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Luo Q, Xie Y, Bao Y, Wei Y, Lin C, Zhang N, Ling T, Chen K, Pan W, Wu L, Jin Q. Utilization of steerable sheath improves the efficiency of atrial fibrillation ablation guided by robotic magnetic navigation compared with fixed-curve sheath. Clin Cardiol 2022; 45:482-487. [PMID: 35195273 PMCID: PMC9045062 DOI: 10.1002/clc.23801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/05/2022] [Accepted: 02/11/2022] [Indexed: 12/12/2022] Open
Abstract
Background The objective of this study was to assess the impact of steerable sheaths compared with fixed‐curve sheaths on the procedural outcomes of atrial fibrillation (AF) ablation guided by robotic magnetic navigation (RMN). Methods and Results In this retrospective case−control study, 110 patients scheduled for AF catheter ablation were enrolled and divided into two groups. Fifty‐five patients (paroxysmal, 70%) were treated with RMN‐guided ablation utilizing a steerable sheath and another 55 patients (paroxysmal, 70%) were ablated with RMN using a fixed‐curve sheath. Clinical characteristics were similar between the two groups. Compared with the fixed‐curve sheath group, the steerable sheath group procedure time (111.9 ± 25.2 vs. 90.4 ± 20.7 min, p < .001) and radiofrequency (RF) time (35.9 ± 9.0 vs. 30.5 ± 7.4 min, p < .001) were significantly shortened. Additionally, the navigation index was significantly improved (0.41 ± 0.06 vs. 0.48 ± 0.08, p < .001) in the steerable sheath group. By employing a large catheter loop for targeting the right pulmonary veins (PVs), the steerable sheath group significantly reduced the RF delivery time (15.0 ± 3.0 vs. 12.0 ± 2.1 min, p < .001) during right‐side PV isolation (PVI). However, total fluoroscopy time was similar between the two groups (5.6 ± 2.6 vs. 5.0 ± 2.0 min, p > .05). Acute PVI success rates were similar between the two groups. No major or minor complications occurred in either group. Conclusion Appropriate utilization of steerable sheath technology can improve the efficiency of AF ablation guided by RMN, primarily by reducing the total procedure and RF delivery times of right‐side PVI without compromising safety.
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Affiliation(s)
- Qingzhi Luo
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yun Xie
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yangyang Bao
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Wei
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Changjian Lin
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ning Zhang
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianyou Ling
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kang Chen
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenqi Pan
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liqun Wu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Jin
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Radiofrequency atrial fibrillation ablation with irrigated tip catheter using remote magnetic navigation compared with conventional manual method. J Interv Card Electrophysiol 2020; 62:95-102. [PMID: 32959178 DOI: 10.1007/s10840-020-00879-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/14/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Studies comparing manual catheter navigation (MCN) to remote magnetic navigation (RMN) for atrial fibrillation (AF) ablation showed variable results. OBJECTIVE The aim of this meta-analysis is to compare the safety and clinical outcomes of AF radiofrequency (RF) ablation using MCN versus RMN with irrigated tip catheters. METHODS Medline and the Cochrane Central Register of Controlled Trials (CENTRAL) were queried from inception through January 2019. Studies comparing safety and clinical outcomes of AF ablation with RF using MCN versus RMN with irrigated tip catheters were included. Random effects meta-analysis was used to pool outcomes across studies. Study endpoints included freedom of AF at the end of the study, procedure total time, fluoroscopy time, and complications. RESULTS A total of 14 studies (3 controlled non-randomized trials, 1 prospective observational, and 10 retrospective observational studies) involving 3375 patients (1871 in MCN and 1504 in RMN) were included in this meta-analysis. There was no significant difference between the two groups in terms of freedom of AF (OR 1.08, 95% CI 0.82-1.42, p = 0.52). The MCN group was associated with shorter procedure time (mean difference in minutes - 50.39, 95% CI - 67.99 to - 32.79, p < 0.01), longer fluoroscopy time (mean difference in minutes 18.01, 95% CI 10.73-25.29, p < 0.01), and higher complication rate (OR 2.18, 95% CI 1.24-3.82, p < 0.01). CONCLUSIONS AF ablation utilizing MCN was associated with similar efficacy to RMN but with higher complication rates. Although the procedure time was shorter with MCN, the fluoroscopy time was more prolonged. Randomized clinical studies are needed to further verify these results.
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Li X, Jin Q, Zhang N, Ling T, Lin C, Jia K, Bao Y, Xie Y, Wei Y, Chen K, Pan W, Xie Y, Wu L. Procedural outcomes and learning curve of cardiac arrhythmias catheter ablation using remote magnetic navigation: Experience from a large-scale single-center study. Clin Cardiol 2020; 43:968-975. [PMID: 32453461 PMCID: PMC7462195 DOI: 10.1002/clc.23391] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/21/2020] [Accepted: 05/07/2020] [Indexed: 01/22/2023] Open
Abstract
Background Remote magnetic navigation (RMN)‐guided ablation has become an inspiring method of catheter ablation for tachyarrhythmias. Hypothesis Data from a large‐scale single center may provide further insight into the safety of and the learning curve for RMN‐guided ablation. Methods A total of 1003 catheter ablation procedures using RMN for conditions including supraventricular ventricular tachycardia, atrial tachyarrhythmias, and premature ventricular contraction/ventricular tachycardia (PVC/VT) were retrospectively analyzed from an ablation registry. Procedural outcomes, including procedure time, mapping time, X‐ray time, and RF time, were assessed. The complications were classified into two categories: major and minor. A subanalysis was used to illustrate the learning curve of RMN‐guided ablation by assessing procedure time and total X‐ray time of 502 atrial fibrillation (AF) ablation procedures. Results Among these procedures, 556 (55.4%) were AF and 290 (28.9%) were PVC/VT. Electrical pulmonary vein isolation was achieved in 99.0% of AF procedures, and acute success reached 90.3% in PVC/VT procedures. The overall complication rate was 0.5%. In the subanalysis of AF procedures, the overall procedure time and X‐ray time of procedures were short (125.9 ± 54.6 and 5.3 ± 3.9 minutes, respectively) and proceeded to decrease from the initial 30 procedures to about 300 procedures, where the learning curve reached plateau, demonstrating maximum procedure efficiency. Conclusions RMN‐guided ablation is safe, as verified by very low overall complication rate and reduced X‐ray time. In our study, even the first AF procedures had a relatively low procedure time and total X‐ray time, and procedure efficiency improved during the learning curve.
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Affiliation(s)
- Xiang Li
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Jin
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ning Zhang
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianyou Ling
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Changjian Lin
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kangni Jia
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yangyang Bao
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yun Xie
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Wei
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kang Chen
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenqi Pan
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yucai Xie
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liqun Wu
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Jez J, Jadczyk T, Lehar F, Pesl M, Kulik T, Belaskova S, Soucek F, Caluori G, Wojakowski W, Starek Z. Comparison of atrial fibrillation ablation efficacy using remote magnetic navigation vs. manual navigation with contact-force control. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 164:387-393. [PMID: 31645769 DOI: 10.5507/bp.2019.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/04/2019] [Indexed: 11/23/2022] Open
Abstract
AIMS This study aims to compare procedural parameters and clinical efficacy of remote magnetic navigation (RMN) vs. manual navigation (MAN) approach for radiofrequency ablation (RFA) in patients with atrial fibrillation (AF). METHODS 146 patients with AF were enrolled in the study. In the RMN group (n=57), patients were treated with the CARTO® 3 in combination with the Niobe ES system. In the MAN group (n=89), ablation was performed with the EnSite Velocity and TactiCath™ Quartz catheter with direct contact force measurement. Procedural time, ablation time, fluoroscopy time, radiation dose and ablation counts were measured and compared between the groups. Recurrence of AF was evaluated after 6 months of follow-up. RESULTS Mean procedure times (236.87±64.31 vs. 147.22±45.19 min, P<0.05), counts of RF applications (74.30±24.77 vs. 49.15±20.33, P<0.05) and total RFA times (4323.39±1426.69 vs. 2780.53±1157.85 s, P<0.05) were all significantly higher in the RMN than in the MAN group, respectively. In the same order, mean X-ray dose (9722.6±7507.4 vs. 8087.9±6051.5 mGy/cm2, P=0.12) and mean total X-ray exposure time (8.07±4.20 vs. 9.54±5.47 min, P=0.08) were not statistically different. At 6-month follow-up, freedom from AF was similar in RMN and MAN group for paroxysmal (60.8% and 73%, respectively, P=0.42) and persistent AF (69.6% and 75.0%, respectively, P=0.77). CONCLUSIONS Due to the fact that mid-term clinical outcomes showed no significant differences in AF recurrences between groups and manual ablation strategy provided more favorable results regarding acute procedural parameters, we can conclude that the remote magnetic navigation is not superior to the manual approach.
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Affiliation(s)
- Jiri Jez
- International Clinical Research Center, Interventional Cardiac Electrophysiology, St. Anne's University Hospital Brno, Czech Republic.,Department of Cardiovascular Diseases, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomasz Jadczyk
- International Clinical Research Center, Interventional Cardiac Electrophysiology, St. Anne's University Hospital Brno, Czech Republic.,Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Frantisek Lehar
- International Clinical Research Center, Interventional Cardiac Electrophysiology, St. Anne's University Hospital Brno, Czech Republic.,Department of Cardiovascular Diseases, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Pesl
- International Clinical Research Center, Interventional Cardiac Electrophysiology, St. Anne's University Hospital Brno, Czech Republic.,Department of Cardiovascular Diseases, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Kulik
- International Clinical Research Center, Interventional Cardiac Electrophysiology, St. Anne's University Hospital Brno, Czech Republic
| | - Silvie Belaskova
- Biostatistics, International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Filip Soucek
- International Clinical Research Center, Interventional Cardiac Electrophysiology, St. Anne's University Hospital Brno, Czech Republic
| | - Guido Caluori
- International Clinical Research Center, Interventional Cardiac Electrophysiology, St. Anne's University Hospital Brno, Czech Republic.,CEITEC, Masaryk University, Brno, Czech Republic
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Zdenek Starek
- International Clinical Research Center, Interventional Cardiac Electrophysiology, St. Anne's University Hospital Brno, Czech Republic.,Department of Cardiovascular Diseases, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Virk SA, Kumar S. Remote Magnetic Versus Manual Catheter Navigation for Atrial Fibrillation Ablation. Circ Arrhythm Electrophysiol 2019; 12:e007517. [DOI: 10.1161/circep.119.007517] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sohaib A. Virk
- Department of Cardiology, Westmead Hospital, Sydney, Australia (S.A.V., S.K.)
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia (S.A.V., S.K.)
- Westmead Applied Research Centre, University of Sydney, Australia (S.K.)
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Jia K, Jin Q, Liu A, Wu L. Remote magnetic navigation versus manual control navigation for atrial fibrillation ablation: A systematic review and meta-analysis. J Electrocardiol 2019; 55:78-86. [PMID: 31152995 DOI: 10.1016/j.jelectrocard.2019.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/25/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this review was to evaluate the efficacy and safety between remote magnetic navigation (RMN) and manual control navigation (MCN) for atrial fibrillation (AF) ablation. METHODS We searched the PubMed, EMBASE and Cochrane library databases using the key words AF, ablation and magnetic navigation. RESULTS Eighteen studies were identified in this analysis including 4046 patients comparing RMN and MCN in AF ablation, which were all non-randomized controlled studies. No significant difference of AF recurrence rate (40% vs. 38%, OR 1.00, 95% CI 0.82-1.22, p = 0. 97) and acute success rate in achieving pulmonary vein isolation (91% vs. 93%, OR 0.44, 95% CI 0.16-1.17, p = 0.10) was found between RMN and MCN. However, compared with MCN, RMN was associated with significantly lower complication rate (2% vs. 5%, OR 0.44, 95% CI 0.28-0.69, p = 0. 0003) and shorter fluoroscopy time (MD -9.71 min, 95% CI -15.80 to -3.63, p = 0.002). Procedure time (MD 47.05 min, 95% CI 27.5-66.58, p < 0.00001) and ablation time (MD 15.90 min, 95% CI 9.62-22.18, p < 0.00001) of RMN guided AF ablation were significantly longer than those of MCN. CONCLUSION The results of this study suggest that RMN is as effective as MCN in achieving pulmonary vein isolation and freedom from AF recurrence, and has superior safety with less complications and shorter fluoroscopy time.
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Affiliation(s)
- Kangni Jia
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Jin
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Ao Liu
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liqun Wu
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Zhao XX, Li KL, Wang RX, Zheng J, Liu XY, Dang SP, Yu ZM, Zhang CY, Yang XJ. Comparisons of efficacy, safety, and recurrence risk factors of paroxysmal and persistent atrial fibrillation catheter ablation using robotic magnetic navigation system. Clin Cardiol 2019; 42:418-424. [PMID: 30652336 PMCID: PMC6712313 DOI: 10.1002/clc.23156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 01/09/2019] [Accepted: 01/14/2019] [Indexed: 01/24/2023] Open
Abstract
Background No data exist on comparisons of efficacy, safety, and recurrence risk factors of paroxysmal and persistent atrial fibrillation (AF) ablation using robotic magnetic navigation system (MNS), respectively. Methods About 151 AF patients were prospectively enrolled and divided into paroxysmal AF group (n = 102) and persistent AF group (n = 49). Circumferential pulmonary vein antrum isolation (CPVI) was performed in all patients. Linear ablation at the left atrial roof and mitral isthmus was performed in patients with persistent AF in addition to CPVI. The procedural time, X‐ray exposure time, acute and long‐term success rates of CPVI, and procedure‐related complications were analyzed. The AF recurrence rates in the two groups were compared during 1 year, and Cox regression was used to analyze the recurrence risk factors. Results The acute success rates of CPVI in the two groups were 98.04% and 97.96%, respectively. There were no significant differences in the procedural time, X‐ray exposure time, and ablation time between the two groups (P > 0.05). No serious complications appeared in either group. The AF ablation success rates were 70.6% and 57.1% for the paroxysmal and persistent groups respectively at 12‐month follow‐up (P = 0.102). AF duration and coronary heart disease prior to ablation were associated with the higher AF recurrence in patients with persistent AF. Conclusion Ablation using MNS is effective and safe both in patients with paroxysmal and persistent AF. AF duration and coronary heart disease prior to ablation are two independent risk factors of AF recurrence in patients with persistent AF postoperatively.
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Affiliation(s)
- Xiao-Xi Zhao
- Department of Cardiology, The First Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China.,Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Ku-Lin Li
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Ru-Xing Wang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Jie Zheng
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Xiao-Yu Liu
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Shi-Peng Dang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Zhi-Ming Yu
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Chang-Ying Zhang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Xiang-Jun Yang
- Department of Cardiology, The First Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
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The Impact of Left Atrial Size in Catheter Ablation of Atrial Fibrillation Using Remote Magnetic Navigation. Cardiol Res Pract 2019; 2018:3096261. [PMID: 30622820 PMCID: PMC6304809 DOI: 10.1155/2018/3096261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 11/07/2018] [Indexed: 11/17/2022] Open
Abstract
Objective The objective of this study was to investigate the impact of left atrial (LA) size for the ablation of atrial fibrillation (AF) using remote magnetic navigation (RMN). Methods A total of 165 patients with AF who underwent catheter ablation using RMN were included. The patients were divided into two groups based on LA diameter. Eighty-three patients had small LA (diameter <40 mm; Group A), and 82 patients had a large LA (diameter ≥40 mm; Group B). Results During mapping and ablation, X-ray time (37.0 (99.0) s vs. 12 (30.1) s, P < 0.001) and X-ray dose (1.4 (2.7) gy·cm2 vs. 0.7 (2.1) gy·cm2, P=0.013) were significantly higher in Group A. No serious complications occurred in any of the patients. There was no statistical difference in the rate of first anatomical attempt of pulmonary vein isolation between the two groups (71.1% vs. 57.3%, P=0.065). However, compared with Group B, the rate of sinus rhythm was higher (77.1% vs. 58.5%, P < 0.001) during the follow-up period. More patients in Group A required a sheath adjustment (47/83 vs. 21/82, P < 0.001), presumably due to less magnets positioned outside of the sheath. In vitro experiments with the RMN catheter demonstrated that only one magnet exposed created the sheath affects which influenced the flexibility of the catheter. Conclusions AF ablation using RMN is safe and effective in both small and large LA patients. Patients with small LA may pose a greater difficulty when using RMN which may be attributed to the fewer magnets beyond the sheath. As a result, the exposure of radiation was increased. This study found that having at least two magnets of the catheter positioned outside of the sheath can ensure an appropriate flexibility of the catheter.
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