 0.7 V @ 0.4 ms, with a sensing of 8.7 mV, impedance of 643 ohms and a paced QRS-width of 112 ms [Fig. 2]. An atrial lead was added (history of intermittent sinus rhythm) and a dual-chamber pacemaker was connected. Fluoroscopy was required for lead fixation into the IVS, atrial lead placement as well as for sheath angiography and lead length-optimization. Total fluoroscopy time was 1.13 minutes with a radiation dose of 45.04 μGy m2, procedure time 64 minutes. AVN total ablation was performed the following day without complications. Conclusions CSP using a 3D mapping system is simple, facilitates understanding of important anatomical structures and helps to reduce the required radiation dose to a necessary minimum. In individual cases, procedures requiring almost zero-fluoroscopy are possible. Funding Acknowledgement Type of funding sources: None.

Prevalence of atrial fibrillation and feasibility of pulmonary vein isolation after patent foramen ovale closure

Abstract Background Data about prevalence and the risk of atrial fibrillation, stroke, and need for pulmonary vein isolation (PVI) after device closure of a patent foramen ovale (PFO) are still lacking. We aim to investigate the prevalence and the risk of atrial fibrillation after PFO closure and the feasibility of PVI in a PFO closure cohort compared to contemporary PVI without PFO closure. Methods Retrospective observational study of consecutive patients undergoing PFO closure enrolled from February 2013 to September 2020. Patients were divided into 3 groups: i) patients without AF before and after the procedure (n=132), ii) patients with paroxysmal AF prior to the procedure (n=21), iii) patients with documented AF after the procedure (n=13). All patients with AF occurrence were treated with adequate anticoagulation therapy according to the current ESC Guidelines. We compared the procedural data of these patients to a matched contemporary cohort without previous PFO closure undergoing PVI in our center. AF and stroke prevalence and PVI feasibility after PFO closure were assessed at follow up. Results One-hundred and sixty-six consecutive PFO closure patients were enrolled; the mean age was 54±13 years. Median follow-up was 3.5±2.5 years. During the study period, 21 patients had AF before or after the PFO closure (group 2) and 13 (7.8%) new onset AF (group 3). Stroke after the PFO closure occurred in 8 patients (4.8%), of which 4 in the group with new onset AF (30% of the group 3). Among the 34 patients with AF, 10 patients (6%) underwent a PVI. Compared to a contemporary matched PVI cohort, total procedural times and fluoroscopy times were significantly higher in the patients with previous PFO closure (108±15 vs 75±29, p=0.002 and 3±1.5 vs 8±7, p&amp;lt;0.001). Similar rate of AF relapses (p=0.198) was observed between the two groups, with a trend for higher rate of complication (pericardial effusion) for the cohort with previous PFO closure (p=0.06). Conclusion This study shows that a more accurate screening and treatment of AF is needed in patients with cryptogenic stroke despite the presence of a PFO, possibly a bystander. In our study, 30% of patients with new onset AF after PFO closure, experienced a further stroke after the procedure. In case of AF, the indication for PVI should be considered prior to the PFO closure since it turns out to be more difficult in terms of procedural and fluoroscopy times and risks of complications after PFO closure. Funding Acknowledgement Type of funding sources: Public Institution(s).

High density catheter approach with liveview dynamic display improves procedural efficiency of atrial fibrillation ablation

Abstract Introduction PVI isolation confirmation after RF ablation is often time-consuming, especially in case of a single transeptal catheter approach into the left atrium. A novel Live View (LV) dynamic display mapping software, utilized in combination with the High Density (HD) Grid mapping catheter, allows to display beat-to-beat, dynamic regional mapping data. Purpose We evaluated the feasibility and the procedural impact of a procedural left atrial workflow with a single transeptal-single HD catheter analysis, incorporating the LV Mapping Software for the assessment of PVI after ablation. Methods Paroxysmal and persistent AF patients scheduled for AF ablation were prospectively enrolled. All patients underwent only PVI under LSI guidance (LSI between 5.5 and 6 anteriorly; LSI between 4.5 and 5 posteriorly) with a point by point strategy and an inter-lesion distance &amp;lt;6 mm. According to the HD mapping strategy used to confirm entrance block after first pass PVI, patients were divided in two groups. The HD-LV Group included patients mapped with the HD-LV software and the HD-standard mapping (SM) group included patients which received a conventional PVI validation with a static voltage/activation map. Left PVI was evaluated during distal coronary sinus pacing and right PVI during sinus rhythm. Exit block was also evaluated to confirm bidirectional block. Procedural efficiency parameters were compared between groups. Results Forty-six patients with AF (58% paroxysmal) were prospectively enrolled. Twenty-five patients were included in the HD-LV Group and 21 in the HD-SM Group. PVI was successful in all patients. LV dynamic display analysis was feasible in all patients and allowed a simple and fast validation of right and left PVI, without the necessity of introducing a second catheter into the left atrium. The split screen modality, with a dynamic activation map on the left and a dynamic voltage map on the right, allowed to switch from CS pacing to sinus rhythm without the necessity of a remap. The overall mapping time (27±10 vs 37±14 min, p=0.006), total procedure time (138±33 vs 178±50 min, p=0.006) and fluoroscopy time (14±5.3 vs 23±11 min, p=0.006) were significantly lower in the HD-LV Group. No complication was seen in either group. Conclusions A simplified clinical utilization of LiveView dynamic display with a single transeptal-single HD catheter approach is feasible and efficient after PVI, potentially simplifying the procedural workflow. A real-time dynamic mapping in daily practice may further enhance the clinical benefits of HD mapping during radiofrequency (RF) catheter ablation procedures. Funding Acknowledgement Type of funding sources: None.

Proximal coil occlusion preceding distal sclerotherapy in patients with pelvic congestion syndrome: A multicenter, retrospective study

ObjectiveWe investigated the efficacy, feasibility, and safety of proximal coil occlusion preceding distal sclerotherapy (PCODS) for patients with pelvic congestion syndrome (PCS). MethodsWe performed a multicenter, retrospective cohort study of 94 patients with PCS who had undergone PCODS and 53 patients who had undergone standard endovascular embolization (control group) between June 2014 and April 2020. The primary end point was the clinical remission rate and the secondary end points were the operative time, total fluoroscopy time, radiation dose, overall length of coils used per case, and adverse events. The patients were followed up at 1, 3, 6, and 12 months. ResultsPCODS was successfully performed in 94 patients (100%). The clinical remission rates were significantly higher in the PCODS group than in the control group at 1, 6, and 12 months (P = .036, P = .032, and P = .032). The operative time and total fluoroscopy time were shorter for the PCODS group than for the control group (48.3 ± 5.2 minutes and 37.7 ± 4.4 minutes vs 53.9 ± 4.8 minutes and 42.6 ± 4.1 minutes, respectively; P < .001 for both). The radiation dose was significantly lower in the PCODS group than in the control group (362,634.69 ± 41,533.13 mGy·cm2 vs 421,578.30 ± 49,517.93 mGy·cm2; P < .001). The overall length of coils used per case was 19.8 ± 6.0 cm in the PCODS group and 31.7 ± 8.5 cm in the control group (P < .001). Migration of n-butyl cyanoacrylate to the renal vein occurred in two patients in the control group. ConclusionsWe found PCODS was feasible with a higher clinical remission rate and mild adverse effects in patients with PCS.

Pulsed-field ablation-based pulmonary vein isolation: acute safety, efficacy and short-term follow-up in a multi-center real world scenario

PurposePulsed-field ablation (PFA) is a new energy source to achieve pulmonary vein isolation (PVI) by targeted electroporation of cardiomyocytes. Experimental and controlled clinical trial data suggest good efficacy of PFA-based PVI. We aimed to assess efficacy, safety and follow-up of PFA-based PVI in an early adopter routine care setting.MethodsConsecutive patients with symptomatic paroxysmal or persistent atrial fibrillation (AF) underwent PVI using the Farawave® PFA ablation catheter in conjunction with three-dimensional mapping at two German high-volume ablation centers. PVI was achieved by applying 8 PFA applications in each PV.ResultsA total of 138 patients undergoing a first PVI (67 ± 12 years, 66% male, 62% persistent AF) were treated. PVI was achieved in all patients by deploying 4563 applications in 546 PVs (8.4 ± 1.0/PV). Disappearance of PV signals after the first application was demonstrated in 544/546 PVs (99.6%). More than eight PFA applications were performed in 29/546 PVs (6%) following adapted catheter positioning or due to reconnection as assessed during remapping. Mean procedure time was 78 ± 22 min including pre- and post PVI high-density voltage mapping. PFA catheter LA dwell-time was 23 ± 9 min. Total fluoroscopy time and dose area product were 16 ± 7 min and 505 [275;747] cGy*cm2. One pericardial tamponade (0.7%), one transient ST-elevation (0.7%) and three groin complications (2.2%) occurred. 1-year follow-up showed freedom of arrhythmia in 90% in patients with paroxysmal AF (n = 47) and 60% in patients with persistent AF (n = 82, p = 0.015).ConclusionsPFA-based PVI is acutely highly effective and associated with a beneficial safety and low recurrence rate.Graphical abstract

Differences in beginner and expert neurointerventionalists" heart rate variability during simulated neuroangiographies.

Likewise work experience, heart rate variability (HRV) has repeatedly been correlated with improved performance under real life and simulator conditions. Using HRV as a correlate of workload, it is meaningful to assess the impact of work experience. To understand the impact of work experience on HRV metrics, we examined differences in HRV among experts and beginners during simulated endovascular neuroradiological procedures. Six inexperienced radiologists (beginners) and five experts in neurological endovascular intervention each performed 10 diagnostic angiographies on a Vascular Interventional System Trainer (VIST) simulator (Mentice AB, SW). Beyond total time, fluoroscopy time, and amount of contrast medium used, heart rate variability and the NASA-task load index were gathered as correlates of workload. The t-Test for independent samples as well as Mann-Whitney-U tests were applied for group-wise comparison between beginners and experts. Multivariate regression was used to assess the influence of age and expert status. Ten participants completed all scenarios; one participant only completed the first five scenarios. Accordingly, 105 simulations were analyzed (beginners N = 60; experts N = 45, respectively). The heart rate variability of experts and beginners significantly differed in three time domain HRV metrics (decreased RMSSD, NN50, pNN50 in experts; all p < 0.05) as well as with respect to its distribution in the frequency spectrum (LF/HF ratio; p < 0.001, increased high frequency components in experts). The HRV of beginners and expert neurointerventionalists significantly differed during simulated endovascular neuroradiological procedures. Experts presented decreased HRV, this could be a cardiovascular surrogate to the effort the subjects expend on their performance. It is in line with previous studies on vagal influences on the heart and cognitive-executive performance.

A SiMplified bARe-Wire Target Vessel (SMART) Technique for Fenestrated Endovascular Aortic Repair

Purpose: The aim of this study was to present a new technique for fenestrated endovascular aortic aneurysm repair (FEVAR) and to review its preliminary results. The SiMplified bARe-wire Target vessel (SMART) technique for FEVAR aims to simplify the procedure by avoiding guiding sheaths into visceral arteries during the main graft deployment. Materials and Methods: The SMART technique requires a 12 to 16Fr contralateral introducer, depending on number of fenestrations—compared with standard 18 to 22Fr for 3 to 4 FEVAR—to achieve target vessel catheterization and stenting during FEVAR by avoiding the use of parallel 6 to 7Fr guiding sheaths into each visceral vessel. Fenestrations are sequentially catheterized, assisted by a steerable sheath. A Rosen wire is maintained in each fenestration, with a single sheath parked in the final target vessel while releasing the fenestrated graft. Data on patients treated for pararenal or thoracoabdominal aortic aneurysms with FEVAR, adopting the SMART technique, were retrospectively reviewed. End points were technical success, intraprocedural variables, 90-day mortality, major adverse events (MAEs), and target vessel patency. Results: From May 2018 to December 2020, 57 consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. Median total procedure time and total fluoroscopy time were 223 (196–271) minutes and 81 (71–94) minutes, respectively. Primary technical success was 96.4% (55/57). No misalignment occurred from graft deployment. The total number of fenestrations was 169, including 54 left and 53 right renal arteries, 43 superior mesenteric arteries and 18 celiac trunks (3.0±0.9 vessels/patient), with target vessel technical success of 98.2%. During the first 90 days, there were no deaths (0%). The MAEs included acute kidney injury (AKI) in 3 patients (5%) with no new dialysis onset, respiratory failure requiring prolonged ventilation in 2 patients (4%), myocardial ischemia in 1 patient (2%), but no lower limb ischemia, stroke, or spinal cord ischemia (SCI) occurred. After a mean follow-up of 14±10 months, there was 1 aortic-related death. Primary and assisted primary target vessel patency was 94.6%±1.8 and 97.0%±1.3% respectively. Conclusions: The SMART technique proved to be a safe alternative to standard FEVARs, with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity. Clinical Impact This study evalautes the outcome of fenestrated endovascular aortic repair (FEVAR) procedures at Uppsala university hospital using a simplified bare-wire Target vessel (SMART) technique. The SMART technique requires a smaller contralateral introducer compared to standard 18-22Fr for 3-4 FEVAR to achieve target vessel catetherization and stenting. Fifty-seven consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. The SMART technique proved to be a safe alternative to standard FEVARs with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity.

Radiation reduction in a modern catheterization laboratory: A single-center experience.

Measures were undertaken at the Cleveland Clinic to reduce radiation exposure to patients and personnel working in the catheterization laboratories. We report our experience with these improved systems over a 7-year period in patients undergoing diagnostic catheterization (DC) and percutaneous coronary interventions (PCIs). Patients were categorized into preinitiative (2009-2012) and postinitiative (2013-2019) groups in the DC and PCI cohorts. Propensity score matching was done between the pre- and postinitiative groups for both cohorts based on age, sex, body surface area, total fluoroscopy time, and total acquisition time. The effectiveness of radiation reduction measures was assessed by comparing the total air kerma (Ka,r ), and fluoroscopy- and acquisition-mode air kerma in patients in the two groups. In the DC cohort, there was a significant reduction in Ka,r in the postinitiative group in comparison to the preinitiative group (median, 396vs. 857 mGy; p < 0.001). In the PCI cohort, Ka,r in the postinitiative group was 1265 mGy, which was significantly lower than the corresponding values in the preinitiative group (1994 mGy; p < 0.001). We also observed a significant reduction in fluoroscopy- and acquisition-based air kerma rates, and air kerma area product in the postinitiative group in comparison to the preinitiative group in both matched and unmatched DC and PCI cohorts after the institution of radiation reduction measures. There was a significant and sustained reduction in radiation exposure to patients in the catheterization laboratory with the implementation of advanced protocols. Similar algorithms can be applied in other laboratories to achieve a similar reduction in radiation exposure.

Transseptal versus retrograde approach for ablation of left-sided accessory pathways: impact on radiation exposure

Management of left-sided accessory pathways (APs) is based on catheter ablation through an antegrade or retrograde approach. Both are safe and effective but are associated with exposure to x-rays; however, recipients of ablation are generally young. We sought to evaluate the impact of the approach chosen on dose–area product (DAP). A total of 95 patients who underwent radiofrequency ablation of a left-sided AP between January 2011 and January 2020 were included. The primary endpoint was the radiation dose received by the patient. Secondary endpoints were procedural success and complication and recurrence rates. The mean age of the study population was 34.3 ± 16.6 years. The antegrade transseptal approach was used in 63.5% of cases. By multivariate analysis, the antegrade transseptal approach was associated with a 53% reduction in DAP (p < 0.001). The radiation dose received was also significantly associated with body mass index and total fluoroscopy time (p < 0.001). There was no significant difference in other secondary endpoints between approaches. The use of an antegrade transseptal approach is associated with a significant reduction in DAP compared with the retrograde approach, and procedural success and complication and recurrence rates are similar.

P141. Robotics versus navigation for minimally invasive elective lumbar fusion

P141. Robotics versus navigation for minimally invasive elective lumbar fusion

Left bundle branch potential predicts better electrical synchrony in bradycardia patients receiving left bundle branch pacing

BackgroundLeft bundle branch pacing (LBBP) is a novel physiological pacing technology. We aim to explore the relation between LBB potential (LBB Po) and left ventricular (LV) electrical/mechanical synchrony in bradycardia patients without heart failure (HF) receiving LBBP.MethodsA total of 62 patients undergoing LBBP were categorized by LBB Po: the LBB Po positive (+) group and the LBB Po negative (−) group. The perioperative electrocardiographic and echocardiography parameters related to cardiac synchrony were analyzed.ResultsThere were 42 (67.74%) patients in the LBB Po (+) group and 20 patients in the LBB Po (−) group. Paced QRS duration (113.50 ± 17.65 ms vs. 123.40 ± 13.18 ms, P = 0.031) and stimulus left ventricular activation time (71.76 ± 3.53 ms vs. 74.45 ± 3.12 ms, P = 0.005) were shorter in the LBB Po (+) group than in the LBB Po (−) group. No significant differences in the LV mechanical synchrony (Ts-SD-12, 36.55 ± 19.76 vs. 39.95 ± 16.04, P = 0.505; PSD, 51.14 ± 17.69 vs. 45.65 ± 10.55, P = 0.205) between the two groups. There was not statistically difference in ventricular lead parameters measured intraoperative between the two groups. Compared with the LBB Po (−) group, the LBB Po (+) group showed a dramatically higher total procedure duration time (93.52 ± 9.18 min vs. 86.25 ± 10.54 min, p = 0.007) and fluoroscopy time for ventricle lead implantation (18.95 ± 3.43 min vs. 14.00 ± 3.16 min, p < 0.001).ConclusionsThe appearance of LBB Po may suggest better electrical synchrony during LBBP, but similar in LV mechanical synchrony. However, the total operation duration and fluoroscopy time of ventricular lead implantation in the LBB Po (+) group were longer. Therefore, it may be unnecessary to deliberately recognize the LBB Po when it is difficult to detect LBB Po and meet the LBBP criterion.

Added Value of Selective Intra-arterial Cone-Beam CT Angiography in the Management of Visceral Artery Aneurysms

Purpose: The aim of this study is to evaluate the value of selective intra-arterial cone-beam computed tomography angiography (CBCTA) relative to conventional computed tomography angiography (CTA) in understanding visceral artery aneurysm (VAA) morphology, and its impact on treatment planning. Materials and Methods: Between January 2017 and August 2021, all patients who had a diagnosis of VAA and underwent intraoperative CBCTA imaging were retrospectively reviewed. Impact on treatment decisions, optimal C-arm angulations derived from CBCTA, and additional radiation exposure were reported. Two blinded independent reviewers qualitatively reviewed CBCTA and conventional CTA images. A 5-point Likert scale (1=poor image quality, 5=excellent image quality) was used to assess the overall image quality of each modality. Number of vessels arising from the aneurysm sac was counted. Results: A total of 16 patients had a diagnosis of VAA during the study period, of whom 10 patients had intraoperative CBCTA and conventional CTA available for review. Out of 10 patients, 7 underwent successful endovascular treatment, 2 were deemed not amenable for endovascular embolization based on intraoperative CBCTA findings, and 1 had resolved pseudoaneurysm. Total fluoroscopy time and radiation dose (dose area product [DAP] and skin dose) for all procedures were 27.7 ± 19.9 minutes, 28 362 (±18 651) µGy*m2, and 1879 (±1734) mGy, respectively. Radiation exposure from CBCTA (DAP and skin dose) was 5703 (±3967) µGy*m2 and 223.6 (±141.3) mGy, respectively. In patients who underwent endovascular treatment, the proportional DAP from CBCTA was 18.3% (±15.3%) of the total procedural radiation dose. Qualitative rating of overall image quality of CBCTA images was superior to CTA images (mean score: 4.55 vs 3, p<0.001). More branch vessels arising from the VAA were identified by all reviewers in CBCTA as compared with conventional CTA (median, min-max: 3, 0–4 vs 2,1–3 vessels). Conclusion: Intraoperative CBCTA after selective intra-arterial contrast injection, with better spatial resolution, provided better delineation of visceral aneurysm morphology as compared with conventional, intravenous CTA and enabled optimal treatment planning at a reasonable additional radiation exposure. Clinical Impact Visceral artery aneurysms (VAA) are often diagnosed incidentally by conventional computed tomographic angiography (CTA). Endovascular treatment typically requires selective angiographies at multiple projections to better understand aneurysm morphology, location, and efferent branch vessels. Intra-arterial cone-beam CT angiography (CBCTA) for VAA has the advantage of selective contrast opacification, better spatial resolution, and three-dimensional/multi-planar visualization of aneurysm morphology. In addition, CBCTA enables identification of optimal C-arm working projection for subsequent endovascular treatment. The aim of this study is to evaluate the value of intraoperative CBCTA relative to conventional CTA in understanding visceral artery aneurysm morphology and its impact on treatment planning.