Zero x-ray cardiac resynchronization therapy device implantation guided by a nonfluoroscopic mapping system: A pilot study

An Overview of Arrhythmias in Pregnancy

Cardiovascular disease significantly jeopardizes pregnancies in the United States, impacting 1% to 4% of pregnancies annually. Among complications, cardiac arrhythmias are prevalent, posing concerns for maternal and fetal health. The incidence of arrhythmias during pregnancy is rising, partly due to advances in congenital heart surgery and a growing population of women with structural heart disease. While most arrhythmias are benign, the increasing prevalence of more serious arrhythmias warrants a proactive approach. Guidance and reassurance suffice in many cases, but persistent symptoms require cautious use of antiarrhythmic drugs or other therapies for a safe outcome. Managing more serious arrhythmias requires a comprehensive, multidisciplinary approach involving specialists, including maternal-fetal medicine physicians, cardiologists, electrophysiologists, and anesthesiologists.

Bedside zero-fluoroscopy temporary permanent pacemaker implantation in the electrical storm treatment under the guidance of EnSite 3D system: a case report

BACKGROUND

Electrical storm (ES) is a clinical emergency characterized by multiple malignant ventricular arrhythmias or ICD discharges within 24 h, requiring early rational management.

CASE PRESENTATION

We report a 55-year-old man who underwent aortic valve replacement experienced recurrent ventricular tachycardia/ventricular fibrillation. A temporary permanent pacemaker with the EnSite system was implanted, and significant inhibition of the electrical storm, attributed to the atrial overdrive pacing, ensued.

CONCLUSIONS

In emergency regarding an electrical storm, the bedside temporary permanent pacemaker implantation with the EnSite system is concluded to be feasible and safe.

Zero to minimal fluoroscopy for cardiac electronic device implantation: A systematic review and meta-analysis

Background

Fluoroscopy is conventionally performed for cardiac implantable electronic device (CIED) therapy and carries radiation drawback for both patients and medical workers. Recently, zero to minimal fluoroscopy (ZMF) approach is introduced to reduce radiation exposure of fluoroscopy. This study compares the feasibility and safety of ZMF approach to fluoroscopy for CIEDs therapy in adults.

Method

A systematic literature search was conducted on PubMed, ScienceDirect, and Web of Science in March 2023. All observational or experimental studies comparing ZMF approach to fluoroscopy for adult CIEDs therapy were included. Reviews, case report/series, animal studies, and non-English articles were excluded. The success rate, procedural time, fluoroscopy time, radiation dose, and complications rate were compared for each approach.

Results

Seven articles for permanent and three articles for temporary CIEDs were included for analysis. The success rate of ZMF for permanent CIEDs was similar to fluoroscopy method (OR: 0.77, 95% CI: 0.33-4.15). The procedural time of ZMF was similar to fluoroscopy for both permanent and temporary CIEDs (standardized mean difference [SMD]: 0.10, 95% CI: -0.35 to 0.55 and SMD: -0.71, 95% CI: -1.87-0.44, respectively). However, ZMF approach markedly reduced the fluoroscopy time and radiation exposure for permanent CIEDs (SMD: -1.80, 95% CI: -2.49 to -1.12 and SMD: -1.26, 95% CI: -2.24 to -0.29). The complication rate was similar for permanent CIEDs (OR: 1.08, 95% CI: 0.41-2.84), yet lowered for temporary CIEDs (OR: 0.34, 95% CI: 0.20-0.59).

Conclusion

ZMF had similar success rate, procedural time, and sum complication rate for permanent CIEDs implantation with a significant reduction of fluoroscopy time and radiation exposure.

Low fluoroscopy permanent His bundle pacing using a new electroanatomic mapping system (KODEX EPD). A multicenter experience

Background

His bundle pacing (HBP) may be a challenging procedure, often involving a long fluoroscopic time (FT) and a long procedural time (PT). We sought to evaluate whether the use of a new nonfluroscopic mapping (NFM) system, the KODEX-EPD, is able to reduce FT and PT when mapping is performed by the pacing catheter rather than an electrophysiological mapping catheter.

Methods and Results

We included 46 consecutive patients (77 ± 8 years; 63% male) who underwent HBP; in 22 a NFM-guided procedure with the KODEX-EPD system was performed (group 1), whereas in 24 a conventional fluoroscopy-guided approach was used (group 2). Pacing indications were sick sinus syndrome in 13, atrioventricular block in 21, and cardiac resynchronization therapy in 12 cases. Both a lumen-less fixed helix lead and a stylet-driven extendable helix lead were used, respectively, in 24% and 76% of patients. HBP was successful in 22 patients (100%) in group 1 and 23 patients (96%) in group 2. The FT was significantly reduced in group 1 (183 ± 117 s vs 464.1 ± 352 s in group 2, p = .012). There were no significant differences between groups in PT and other procedural outcomes.

Conclusions

The KODEX-EPD system may be safely used in HBP procedures. It is effective in reducing ionizing radiation exposure, as evidenced by the significant drop in FT, without increasing PT.

Three-dimensional mapping in cardiac implantable electronic device - a feasible and effective alternative to fluoroscopy

BACKGROUND

During the last decade, three-dimensional mapping technology has substantially aided the development of cardiac implanted electronic devices (CIEDs). This article intends to present an outline of the use and benefits of three-dimensional (3D) mapping systems in CIEDs.

RESULT

As an alternative to fluoroscopy, 3D mapping greatly minimizes radiation exposure and eliminates the need for contrast dye during the implantation of CIEDs. Based on the visualization of the pacing lead tip and accurate anatomic reconstruction of the chamber of interest and a specialized mapping technique, 3D mapping technology dramatically improves the efficacy and success of the advanced cardiac implantable devices' placement. Additionally, it provides a superior option for those with complex medical conditions.

CONCLUSION

The use of 3D mapping technology in CIEDs has been proven feasible and effective by accumulating evidence. It is fair to anticipate that it will be widely used in CIED implantation in the future.

Electroanatomic voltage mapping for tissue characterization beyond arrhythmia definition: A systematic review

Three-dimensional (3D) reconstruction by means of electroanatomic mapping (EAM) systems, allows for the understanding of the mechanism of focal or re-entrant arrhythmic circuits, which can be identified by means of dynamic (activation and propagation) and static (voltage) color-coded maps. However, besides this conventional use, EAM may offer helpful anatomical and functional information for tissue characterisation in several clinical settings. Today, data regarding electromechanical myocardial viability, scar detection in ischaemic and nonischaemic cardiomyopathy and arrhythmogenic right ventricle dysplasia (ARVC/D) definition are mostly consolidated, while emerging results are becoming available in contexts such as Brugada syndrome and cardiac resynchronisation therapy (CRT) implant procedures. As part of an invasive procedure, EAM has not yet been widely adopted as a stand-alone tool in the diagnostic path. We aim to review the data in the current literature regarding the use of 3D EAM systems beyond the definition of arrhythmia.

Innovation in Permanent Pacemaker's Implantation Technique: Trans-Axillary Approach

INTRODUCTION

Permanent pacemakers' (PPM) implantation is an integral part of electrophysiology and general cardiology. The implantation technique has evolved a lot since the first implantation. Several innovations have been undertaken to improve the effectiveness, life of the transplant, and patient outcomes. In this study, we introduced a new implantation technique to improve the procedure and possibly reduce the rate of complication.

METHODS

This study was conducted from January 2016 to February 2017 in Hayatabad Medical Complex, Peshawar. Patients destined for implantation of PPM based on a clinical treatment plan, after proper explanation of the procedure, were brought to the catheterization laboratory. Venogram of the upper limb performed. Patients were scrubbed and draped. The axillary vein was approached via the Seldinger technique. About 2 to 3 cm superolateral to the puncture site, a skin incision was made and subcutaneous pocket constructed, and a guidewire external end was pulled in from inside the pocket keeping the venous end at the place. Subsequently, in a routine way, lead was placed, secured and the wound was closed in layers.

RESULTS

A total of 690 PPM were implanted under the study. About 290 devices were implanted in the conventional way and 380 devices via the trans-axillary approach. The mean implantation time was less than 30 minutes via the trans-axillary approach. Immediate and delayed complications of the procedure were minimal.

CONCLUSION

Trans-axillary approach holds some significant advantages over the conventional technique. The subcutaneous pocket and venous puncture successfully reduce the burden of foreign material, minimize the tension on the wound, shorten implantation time and reduce the chances of erosion of the device.

Into a Fluoroless Future: an Appraisal of Fluoroscopy-Free Techniques in Clinical Cardiac Electrophysiology

Purpose of Review

There are risks to both patients and electrophysiology providers from radiation exposure from fluoroscopic imaging, and there is increased interest in fluoroscopic reduction. We review the imaging tools, their applications, and current uses to eliminate fluoroscopy.

Recent Findings

Multiple recent studies provide supporting evidence for the transition to fluoroscopy-free techniques for both ablations and device implantation. The most frequently used alternative imaging approaches include intracardiac echocardiography, cardiac MRI guidance, and 3D electroanatomic mapping systems. Electroanatomic mapping and intracardiac echocardiography originally used to augment fluoroscopy imaging are now replacing the older imaging technique. The data supports that the future of electrophysiology can be fluoroscopy-free or very low fluoroscopy for the vast majority of cases.

Summary

As provider and institution experience grows with these techniques, many EP labs may choose to completely forego the use of fluoroscopy. Trainees will benefit from early experience with these techniques.

Novel electroanatomical map for permanent his bundle pacing: the Mont Blanc approach - influence of the learning curve and procedural outcome

AIMS

Pacing the specific conduction system like the Bundle of His (HB) can lead to more physiologic activation patterns compared to traditional right ventricular apical pacing. The aim of this study was to estimate the feasibility and value of electroanatomical mapping (EAM) for HB pacing during the learning curve and its impact on procedural outcome.

METHODS AND RESULTS

Fifteen consecutive patients were treated using EAM of the His bundle region before implantation. Voltage and activation maps of HB potentials were performed. The activation time from His potential to R wave (ECG-reference) was measured and correlated to the HV interval. The atrial and ventricular potentials were blended so the active window could only see the His potential. After completing the activation map, it was transformed into a peak-to-peak voltage map of the HB. With reversed black and white colour scale, the exact point of the maximal His signal amplitude was visualized. Procedural data for the implantation were analysed using this innovative approach. The average total procedural time and fluoroscopy time was 88.2 ± 19.1 min and 10.9 ± 4.5 min, respectively. The 3D mapping time was 18.4 ± 5.1 min. The 13.9 ± 5.1 His potential points were needed in average to complete the map. No periprocedural complications were seen in this cohort. In 86.7% of cases, His bundle pacing was successful. The average threshold for the His bundle stimulation and the R-wave amplitude was 1.62 ± 1 V (@1.0 ms) and 4.8 ± 3.2 mV, respectively. The pacing impedance was 513.5 ± 102.8 Ω. Average paced QRS complex width was 116.9 ± 20.3ms. On average 2.6 ± 1.6 lead positions were targeted to find the optimal pacing site.

CONCLUSION

Electroanatomical mapping-guided implantation of His-bundle leads can facilitate the identification of optimal pacing sites and allow to minimize procedure and fluoroscopy times even during the phase of the learning curve.

Progress in zero-fluoroscopy implantation of cardiac electronic device

Fluoroscopy is the imaging modality routinely used for cardiac device implantation. Due to the rising concern regarding the harmful effects of radiation exposure to both the patients and operation staffs, many efforts have been made to develop alternative techniques to achieve zero-fluoroscopy implantation. In this review, we describe the different methods aimed at avoiding the application of fluoroscopy in recent years, and evaluate their feasibility and safety in cardiac electronic device implantation.

Fluoroscopy reduction during device implantation by using three-dimensional navigation. A single-center experience

BACKGROUND AND OBJECTIVES

The use of nonfluoroscopic three-dimensional electroanatomic mapping (3DM) systems reduces radiation exposure during ablation procedures. In this study, we sought to determine the value of 3DM during routine device implant procedures.

METHODS

Seventy nonselected patients underwent implantation of a single chamber, dual chamber, or biventricular device guided by Ensite (Abbott Laboratories) to limit fluoroscopy use and compared with 70 consecutive patients, who underwent matching procedures with standard fluoroscopy use (FL) in the period immediately preceding the use of 3DM. The venous anatomy, right atrium, and ventricle and coronary sinus were mapped with 0.035 inch J-wire, quadripolar catheter, and/or angioplasty wire. The leads were advanced under real-time visualization in Ensite.

RESULTS

3DM reduced both fluoroscopy time and dose. Median fluoroscopy time for FL vs 3DM was 5.5 minutes (interquartile range [IQR]: 3.8-8.1) vs 0.9 minutes (IQR: 0.6-1.9) (P < .001) for single chamber devices, 6.3 minutes (IQR: 5.1-7.9) vs 3.3 minutes (IQR: 1.9-4) (P < .001) for dual-chamber devices, and 28.6 minutes (IQR: 19.6-36.2) to 14.7 minutes (IQR: 10.4-22.3) (P = .009) for biventricular devices, respectively. The median air kerma for FL vs 3DM was 15.4 mGy (IQR: 8.1-30.2) vs 4 mGy (IQR: 1.8-8) (P < .001) for single chamber devices, 16 mGy (IQR: 12-18.5) to 9.4 mGy (IQR: 7.5-11.3) (P = .001) for dual-chamber devices, and 324 mGy (IQR: 143-668.7) to 115 mGy (IQR:77-204) (P = .014) for biventricular devices, respectively. There were no procedural complications. At 3-month follow-up, there was no difference in voltage threshold measurements between the groups.

CONCLUSION

The use of 3DM leads to significantly reduced fluoroscopy time and fluoroscopy dose during routine device implantation.

Historical Perspectives on Cardiac Mapping and Ablation

Cardiac mapping has evolved from single point-by-point registration of cardiac electrical activity to its utmost real-time multimodality of mapping and imaging for catheter ablation of arrhythmias. The technology began with electrocardiogram recordings and evolved to the simultaneous registration of depolarization and repolarization using optical mapping and real-time multimodality imaging. Zero to near-zero fluoroscopy is currently used in practice to avoid radiation exposure. Real-time noninvasive mapping, imaging, and ablation of arrhythmias are in use in practice. We present the contemporary up-to-date progress on the role of cardiac mapping and imaging in the diagnosis and management of cardiac arrhythmias.

Impact of cardiac resynchronisation therapy on cardiologists' exposure to radiation during implantation of pacemakers and implantable cardioverter-defibrillators

Cardiologists are among the health professionals that are most exposed to ionizing radiation, but there is no recent study quantifying overexposure of physicians during cardiac resynchronisation therapy (CRT) procedures compared to 'classical' implantation of pacemakers (PMs) or implantable cardioverter-defibrillators (ICDs). We aimed to measure and compare operator exposure to radiation during implantation of PM and ICD with or without CRT. The study population comprised all PMs and ICDs implanted in a large referral centre over a six months period. The endpoint was operator radiation exposure, assessed using a personal electronic dosimeter located on operator's chest. In total, 169 PM/ICD implantations were analysed, 19 of which included CRT. Compared with 'classical' implantation, cardiologist radiation exposure was 9-fold greater during CRT procedures (p < 0.001). Physician exposure was related to dose-area product (R² = 0.21 during 'classical' implantations and R² = 0.57 during CRT procedures). Our study shows that cardiologists' exposure to radiation during CRT implantation was 9-fold greater than during procedures without CRT.

Long-term efficacy and safety of radiofrequency catheter ablation of atrial fibrillation in patients with cardiac implantable electronic devices and transvenous leads

INTRODUCTION

Long-term efficacy and safety are uncertain in patients with cardiac implantable electronic devices (CIED) and transvenous leads (TVL) undergoing radiofrequency catheter ablation of atrial fibrillation (AF). Thus, we assessed the outcome of AF ablation in those patients during long-term follow-up using continuous atrial rhythm monitoring (CARM).

METHODS AND RESULTS

A total of 190 patients (71.3 ± 10.7 years; 108 (56.8% men) were included in this study. At index procedure 81 (42.6%) patients presented with paroxysmal AF and 109 (57.4%) with persistent AF. The ablation strategy included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines, if appropriate. AF recurrences were assessed by CARM- and CIED-related complications by device follow-up. After a mean follow-up of 55.4 ± 38.1 months, freedom of AF was found in 86 (61.4%) and clinical success defined as an AF burden less than or equal to 1% in 101 (72.1%) patients. Freedom of AF was reported in 74.6% and 51.9% (P = 0.006) and clinical success in 89.8% and 59.3% (P < 0.001) of patients with paroxysmal and persistent AF, respectively. In 3 of 408 (0.7%) ablation procedures, a TVL malfunction occurred within 90 days after catheter ablation. During long-term follow-up 9 (4.7%) patients showed lead dislodgement, 2 (1.1%) lead fracture, and 2 (1.1%) lead insulation defect not related to the ablation procedure.

CONCLUSION

Our findings using CARM demonstrate long-term efficacy and safety of radiofrequency catheter ablation of AF in patients with CIED and TVL.

A Review of Image-guided Approaches for Cardiac Resynchronisation Therapy

Cardiac resynchronisation therapy (CRT) is a standard treatment for patients with heart failure; however, the low response rate significantly reduces its cost-effectiveness. A favourable CRT response primarily depends on whether implanters can identify the optimal left ventricular (LV) lead position and accurately place the lead at the recommended site. Myocardial imaging techniques, including echocardiography, cardiac magnetic resonance imaging and nuclear imaging, have been used to assess LV myocardial viability and mechanical dyssynchrony, and deduce the optimal LV lead position. The optimal position, presented as a segment of the myocardial wall, is then overlaid with images of the coronary veins from fluoroscopy to aid navigation of the LV lead to the target venous site. Once validated by large clinical trials, these image-guided techniques for CRT lead placement may have an impact on current clinical practice.