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Luani B, Basho M, Ismail A, Rauwolf T, Kaese S, Tobli N, Samol A, Pankraz K, Schmeisser A, Wiemer M, Braun-Dullaeus RC, Genz C. Catheter navigation by intracardiac echocardiography enables zero-fluoroscopy linear lesion formation and bidirectional cavotricuspid isthmus block in patients with typical atrial flutter. Cardiovasc Ultrasound 2023; 21:13. [PMID: 37537565 PMCID: PMC10398930 DOI: 10.1186/s12947-023-00312-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION One of the most helpful aspects of intracardiac echocardiography (ICE) implementation in electrophysiological studies (EPS) is the real-time visualisation of catheters and cardiac structures. In this prospective study, we investigated ICE-guided zero-fluoroscopy catheter navigation during radiofrequency (RF) ablation of the cavotricuspid isthmus (CTI) in patients with typical atrial flutter (AFL). METHODS AND RESULTS Thirty consecutive patients (mean age 72.9 ± 11.4 years, 23 male) with ongoing (n = 23) or recent CTI-dependent AFL underwent an EPS, solely utilizing ICE for catheter navigation. Zero-fluoroscopy EPS could be successfully accomplished in all patients. Mean EPS duration was 41.4 ± 19.9 min, and mean ablation procedure duration was 20.8 ± 17.1 min. RF ablation was applied for 6.0 ± 3.1 min (50W, irrigated RF ablation). Echocardiographic parameters, such as CTI length, prominence of the Eustachian ridge (ER), and depth of the CTI pouch on the ablation plane, were assessed to analyse their correlation with EPS- or ablation procedure duration. The CTI pouch was shallower in patients with an ablation procedure duration above the median (4.8 ± 1.1 mm vs. 6.4 ± 0.9 mm, p = 0.04), suggesting a more lateral ablation plane in these patients, where the CTI musculature is stronger. CTI length or ER prominence above the respective median did not correlate with longer EPS duration. CONCLUSIONS Zero-fluoroscopy CTI ablation guided solely by intracardiac echocardiography in patients with CTI-dependent AFL is feasible and safe. ICE visualisation may help to localise the optimal ablation plane, detect and correct poor tissue contact of the catheter tip, and recognise early potential complications during the ablation procedure.
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Affiliation(s)
- Blerim Luani
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany.
| | - Maksim Basho
- Department of Radiology, University Hospital Center Mother Teresa, Tirana, Albania
| | - Ammar Ismail
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Thomas Rauwolf
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | - Sven Kaese
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Ndricim Tobli
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Alexander Samol
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Katharina Pankraz
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Alexander Schmeisser
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | - Marcus Wiemer
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Rüdiger C Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | - Conrad Genz
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
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Kashiwagi M, Kuroi A, Higashimoto N, Mori K, Takemoto K, Taniguchi M, Nishi T, Asae Y, Ota S, Tanimoto T, Kitabata H, Tanaka A. Impact of tag index and local electrogram for successful first-pass cavotricuspid isthmus ablation. Heart Rhythm O2 2023; 4:350-358. [PMID: 37361616 PMCID: PMC10288023 DOI: 10.1016/j.hroo.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Background The optimal ablation index (AI) value for cavotricuspid isthmus (CTI) ablation is unknow. Objective This study investigated the optimal AI value and whether preassessment of local electrogram voltage of CTI could predict first-pass success of ablation. Methods Voltage maps of CTI were created before ablation. In the preliminary group, the procedure was performed in 50 patients targeting an AI ≥450 on the anterior side (two-thirds segment of CTI) and AI ≥400 on the posterior side (one-third segment of CTI). The modified group also included 50 patients, but the target AI for the anterior side was modified to ≥500. Results In the modified group, the first-pass rate of success was higher (88% vs 62%; P < .01) than in the preliminary group, and there were no differences in the average bipolar and unipolar voltages at the CTI line. Multivariate logistic regression analysis revealed that ablation with an AI ≥500 on the anterior side was the only independent predictor (odds ratio 4.17; 95% confidence interval 1.44-12.05; P < .01). The bipolar and unipolar voltages were higher at sites without conduction block than at sites with conduction block (both P < .01). The cutoff values for predicting conduction gap were ≥1.94 mV and ≥2.33 mV with areas under the curve of 0.655 and 0.679, respectively. Conclusions CTI ablation with a target AI >500 on the anterior side was shown to be more effective than an AI >450, and local voltage at a conduction gap was higher than without a conduction gap.
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Affiliation(s)
- Manabu Kashiwagi
- Address reprint requests and correspondence: Dr Manabu Kashiwagi, Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
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De Ruvo E, De Luca L, Grieco D, Fagagnini A, Rebecchi M, Schillaci V, Stabile G, Arestia A, Salito A, Martino AM, Calò L, Solimene F. Tissue thickness measured with dielectric-based technology during radiofrequency catheter ablation. Eur Heart J Suppl 2023; 25:C253-C257. [PMID: 37125309 PMCID: PMC10132622 DOI: 10.1093/eurheartjsupp/suad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Radiofrequency catheter ablation of the cavotricuspid isthmus is the standard treatment for patients suffering from typical atrial flutter. The aim of this study was to test the feasibility of tissue thickness and lesion transmurality measurement by a novel dielectric system. This was a retrospective multicentric non-randomized open-label, single-arm study. The atrial wall thickness was significantly higher close to the tricuspid annulus than close to the inferior vena cava and a trend towards a progressive decrease of atrial wall thickness was observed moving the mapping catheter from the tricuspid valve to the inferior vena cava. The possibility to visualize the tissue thickness could modify the way to deliver radiofrequency energy, allowing a tailored approach in cardiac ablation procedures.
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Affiliation(s)
| | - Lucia De Luca
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Roma (RM) 00169, Italy
| | - Domenico Grieco
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Roma (RM) 00169, Italy
| | - Alessandro Fagagnini
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Roma (RM) 00169, Italy
| | - Marco Rebecchi
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Roma (RM) 00169, Italy
| | | | - Giuseppe Stabile
- Clinica Montevergine, Mercogliano (AV), Italy
- Casa di Cura San Michele, Maddaloni (CE), Italy
- Department of Cardiac Electrophysiology and Pacing, Anthea Hospital, Bari, Italy
| | | | | | - Anna Maria Martino
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Roma (RM) 00169, Italy
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Roma (RM) 00169, Italy
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Sumi H, Hoshiyama T, Morihisa K, Noda K, Kaneko S, Kanazawa H, Ishii M, Fujisue K, Sueta D, Takashio S, Usuku H, Matsushita K, Tsujita K. Effect of contact vector direction on achieving cavotricuspid isthmus block. Sci Rep 2023; 13:2579. [PMID: 36781935 PMCID: PMC9925428 DOI: 10.1038/s41598-023-29738-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Cavotricuspid isthmus (CTI) ablation is an important treatment strategy for CTI-dependent atrial flutter (AFL). The location of the catheter contact area is confirmed by the contact vector direction (CVD) through three-dimensional mapping during the procedure. However, the relationship between CVD during radiofrequency ablation and its efficacy in achieving CTI block has not been clarified. This study aimed to investigate the relationship between CVD and efficacy in achieving CTI block. CVDs during radiofrequency ablation were divided into proximal vectors against the distal tip (P-vector) and other vectors (normal-vector). In 39 patients who underwent CTI linear ablation, the CTIs were divided into two segments: the tricuspid valve area (anterior) and inferior vena cava area (posterior). The frequency of the residual conduction gap was compared between segments in which the P- and normal-vectors were observed. P-vectors were observed in 13 of the 78 segments. The median ablation index was not significantly different between segments in which the P-vector and normal-vector were observed (398.2 [384.2-402.2] vs. 393.3 [378.3-400.1], p = 0.15). However, residual conduction gaps were significantly more frequently observed in the segment in which the P-vector was observed than those in which only the normal-vector was observed (6/13, 46.2% vs. 3/65, 4.6%; p < 0.01). During a 6-month follow-up, two patients required a second session of ablation due to AFL recurrence. A residual conduction gap was observed in one patient at the site where the P-vector was observed in the first session. Avoiding the P-vector might be an important factor in improving CTI block and reducing AFL recurrence.
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Affiliation(s)
- Hitoshi Sumi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Tadashi Hoshiyama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan.
| | - Kenji Morihisa
- Kumamoto Chuo Hospital, 1-5-1, Tainoshima Minami-Ku, Kumamoto, 862-0965, Japan
| | - Katsuo Noda
- Kumamoto Chuo Hospital, 1-5-1, Tainoshima Minami-Ku, Kumamoto, 862-0965, Japan
| | - Shozo Kaneko
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Hisanori Kanazawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Koichiro Fujisue
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Kenichi Matsushita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
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Ablation index-guided high-power vs. moderate-power cavotricuspid isthmus ablation. Heart Vessels 2023; 38:90-95. [PMID: 35852611 DOI: 10.1007/s00380-022-02125-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/15/2022] [Indexed: 01/06/2023]
Abstract
Ablation index (AI)-guided ablation is useful for pulmonary vein isolation (PVI) and cavotricuspid isthmus (CTI) ablation. However, the impact of radiofrequency (RF) application power on CTI ablation with a fixed target AI remains unclear. One-hundred-thirty drug-refractory atrial fibrillation and/or atrial flutter patients who underwent AI-guided CTI ablation with or without PVI between July 2020 and August 2021 were randomly assigned to high-power (45 W) and moderate-power (35 W) groups. We performed CTI ablation with the same target AI value in both groups: 500 for the anterior 1/3 segments and 450 for the posterior 2/3 segments. In total, first-pass conduction block of the CTI was obtained in 111 patients (85.4%), with 7 patients (5.4%) showing CTI reconnection. The rate of first-pass conduction block was significantly higher in the 45 W group (61/65, 93.8%) than in the 35 W group (50/65, 76.9%, P = 0.01). CTI ablation and CTI fluoroscopy time were significantly shorter in the 45 W group than in the 35 W group (CTI ablation time: 192.3 ± 84.8 vs. 319.8 ± 171.4 s, P < 0.0001; CTI fluoroscopy time: 125.2 ± 122.4 vs. 171.2 ± 124.0 s, P = 0.039). Although there was no significant difference, steam pops were identified in two patients from the 45 W group at the anterior segment of the CTI. The 45 W ablation strategy was faster and provided a higher probability of first-pass conduction block than the 35 W ablation strategy for CTI ablation with a fixed AI target.
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Ulbrich S, Huo Y, Tomala J, Wagner M, Richter U, Pu L, Mayer J, Zedda A, Krafft AJ, Lindborg K, Piorkowski C, Gaspar T. Magnetic resonance imaging–guided conventional catheter ablation of isthmus-dependent atrial flutter using active catheter imaging. Heart Rhythm O2 2022; 3:553-559. [DOI: 10.1016/j.hroo.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Schillaci V, Stabile G, Arestia A, Shopova G, Agresta A, Salito A, Giannitti CM, Natalizia A, De Simone A, Solimene F. Dielectric-based Tissue Thickness Measured During Radiofrequency Catheter Ablation. J Cardiovasc Electrophysiol 2022; 33:1587-1589. [PMID: 35557022 DOI: 10.1111/jce.15530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/16/2022] [Accepted: 04/06/2022] [Indexed: 11/30/2022]
Abstract
A new dielectric-based method (KODEX-EPD mapping system, EPD Solutions, a Philips company) for measuring tissue thickness at the catheter-tissue interface has recently been developed. We reported preliminary data on real-time catheter-based measuring myocardial wall thickness in vivo, during typical atrial flutter radiofrequency ablation. The atrial wall thickness was significantly higher close to the tricuspid annulus than close to the inferior vena cava (3.6±0.5 mm vs 2.4±0.3 mm, p<0.001) and a trend towards a progressive decrease of atrial wall thickness was observed moving the mapping catheter from the tricuspid valve to the inferior vena cava. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Giuseppe Stabile
- Clinica Montevergine, Mercogliano, (AV), Italy.,Casa di Cura San Michele, Maddaloni, (CE), Italy.,Anthea Hospital, Bari
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Arnold R, Hofer E, Haas J, Sanchez-Quintana D, Plank G. Diversity and complexity of the cavotricuspid isthmus in rabbits: A novel scheme for classification and geometrical transformation of anatomical structures. PLoS One 2022; 17:e0264625. [PMID: 35231058 PMCID: PMC8887761 DOI: 10.1371/journal.pone.0264625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/14/2022] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to describe the morphology of the cavotricuspid isthmus (CTI) in detail and introduce a comprehensive scheme to describe the topology of this region based on functional considerations. This may lead to a better understanding of isthmus-dependent flutter and fibrillation and to improved intervention strategies. We used images of the cavotricuspid isthmus from 52 rabbits of both sexes with a median weight of 3.40 ± 0.93 kg. The area of the CTI was 124.25 ± 42.14 mm2 with 53.28 ± 21.13 mm2 covered by pectinate muscles connecting the terminal crest and the vestibule. Isthmus length decreased from inferolateral (13.09 ±2.14 mm) to central (9.85 ± 2.14 mm) to paraseptal (4.88 ± 1.96 mm) resembling the overall human geometry. Ramification sites of pectinate muscles were identified and six levels dividing the CTI from posterior to anterior were introduced. This allowed the classification of pectinate muscle segments based on the connected ramification level. To account for the high inter-individual variations in size and shape, the CTI was projected onto a normalized reference frame using bilinear transformation. Furthermore, two measures of complexity were introduced: (i) the ramification index, which reflects the total number of muscle segments connected to a ramification site and (ii) the complexity index, which reflects the type of ramification (branching or merging site). Topological analysis showed that the complexity of the pectinate muscle network decreases from inferolateral to paraseptal and that the number of electrically uncoupled parallel pathways increases in the central section between the terminal crest and the vestibule which introduces potential reentry pathways.
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Affiliation(s)
- Robert Arnold
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
- * E-mail:
| | - Ernst Hofer
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
| | - Josef Haas
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Damian Sanchez-Quintana
- Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Gernot Plank
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
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Kashiwagi M, Kuroi A, Katayama Y, Terada K, Fujita S, Hozumi T, Shimamura K, Shiono Y, Tanimoto T, Kubo T, Tanaka A, Akasaka T. Impact of cavotricuspid isthmus depth on the ablation index for successful first-pass typical atrial flutter ablation. Sci Rep 2021; 11:22413. [PMID: 34789842 PMCID: PMC8599492 DOI: 10.1038/s41598-021-01846-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 11/01/2021] [Indexed: 11/18/2022] Open
Abstract
Cavotricuspid isthmus (CTI) linear ablation has been established as the treatment for typical atrial flutter. Recently, ablation index (AI) has emerged as a novel marker for estimating ablation lesions. We investigated the relationship between CTI depth and ablation parameters on the procedural results of typical atrial flutter ablation. A total of 107 patients who underwent CTI ablation were retrospectively enrolled in this study. All patients underwent computed tomography before catheter ablation. From the receiver-operating curve, the best cut-off value of CTI depth was < 4.1 mm to predict first-pass success. Although the average AI was not different between deep CTI (DC; CTI depth ≥ 4.1) and shallow CTI (SC; CTI depth < 4.1), DC required a longer ablation time and showed a lower first-pass success rate (p < 0.01). In addition, the catheter inversion technique was more frequently required in the DC (p < 0.01). The lowest AI sites of the first-pass CTI line were determined in both the ventricular (2/3 segment of CTI) and inferior vena cava (IVC, 1/3 segment of CTI) sides. The best cut-off values of the weakest AIs at the ventricular and IVC sides for predicting first-pass success were > 420 and > 386, respectively. Among patients with these cut-off values, the first-pass success rate was 89% in the SC and 50% in the DC (p < 0.01). Although ablation parameters were not significantly different, the first-pass success rate was lower in the DC than in the SC. Further investigation might be required for better outcomes in deep CTIs.
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Affiliation(s)
- Manabu Kashiwagi
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
| | - Akio Kuroi
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Yosuke Katayama
- Department of Cardiovascular Medicine, Shingu Municipal Medical Center, 18-7, Hachibuse, Shingu, Wakayama, 647-0072, Japan
| | - Kosei Terada
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Suwako Fujita
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Takeshi Hozumi
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Kunihiro Shimamura
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
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Santoro A, Baiocchi C, Sisti N, Zacà V, Pondrelli CR, Falciani F, Lamberti F. Catheter inversion during cavotricuspid isthmus catheter ablation: The new shaft visualization catheter reduces fluoroscopy use. J Arrhythm 2021; 37:1311-1317. [PMID: 34621430 PMCID: PMC8485825 DOI: 10.1002/joa3.12596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 06/14/2021] [Accepted: 06/25/2021] [Indexed: 11/06/2022] Open
Abstract
AIMS Catheter ablation (CA) is the choice therapy of cavotricuspid isthmus (CTI) atrial flutter. The aim of this study was to describe our approach to improve the CTI ablation using a zero-fluoroscopy (ZF). The procedural difficulties could be related to anatomical characteristics of the CTI. METHODS One hundred eighty-eight patients that performed CA of CTI were retrospectively and consecutively evaluated between 2017 and 2019. The studied population was divided into two groups. Eighty-eight patients who were undergone CA using ablation catheter without shaft visualization catheter (NSV) were Group 1. One hundred patients were undergone CA using ablation catheter with a shaft visualization (SV); they were Group 2. The catheter was looped at the Eustachian ridge after 200 seconds of radiofrequencies (RF) without elimination of local electrogram. RESULTS A conduction line block of CTI was obtained in all patients of Group 2 using a ZF approach. In 16 patients of Group 1, the catheter inversion was obtained using fluoroscopy to avoid damages during its loop. In Group 2, a complete CTI block was obtained with a catheter inversion approach in ten patients without fluoroscopy, visualizing the shaft and the tip of the ablation catheter on the electroanatomic (EAM) map. In the overall population studied the use of SV had a linear correlation with the ZF approach (r = .629; P < .001). The duration of RF was lower in Group 2 than in Group 1 (Group 1: 27.8 ± 6.3 vs Group 2: 15.6 ± 7.2 minutes; P < .01). The procedure time between two groups was lower in Group 2 than in Group 1 (Group 1: 58.4 ± 22.4 vs Group 2: 42.2 ± 15.7 minutes; P < .01). No differences between two groups were documented regarding success and complications. CONCLUSIONS The visualization of the shaft's catheter on the EAM permitted the catheter inversion safely in order to overcome some complex CTI anatomy and obtain bidirectional block. The SV reduced procedure time, RF applications and fluoroscopy exposition during CTI ablation.
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Affiliation(s)
- Amato Santoro
- Division of Cardiology Azienda Ospedaliera Universitaria Senese Siena Italy
| | - Claudia Baiocchi
- Division of Cardiology Azienda Ospedaliera Universitaria Senese Siena Italy
| | - Nicolò Sisti
- Division of Cardiology Azienda Ospedaliera Universitaria Senese Siena Italy
| | - Valerio Zacà
- Division of Cardiology Azienda Ospedaliera Universitaria Senese Siena Italy
| | | | | | - Filippo Lamberti
- Division of Medicine Cardiovascular Section San Eugenio Hospital Rome Italy
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Maclean E, Simon R, Ang R, Dhillon G, Ahsan S, Khan F, Earley M, Lambiase PD, Rosengarten J, Chow AW, Dhinoja M, Providencia R, Markides V, Wong T, Hunter RJ, Behar JM. A multi-center experience of ablation index for evaluating lesion delivery in typical atrial flutter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1039-1046. [PMID: 33782987 DOI: 10.1111/pace.14228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/18/2021] [Accepted: 03/21/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Anatomical studies demonstrate significant variation in cavotricuspid isthmus (CTI) architecture. METHODS Thirty-eight patients underwent CTI ablation at two tertiary centers. Operators delivered 682 lesions with a target ablation index (AI) of 600 Wgs. Ablation parameters were recorded every 10-20 ms. Post hoc, Visitags were trisected according to CTI position: inferior vena cava (IVC), middle (Mid), or ventricular (V) lesions. RESULTS There were no complications. 92.1% of patients (n = 35) remained in sinus rhythm after 14.6 ± 3.4 months. For the whole CTI, peak AI correlated with mean impedance drop (ID) (R2 = 0.89, p < .0001). However, analysis by anatomical site demonstrated a non-linear relationship Mid CTI (R2 = 0.15, p = .21). Accordingly, while mean AI was highest Mid CTI (IVC: 473.1 ± 122.1 Wgs, Mid: 539.6 ± 103.5 Wgs, V: 486.2 ± 111.8 Wgs, ANOVA p < .0001), mean ID was lower (IVC: 10.7 ± 7.5Ω, Mid: 9.0 ± 6.5Ω, V: 10.9 ± 7.3Ω, p = .011), and rate of ID was slower (IVC: 0.37 ± 0.05 Ω/s, Mid: 0.18 ± 0.08 Ω/s, V: 0.29 ± 0.06 Ω/s, p < .0001). Mean contact force was similar at all sites; however, temporal fluctuations in contact force (IVC: 19.3 ± 12.0 mg/s, Mid: 188.8 ± 92.1 mg/s, V: 102.8 ± 32.3 mg/s, p < .0001) and catheter angle (IVC: 0.42°/s, Mid: 3.4°/s, V: 0.28°/s, p < .0001) were greatest Mid CTI. Use of a long sheath attenuated these fluctuations and improved energy delivery. CONCLUSIONS Ablation characteristics vary across the CTI. At the Mid CTI, higher AI values do not necessarily deliver more effective ablation; this may reflect localized fluctuations in catheter angle and contact force.
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Affiliation(s)
- Edd Maclean
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Ron Simon
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Richard Ang
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Gurpreet Dhillon
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Syed Ahsan
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Fakhar Khan
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Mark Earley
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Pier D Lambiase
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - James Rosengarten
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Anthony W Chow
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Mehul Dhinoja
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Rui Providencia
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Vias Markides
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Tom Wong
- Department of Cardiac Electrophysiology, Royal Brompton Hospital, London, UK
| | - Ross J Hunter
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Jonathan M Behar
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, W Smithfield, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK.,Department of Cardiac Electrophysiology, Royal Brompton Hospital, London, UK
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Ruipérez-Campillo S, Castrejón S, Martínez M, Cervigón R, Meste O, Merino JL, Millet J, Castells F. Non-invasive characterisation of macroreentrant atrial tachycardia types from a vectorcardiographic approach with the slow conduction region as a cornerstone. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 200:105932. [PMID: 33485078 DOI: 10.1016/j.cmpb.2021.105932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Macroreentrant atrial tachyarrhythmias (MRATs) can be caused by different reentrant circuits. The treatment for each MRAT type may require ablation at different sites, either at the right or left atria. Unfortunately, the reentrant circuit that drives the arrhythmia cannot be ascertained previous to the electrophysiological intervention. METHODS A noninvasive approach based on the comparison of atrial vectorcardiogram (VCG) loops is proposed. An archetype for each group was created, which served as a reference to measure the similarity between loops. Methods were tested in a variety of simulations and real data obtained from the most common right (peritricuspid) and left (perimitral) macroreentrant circuits, each divided into clockwise and counterclockwise subgroups. Adenosine was administered to patients to induce transient AV block, allowing the recording of the atrial signal without the interference of ventricular signals. From the vectorcardiogram, we measured intrapatient loop consistence, similarity of the pathway to archetypes, characterisation of slow velocity regions and pathway complexity. RESULTS Results show a considerably higher similarity with the loop of its corresponding archetype, in both simulations and real data. We found the capacity of the vectorcardiogram to reflect a slow velocity region, consistent with the mechanisms of MRAT, and the role that it plays in the characterisation of the reentrant circuit. The intra-patient loop consistence was over 0.85 for all clinical cases while the similarity of the pathway to archetypes was found to be 0.85 ± 0.03, 0.95 ± 0.03, 0.87 ± 0.04 and 0.91 ± 0.02 for the different MRAT types (and p<0.02 for 3 of the 4 groups), and pathway complexity also allowed to discriminate among cases (with p<0.05). CONCLUSIONS We conclude that the presented methodology allows us to differentiate between the most common forms of right and left MRATs and predict the existence and location of a slow conduction zone. This approach may be useful in planning ablation procedures in advance.
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Affiliation(s)
- Samuel Ruipérez-Campillo
- ITACA Institute, Universitat Politècnica de València, Valencia, Spain; Department of Information Technology and Electrical Engineering, Swiss Federal Institute of Technology (ETH), Zürich, Zürich, Switzerland; Department of Bioengineering and Aeroespace Engineering, Universidad Carlos III de Madrid, Madrid, Spain.
| | - Sergio Castrejón
- Unidad de Arritmias y Electrofisiología Robotizada, Hospital Universitario La Paz, IdiPaz, Universidad Autónoma, Madrid, Spain
| | - Marcel Martínez
- Unidad de Arritmias y Electrofisiología Robotizada, Hospital Universitario La Paz, IdiPaz, Universidad Autónoma, Madrid, Spain
| | - Raquel Cervigón
- Escuela Politécnica, Universidad de Castilla la Mancha, Cuenca, Spain
| | - Olivier Meste
- Université Cote d'Azur, CNRS, Lab. I3S, Sophia Antipolis, France
| | - José Luis Merino
- Unidad de Arritmias y Electrofisiología Robotizada, Hospital Universitario La Paz, IdiPaz, Universidad Autónoma, Madrid, Spain
| | - José Millet
- ITACA Institute, Universitat Politècnica de València, Valencia, Spain
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Impact of catheter-tissue contact force on lesion size during right ventricular outflow tract ablation in a swine model. Chin Med J (Engl) 2020; 133:1680-1687. [PMID: 32496308 PMCID: PMC7401743 DOI: 10.1097/cm9.0000000000000859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The catheter-tissue contact force (CF) is one of the significant determinants of lesion size and thus has a considerable impact on the effectiveness of ablation procedures. This study aimed to evaluate the impact of CF on the lesion size during right ventricular outflow tract (RVOT) ablation in a swine model. Methods Twelve Guangxi Bama miniature male pigs weighing 40 to 50 kg were studied. After general anesthesia, a ThermoCool SmartTouch contact-sensing ablation catheter was introduced to the RVOT via the femoral vein under the guidance of the CARTO 3 system. The local ventricular voltage amplitude and impedance were measured using different CF levels. We randomly divided the animals into the following four groups according to the different CF levels: group A (3–9 g); group B (10–19 g); group C (20–29 g); and group D (30–39 g). Radiofrequency ablations were performed at three points in the free wall and septum of the RVOT in power control mode at 30 W for 30 s while maintaining the saline irrigation rate at 17 mL/min. At the end of the procedures, the maximum depth, surface diameter, and lesion volume were measured and recorded. A linear regression analysis was performed to determine the relationship between continuous variables. Results A total of 72 ablation lesions were created in the RVOT of the 12 Bama pigs. The maximum depth, surface diameter, and volume of the lesions measured were well correlated with the CF (free wall: β = 0.105, β = 0.162, β = 3.355, respectively, P < 0.001; septum: β = 0.093, β = 0.150, β = 3.712, respectively, P < 0.001). The regional ventricular bipolar voltage amplitude, unipolar voltage amplitude, and impedance were weakly positively associated with the CF (β = 0.065, β = 0.125, and β = 1.054, respectively, P < 0.001). There was a significant difference in the incidence of steam pops among groups A, B, C, and D (free wall: F = 7.3, P = 0.032; septum: F = 10.5, P = 0.009); and steam pops occurred only when the CF exceeded 20 g. Trans-mural lesions were observed when the CF exceeded 10 g in the free wall, while the lesions in the septum were non-trans-mural even though the CF reached 30 g. Conclusions CF seems to be a leading predictive factor for the size of formed lesions in RVOT ablation. Maintaining the CF value between 3 and 10 g may be reasonable and effective for creating the necessary lesion size and reducing the risk of complications, such as steam pops and perforations.
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Garweg C, Vandenberk B, Foulon S, Hermans P, Poels P, Haemers P, Ector J, Willems R. Determinants of the difficulty of leadless pacemaker implantation. Pacing Clin Electrophysiol 2020; 43:551-557. [DOI: 10.1111/pace.13933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/18/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Christophe Garweg
- Department of Cardiovascular SciencesUniversity of Leuven Leuven Belgium
- Department of CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Bert Vandenberk
- Department of Cardiovascular SciencesUniversity of Leuven Leuven Belgium
- Department of CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Stefaan Foulon
- Department of CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Patrick Hermans
- Department of CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Patricia Poels
- Department of CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Peter Haemers
- Department of Cardiovascular SciencesUniversity of Leuven Leuven Belgium
- Department of CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Joris Ector
- Department of Cardiovascular SciencesUniversity of Leuven Leuven Belgium
- Department of CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Rik Willems
- Department of Cardiovascular SciencesUniversity of Leuven Leuven Belgium
- Department of CardiologyUniversity Hospitals Leuven Leuven Belgium
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Anderson RH. The cavotricuspid isthmus in the setting of real cardiac anatomy. Heart Rhythm 2019; 16:1619-1620. [PMID: 31158495 DOI: 10.1016/j.hrthm.2019.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom.
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