Novel catheter technology for ablative cure of atrial fibrillation

Endobronchial high-intensity ultrasound for thermal therapy of pulmonary malignancies: simulations with patient-specific lung models

Objective: This study investigates the feasibility of endobronchial ultrasound applicators for thermal ablation of lung tumors using acoustic and biothermal simulations.Methods: Endobronchial ultrasound applicators with planar (10 mm width) or tubular transducers (6 mm outer diameter (OD)) encapsulated by expandable coupling balloons (10 mm OD) are considered for treating tumors from within major airways; smaller catheter-based applicators with tubular transducers (1.7-4 mm OD) and coupling balloons (2.5-5 mm OD) are considered within deep lung airways. Parametric studies were applied to evaluate transducer configurations, tumor size and location, effects of acoustic reflection and absorption at tumor-lung parenchyma interfaces, and the utility of lung flooding for enhancing accessibility. Patient-specific anatomical lung models, with various geometries and locations of tumors, were developed for further evaluation of device performance and treatment strategies. Temperature and thermal dose distributions were calculated and reported.Results: Large endobronchial applicators with planar or tubular transducers (3-7 MHz, 5 min) can thermally ablate tumors attached to major bronchi at up to 3 cm depth, where reflection and attenuation of normal lung localize tumor heating; with lung flooding, endobronchial applicators can ablate ∼2 cm diameter tumors with up to ∼2 cm separation from the bronchial wall, without significant heating of intervening tissue. Smaller catheter-based tubular applicators can ablate tumors up to 2-3 cm in diameter from deep lung airways (5-9 MHz, 5 min).Conclusion: Simulations demonstrate the feasibility of endobronchial ultrasound applicators to deliver thermal coagulation of 2-3 cm diameter tumors adjacent to or accessible from major and deep lung airways.

Atrial fibrillation: a historical perspective

Atrial fibrillation (AF) undoubtedly has become one of the most well studied arrhythmias today in terms of pathophysiology and diagnostic and therapeutic (interventional) electrophysiology. Although it lends itself to an apparently easy diagnosis on a surface ECG, myriad electromechanical mechanisms underlie its origin. An era of technology has been reached that makes AF not only "treatable" but also potentially "curable." This article aims at walking through the historical corridors and maze that have led to the present-day understanding of this most common yet complex arrhythmia.

Recent insights into the pathophysiology of atrial fibrillation

Although the problem of atrial fibrillation is now widely appreciated, the fundamental mechanisms that lead to arrhythmia onset and persistence have been difficult to elucidate. As a result, available pharmacologic therapies have focused more on modifying ion channel activity than on the underlying mechanisms. Recent studies suggest an important role for alterations in autonomic regulation, neurohormonal activation, and a systemic inflammatory state in the genesis and persistence of atrial fibrillation. The relative contributions of these distinct pathways to atrial fibrillation likely vary from patient to patient, and within a patient, as a function of age. Tailored therapies, together with patient-specific ablative interventions, may increase the success with which atrial fibrillation is treated and minimize the occurrence of life-threatening thromboembolic complications.

Feasibility of noncontact intracardiac ultrasound ablation and imaging catheter for treatment of atrial fibrillation

Atrial fibrillation (AF) affects 1% of the population and results in a cost of 2.8 billion dollars from hospitalizations alone. Treatments that electrically isolate portions of the atria are clinically effective in curing AF. However, such minimally invasive catheter treatments face difficulties in mechanically positioning the catheter tip and visualizing the anatomy of the region. We propose a noncontact, intracardiac transducer that can ablate tissue and provide rudimentary imaging to guide therapy. Our design consists of a high-power, 20 mm by 2 mm, 128-element, transducer array placed on the side of 7-French catheter. The transducer will be used in imaging mode to locate the atrial wall; then, by focusing at that location, a lesion can be formed. Imaging of previously formed lesions could potentially guide placement of subsequent lesions. Successive rotations of the catheter will potentially enable a contiguous circular lesion to be created around the pulmonary vein. The challenge of intracardiac-sized transducers is achieving high intensities (300-5000 W/cm2) needed to raise the temperature of the tissue above 43 degrees C. In this paper, we demonstrate the feasibility of an intracardiac-sized transducer for treatment of atrial fibrillation. In simulations and proof-of-concept experiments, we show a 37 degrees C temperature rise in the lesion location and demonstrate the possibility of lesion imaging.

Real-time, 3-D ultrasound with multiple transducer arrays

Modifications were made to a commercial real-time, three-dimensional (3-D) ultrasound system for near simultaneous 3-D scanning with two matrix array transducers. As a first illustration, a transducer cable assembly was modified to incorporate two independent, 3-D intra-cardiac echo catheters, a 7 Fr (2.3 mm O.D.) side scanning catheter and a 14 Fr (4.7 mm O.D) forward viewing catheter with accessory port, each catheter using 85 channels operating at 5 MHz. For applications in treatment of atrial fibrillation, the goal is to place the sideviewing catheter within the coronary sinus to view the whole left atrium, including a pulmonary vein. Meanwhile, the forward-viewing catheter inserted within the left atrium is directed toward the ostium of a pulmonary vein for therapy using the integrated accessory port. Using preloaded, phasing data, the scanner switches between catheters automatically, at the push of a button, with a delay of about 1 second, so that the clinician can view the therapy catheter with the coronary sinus catheter and vice versa. Preliminary imaging studies in a tissue phantom and in vivo show that our system successfully guided the forward-viewing catheter toward a target while being imaged with the sideviewing catheter. The forward-viewing catheter then was activated to monitor the target while we mimicked therapy delivery. In the future, the system will switch between 3-D probes on a line-by-line basis and display both volumes simultaneously.

Finite-element analysis of temperature rise and lesion formation from catheter ultrasound ablation transducers

A model using finite-element analysis (FEA) has been developed to calculate the temperature rise in tissue from intracardiac ultrasound ablation catheters and to predict if this temperature rise is adequate for producing a lesion in the tissue. In the model, acoustic fields are simulated with Field II, and heat transfer is modeled with an FEA program. To validate the model, we compare its results to experimental results from an integrated, real-time three-dimensional (3-D) ultrasound imaging and ultrasound ablation catheter. The ultrasound ablation transducer is a ring transmitting at 10 MHz capable of producing an acoustic intensity of 16 W/cm2. It was used to ablate four lesions in tissue, and temperature rise as a function of time was monitored by embedded thermocouples. The average absolute difference between final temperatures predicted by FEA and those measured is 1.95 +/- 0.72 degrees C. Additionally, model and experimental lesion size are in good agreement. The model then is used to design a new ultrasound catheter with a 7.5 MHz linear phased array for ablation. Eight designs are modeled, and acoustic intensity, temperature rise, and ablation ability are compared.

Catheter ultrasound phased-array transducers for thermal ablation: a feasibility study

The feasibility of catheter single-element ultrasound transducers for cardiac ablation has been shown previously. We describe the design and testing of catheter-sized linear phased arrays transducers for ultrasound ablation. One array has 86 PZT-4 elements operating at 8 MHz and 5 MHz. The overall array size is 14.9 mm by 3.1 mm (10 Fr). The other array has 50 PZT-5 elements operating at 4 MHz and is 17 mm by 3.1 mm (10 Fr). In order to produce the intensity needed to create lesions in heart tissue, we modified a real-time, 3D scanner to produce 100 Vpp 256-cycle transmit pulses at a pulse repetition frequency of 14.1 kHz. This made it possible for the PZT-4 and PZT-5 transducers to produce ISPTA of 3.26 W/cm2 and 142 W/cm2, respectively. When driving the transducers at high duty factor, the transmit circuitry in the scanner was damaged. A mechanically-focused transducer with the same dimensions as the PZT-4 transducer was built. When transmitting continuously at 9 MHz, it produced an ISPTA of 29.3 W/cm2. This created a lesion 5 mm across and 5 mm deep in beef tissue while raising the focal temperature 23 degrees C. Ablation is within the capabilities of a catheter phased array transducer integrated into a diagnostic ultrasound scanner.

Real-time 3D color flow Doppler for guidance of vibrating interventional devices

The goal of this investigation was to examine the feasibility of guiding interventional devices using piezoelectric buzzers to create velocity sources, which were imaged and tracked with real-time 3D color flow Doppler. The interventional devices examined in this study included a pacemaker lead, Brockenbrough needle for cardiac septal puncture, cardiac guidewire and radiofrequency ablation needles for cancer therapy. Each was mechanically coupled to a piezoelectric buzzer and was imaged using a commercial real-time 3D ultrasound system with either a 2.5 MHz matrix array transducer or a 5 MHz, 22 F catheter transducer equipped with a tool port. In vitro images acquired in tissue phantoms, excised liver with a 'tumor' target and an excised sheep heart show strong vibration signals in 3D color flow Doppler, enabling real-time tracking and guidance of all the devices in three dimensions. In a sheep model, in vivo tracking of the pacing lead was performed in the superior vena cava as well as the right atrium using RT3D color flow Doppler images. The vibrating rf ablation needles were guided through the liver toward "tumor" targets in vivo with real-time 3D color flow Doppler images.

Integrated catheter for 3-D intracardiac echocardiography and ultrasound ablation

A catheter device with integrated ultrasound imaging array and ultrasound ablation transducer is introduced. This device has been designed for use in interventional cardiac procedures in which the cardiac anatomy is first imaged using real-time three-dimensional (3-D) ultrasound, then ablated to treat arrhythmias. The imaging array includes 112 elements operating at 5.4 MHz arranged in a 2-D matrix. Individual elements have a bandwidth of 21% and an insertion loss of 80 dB. The array has an azimuth resolution of 12 degrees and an elevation resolution of 8.7 degrees. The ablation transducer is a concentric piezoelectric transducer PZT-4 ring (outside diameter (O.D.), 4.5 mm, inside diameter (I.D.), 3.1 mm) operating at 10 MHz that surrounds the imaging array. It can produce a spatial-peak, temporal-average intensity up to 16 W/cm2. The entire device fits into a 9 Fr lumen with a 14 Fr tip to accommodate the ablation ring. With this device we have imaged, in realtime 3-D, a variety of targets including wire phantoms, fixed sheep hearts, and fresh bovine tissue. The ablation ring has been used to heat tissue-mimicking rubber 14 degrees C, as well as create lesions in fresh bovine tissue.

Dual lumen transducer probes for real-time 3-D interventional cardiac ultrasound

We have developed dual lumen probes incorporating a forward-viewing matrix array transducer with an integrated working lumen for delivery of tools in real-time 3-D (RT3-D) interventional echocardiography. The probes are of 14 Fr and 22 Fr sizes, with 112 channel 2-D arrays operating at 5 MHz. We obtained images of cardiac anatomy and simultaneous interventional device delivery with an in vivo sheep model, including: manipulation of a 0.36-mm diameter guidewire into the coronary sinus, guidance of a transseptal puncture using a 1.2-mm diameter Brockenbrough needle, and guidance of a right ventricular biopsy using 3 Fr biopsy forceps. We have also incorporated the 22 Fr probe within a 6-mm surgical trocar to obtain apical four-chamber ultrasound (US) scans from a subcostal position. Combining the imaging catheter with a working lumen in a single device may simplify cardiac interventional procedures by allowing clinicians to easily visualize cardiac structures and simultaneously direct interventional tools in a RT3-D image.

Functional disconnection of arrhythmogenic pulmonary veins in patients with paroxysmal atrial fibrillation guided by combined electroanatomical (CARTO) and conventional mapping

BACKGROUND

Isolation of arrhythmogenic pulmonary veins (PVs) by radiofrequency current (RF) application has been introduced as a curative treatment for patients (pts) with paroxysmal atrial fibrillation (AF). The present study sought to investigate the feasibility and efficacy of this approach guided by conventional and electroanatomical mapping (CARTO).

METHODS

Twenty pts (13 male; 57 +/- 8 years) with recurrent documented focally triggered idiopathic AF refractory to multiple antiarrhythmic drugs were prospectively included. Atrial premature beats were present at baseline in 9 pts and could be provoked in further 8 pts. Empirical ablation of both superior PVs was performed in 3 pts with no focal activity. After transseptal puncture selective angiography of all PVs was obtained. Thirty-six PVs (left superior: n = 18, right superior: n = 10, left inferior: n = 8) were targeted for RF ablation. A complete left atrial CARTO-map including the left atrial (LA) to pulmonary vein (PV) junction was obtained during sinus rhythm and/or coronary sinus pacing. RF was initially applied at the PV-LA junction at areas with the shortest left atrial- to PV potential interval (target 50 degrees C, max. 30 W, duration 60 sec). Isolation was confirmed by the complete disappearance of specific PV potentials. RF lesions were analyzed with respect to the number of segment-quarters covering the PV ostium.

RESULTS

Functional isolation could be achieved in 35 out of 36 PVs following 10 +/- 5 RF applications for each PV. RF applications covered 2 or less quarter segments of the overall PV circumference in 29 (80%) PVs. Total session duration was 6.5 +/- 1.6 h with a mean fluoro-time of 54 +/- 18 minutes. For CARTO mapping and ablation a mean fluoro time of 34 +/- 6 min was required. During a mean follow up period of 8.3 +/- 2.5 months AF relapsed in 9 pts (46%). A second approach was performed in 5 pts. and demonstrated either new foci (n = 2) or recurrence of previously isolated PV (n = 8). The second RF ablation procedure led to stable sinus rhythm in 3 out 5 pts. Thus, the overall success rate including the second procedure was 70%.

CONCLUSIONS

CARTO guided functional isolation of presumed arrhythmogenic PVs by RF lesions covering 2 or less segments of the PV ostium in most patients is feasible. However, repeat procedures are often warranted to permanently treat paroxysmal atrial fibrillation.

Current clinical perspectives on implantable devices for atrial defibrillation

The role of devices that deliver shock therapy for atrial fibrillation is still debated. Following technical improvements in catheter-based atrial defibrillation, implantable devices have become available either in the form of stand-alone atrial defibrillators or in the form of dual defibrillators. Although preliminary results do not support their use as a single, unique treatment for atrial fibrillation patients, in combination with drugs, pacing or other treatments such as ablation, atrial defibrillators should help appropriately selected groups of patients.