P1061Incidence and location of PVI gaps identified post-cryoballoon ablation for atrial fibrillation

Background

 Successful delivery of continuous and durable pulmonary vein isolation (PVI) lesion sets is recognized as being critical to long-term clinical outcomes following ablation for atrial fibrillation (AF). Confirmation of PVI following cryoballoon ablation is commonly achieved using a 3.3F circular mapping catheter (CMC) which can be delivered through the central lumen of the cryoballoon, but other diagnostic tools may be used alone or in conjunction with the 3.3F CMC. A high-density, grid-style mapping catheter is now available in multiple geographies; use in cryoballoon ablation procedures and associated outcomes has not been previously reported.

Purpose

 To evaluate diagnostic catheter usage patterns in cryoablation procedures and identify associated trends in procedural characteristics and acute outcomes.

Methods

 Self-reported procedural data was prospectively collected in AF cryoablation cases utilizing various diagnostic catheter tools, including the 3.3F CMC and high-density, grid-style mapping catheter (HD Grid). Procedural characteristics and acute outcomes, including the incidence and location of gaps post-ablation, were recorded and analyzed.

Results

 Data was collected in 23 cryoablation procedures performed in 7 centers across the United States and Europe. De novo and repeat ablations represented 65.2% and 21.7% of cases, respectively (13.0% not reported). 3D mapping was employed in 95.7% of cases. A left common pulmonary vein was present and ablated in 8.7% (2/23). The 28mm cryoballoon was utilized in all cases, with a single case using both a 23mm and 28mm cryoballoon. The 3.3F CMC was used to confirm isolation in all cases using a variety of techniques: voltage mapping (60.9%), exit block (56.5%), entrance block (30.4%), propagation mapping (4.3%), and activation mapping (4.3%); note: total exceeds 100% as more than one technique may be employed in a single case. In 18 cases, PVI was confirmed using a 3.3F CMC followed by secondary confirmation with HD Grid, enabling a direct comparison of the two technologies. The HD Grid identified a total of 12 gaps in 4 (22.2%) patients, which were missed by the 3.3F CMC (Figure 1). No adenosine or isoproterenol use was documented in any case.

Conclusion(s): The 3.3F CMC is routinely used to confirm PVI following cryoballoon ablation for atrial fibrillation, but it may fail to identify gaps in some patients. Subsequent assessment of PVI using the HD Grid identified residual gaps in nearly a quarter of patients, suggesting that sensitivity for gap detection may be improved with this tool. Limitations of this analysis include the small sample size and workflows which consistently assessed PVI with the high-density mapping catheter after confirming isolation with the 3.3F CMC. Despite these limitations, the incidence of residual gaps observed is noteworthy and may warrant additional study.

Abstract Figure.

Ultrasound assessment of pelvic floor muscle contraction: reliability and development of an ultrasound-based contraction scale

OBJECTIVES

To determine intra- and interrater reliability and agreement for ultrasound measurements of pelvic floor muscle contraction and to assess the correlation between ultrasound and vaginal palpation. We also aimed to develop an ultrasound scale for assessment of pelvic floor muscle contraction.

METHODS

This was a cross-sectional study of 195 women scheduled for stress urinary incontinence (n = 65) or prolapse (n = 65) surgery or who were primigravid (n = 65). Pelvic floor muscle contraction was assessed by vaginal palpation using the Modified Oxford Scale (MOS) and by two- and three-dimensional (2D/3D) transperineal ultrasound. Proportional change in 2D and 3D levator hiatal anteroposterior (AP) diameter and 3D levator hiatal area between rest and contraction were used as measures of pelvic floor muscle contraction. One rater repeated all ultrasound measurements on stored volumes, which were used for intrarater reliability and agreement analysis, and three independent raters analyzed 60 ultrasound volumes for interrater reliability and agreement analysis. Reliability was assessed using the intraclass correlation coefficient (ICC) and agreement using Bland-Altman analysis. Tomographic ultrasound was used to identify women with major levator injury. Spearman's rank correlation coefficient (r_S ) was used to assess the correlation between ultrasound measurements of pelvic floor muscle contraction and MOS score. The proportion of women allocated to each category of muscle contraction (absent, weak, moderate or strong) by palpation was used to determine the cut-offs for the ultrasound scale.

RESULTS

Intrarater ICC was 0.81 (95% CI, 0.74-0.85) for proportional change in 2D levator hiatal AP diameter. Interrater ICC was 0.82 (95% CI, 0.72-0.89) for proportional change in 2D AP diameter, 0.80 (95% CI, 0.69-0.88) for proportional change in 3D AP diameter and 0.72 (95% CI, 0.56-0.83) for proportional change in hiatal area. The prevalence of major levator injury was 22.6%. The strength of correlation (r_S ) between ultrasound measurements and MOS score was 0.52 for 2D AP diameter, 0.62 for 3D AP diameter and 0.47 for hiatal area (P < 0.001 for all). On the ultrasound contraction scale, proportional change in 2D levator hiatal AP diameter of < 1% corresponds to absent, 2-14% to weak, 15-29% to normal and > 30% to strong contraction.

CONCLUSIONS

Ultrasound seems to be an objective and reliable method for evaluation of pelvic floor muscle contraction. Proportional change in 2D levator hiatal AP diameter had the highest ICC and moderate correlation with MOS score assessed by vaginal palpation, and we constructed an ultrasound scale for assessment of pelvic floor muscle contraction based on this measure. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Systematic Review on Effectiveness of Patient/Nurse Navigation on Health Outcomes of Breast Cancer Patients

Background: Continued advances in technology and cancer treatment have made cancer care more complex. A wide range of healthcare professionals are involved in the care and there is a potential for poor coordination and miscommunication. Hence there is a need to integrate and coordinate care to enhance quality care and improved health outcomes patient navigation approach was introduced by Dr Harold Freeman at Harlem Hospital Centre, the USA in 1990. Some literature identified nurses as a suitable candidate to assume this role. But there is a need to further explore the effectiveness of patient/nurse navigation program for its effectiveness on health outcomes such as anxiety, psychological distress, mood states, quality of life, symptom distress (nausea, vomiting, sleep disturbances) physical well being, psychological well being, coping, support and patient satisfaction. Aim: To synthesize the best available evidence on the effectiveness of patient/nurse navigation program in the care of women with breast cancer. Methods: This review was conducted according to Cochrane guidelines. An extensive literature search was conducted in PubMed, CINAHL, Proquest, Cochrane Library, IndMed (Indian database of studies) and Shodhganga, a reservoir of Indian theses from January 1990-January 2017 for relevant studies published in the English language. The search criteria were limited to randomized controlled trials with patient or nurse navigation interventions compared with routine/usual care interventions without patient/nurse navigator in women with diagnosis of breast cancer aged 18 years and above, at any stage of illness undergoing any treatment in a hospital setting, including inpatient and outpatient/ambulatory care and studies. Results: Out of 238 studies assessed for eligibility only 6 studies were assessed for methodological quality. Quality assessment was done by using Delphi checklist by two independent reviewers. The risks of bias in RCTs were assessed using Cochrane risk of bias tool. Due to the methodological heterogeneity of the studies, a meta-analysis was not performed. The reviewers categorized the main outcomes as quality of life, patient satisfaction with care, anxiety, psychological distress and physical problems and other outcomes (treatment adherence, barriers to care, diagnostic interval, timely access to care, time to completion of treatment, use of health care resources) and presented it in narrative form. Conclusion: This review provides evidence that navigation programs have some benefit on breast cancer patients' health outcomes. The findings from this review show that there are a limited number of studies reporting health outcomes of breast cancer patients from inpatient settings and especially no studies from Asian countries. This warrants the need for developing navigation programs in developing countries especially in Indian setting where no navigation programs are being reported in cancer care.