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Matía Francés R, Hernández Madrid A, Delgado A, Carrizo L, Pindado C, Moro Serrano C, Zamorano Gómez JL. Characterization of the impact of catheter-tissue contact force in lesion formation during cavo-tricuspid isthmus ablation in an experimental swine model. Europace 2013; 16:1679-83. [PMID: 24225068 DOI: 10.1093/europace/eut351] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Catheter-tissue contact is critical for effective lesion creation. The objective of this study was to determine in an experimental swine model the pathological effects of cavo-tricuspid isthmus ablation using two systems that provide reliable measures of the pressure at the catheter tip during radiofrequency ablation procedures. METHODS AND RESULTS We performed the procedure in eight pigs in our experimental electrophysiology laboratory after right femoral vein dissection and insertion of a 12 Fr. introducer during general anaesthesia and endotracheal intubation. The target contact force during the applications was <10 grs. (axial or lateral), 10-20, 20-30, and >30 grs. in two pigs each. The power was set at 40 W and maximum target temperature at 45°C. We performed a radiofrequency line dragging from the tricuspid valve to the inferior vena cava in the eight pigs. Euthanasia of the animals was carried out a week after the procedure and a pathological examination of the lesions was performed. In the endocardial macroscopic analysis the extent of lesions, presence of thrombus, transmurality, and endothelial rupture was assessed. External surface was examined searching for transmural lesions. The mean contact force applied was 18.7 ± 8.4 grs. and the mean depth of the lesions was 3.6 ± 2 mm. Lesions were never transmural with average forces <10 grs., and the mean depth was very low (0.75 mm). To achieve transmural lesions contact forces of at least 20 grs. were required. We found a positive correlation (r = 0.85, P < 0.05) between the average force during the applications and depth of the lesions. CONCLUSION When ablating the cavo-tricuspid isthmus in a swine model, contact forces of at least 20 grs. are required to achieve transmural lesions. Catheter-tissue contact is critical for effective lesion creation. This information is important for improving ablation efficacy.
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Affiliation(s)
- Roberto Matía Francés
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
| | | | - Antonia Delgado
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
| | - Laura Carrizo
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
| | - Carlos Pindado
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
| | | | - José L Zamorano Gómez
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
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[Relation between cavo-tricuspid isthmus anatomy studied by transesophageal echocardiography and the immediate outcome of radiofrequency ablation of common atrial flutter]. Ann Cardiol Angeiol (Paris) 2010; 59:125-30. [PMID: 20605136 DOI: 10.1016/j.ancard.2010.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 04/06/2010] [Indexed: 11/22/2022]
Abstract
Radiofrequency ablation is the only curative treatment of common atrial flutter. The aim of the treatment is to create a line of bidirectional block at the level of the cavo-tricuspid isthmus. This objective can be achieved in the vast majority of the patients. However, it may difficult or even not possible to create an isthmus block. The anatomy of the right atrium is subject to important variations, especially at the isthmus level. We therefore tested the hypothesis that these anatomic variations might influence the immediate outcome of cavo-tricuspid isthmus ablation. The anatomy of cavo-tricuspid isthmus was studied by trans-oesophageal echocardiography. The shape of the isthmus (concave or not), the presence of diverticula and the degree of development of the Eustachian ridge were analysed. From these data, the cavo-tricuspid anatomy was classified as simple or complex. The immediate outcome of radiofrequency ablation was reviewed in 94 patients (mean age of 63 years) according to the anatomy, simple or complex. When the anatomy was classified as simple, the success rate of radiofrequency ablation was 95.6%; when the anatomy was complex, the success rate was 76.9% (overall success rate for the entire population equal to 90.4%). The length of the cavo-tricuspid isthmus did not influence the outcome of radiofrequency ablation. In summary, it appears that the anatomy of cavo-tricuspid isthmus seems to play a role in the immediate outcome of radiofrequency ablation of cavo-tricuspid isthmus.
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Cuesta A, Mont L, Alvarenga N, Rogel U, Brugada J. Comparison of 8-mm-tip and irrigated-tip catheters in the ablation of isthmus-dependent atrial flutter: a prospective randomized trial. Rev Esp Cardiol 2009; 62:750-6. [PMID: 19709510 DOI: 10.1016/s1885-5857(09)72355-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES Both 8-mm-tip and irrigated-tip catheters improve outcomes in typical atrial flutter ablation. However, it is not yet known which is preferable. The objective was to compare the effectiveness of 8-mm-tip (Group 1) and open irrigated-tip (Group 2) catheters in the first ablation attempt. METHODS A prospective randomized trial with a long-term follow-up was performed in patients with documented typical atrial flutter. For both types of catheter, the power was initially set to 50 W. The primary endpoint was ablation of the cavotricuspid isthmus in a procedure lasting, at most, 600 s. RESULTS Group 1 contained 65 patients and Group 2 contained 66, with no significant intergroup difference in baseline characteristics. Their mean age was 63+/-12 years, 80% were men, and 65% had structural heart disease. The primary endpoint was achieved in 48 patients (73.8%) in Group 1 and 49 (74.2%) in Group 2 (P=NS). In the remaining patients, the procedure was continued at the physician's discretion and ablation was finally achieved in all cases. In the intention-to-treat analysis, there was no significant difference between the groups in the number of applications of the ablation device or in the duration of the ablation procedure, radioscopy or the total procedure. By 16+/-5 months of follow-up (>1 year in 98%), 8 (6.3%) patients had experienced recurrence and 95 (74.2%) were free from any arrhythmia. There was no differences between the groups. CONCLUSIONS No difference was found between the effectiveness of 8-mm-tip and open irrigated-tip catheters in the first attempt at ablation of typical atrial flutter.
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Affiliation(s)
- Alejandro Cuesta
- Sección de Arritmias, Instituto Clínico del Tórax, Hospital Clínic de Barcelona, Barcelona, España.
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Catéter de 8 mm frente a punta irrigada en la ablación del flutter auricular dependiente del istmo: un estudio prospectivo y aleatorizado. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)71688-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Zoppo F, Bertaglia E, Tondo C, Colella A, Mantovan R, Senatore G, Bottoni N, Carreras G, Corò L, Turco P, Mantica M, Stabile G. High prevalence of cooled tip use as compared with 8-mm tip in a multicenter Italian registry on atrial fibrillation ablation: focus on procedural safety. J Cardiovasc Med (Hagerstown) 2008; 9:888-92. [DOI: 10.2459/jcm.0b013e3282f7352a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Meissner A, Borchard R, Maagh P, Christ M, van Bracht M, Wickenbrock I, Trappe HJ, Plehn G. Impact of irrigated energy application on the right coronary artery hemodynamics: FFR measurement in patients who underwent ablation of common type atrial flutter. J Interv Card Electrophysiol 2008; 21:35-42. [DOI: 10.1007/s10840-007-9188-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Accepted: 11/08/2007] [Indexed: 11/29/2022]
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Rotter M, Scavée C, Sacher F, Sanders P, Takahashi Y, Hsu LF, Rostock T, Hocini M, Jaïs P, Clementy J, Haïssaguerre M. Correlation of atrial electrocardiographic amplitude with radiofrequency energy required to ablate cavotricuspid isthmus-dependent atrial flutter. Heart Rhythm 2005; 2:263-9. [PMID: 15851316 DOI: 10.1016/j.hrthm.2004.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2004] [Accepted: 12/13/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate a possible correlation between atrial ECG amplitude in common atrial flutter (AFL) and radiofrequency (RF) energy required to achieve cavotricuspid isthmus block. BACKGROUND The amount of RF delivery required for ablation of typical AFL is variable. This variation has been attributed to the cavotricuspid isthmus anatomy. Atrial ECG amplitude can be a marker of atrial anatomic variations and therefore may correlate with RF duration required to achieve cavotricuspid isthmus block. METHODS Seventy consecutive patients were prospectively studied. Ablation of the cavotricuspid isthmus was performed by creating a line of block between the inferior tricuspid annulus and the inferior caval vein using 8-mm-tip electrode catheters. If more than 20 minutes of RF time was required to achieve conduction block, the catheter was changed to an irrigated-tip catheter. Atrial ECG amplitude was assessed in leads II, III, aVF, and aVL. RESULTS A total of 14 +/- 11 minutes of RF energy was delivered to achieve block in all patients; 12 patients (8%) required more than 20 minutes. Atrial ECG amplitude showed highly significant correlations with cumulative RF energy (F and P waves in lead II: r = 0.703 and r = 0.737, P < .001). P-wave amplitude <0.2 mV and/or flutter wave amplitude <0.35 mV in lead II have a high negative predictive value to predict <20 min RF delivery (96% and 89% respectively). CONCLUSIONS A significant correlation exists between atrial ECG amplitude and amount of RF required to ablate typical AFL. Atrial ECG amplitude may be a surrogate marker of characteristics of isthmus anatomy. These findings may influence the choice of catheter used for cavotricuspid isthmus ablation.
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Affiliation(s)
- Martin Rotter
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux 2, France.
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Cabrera JA, Sánchez-Quintana D, Farré J, Rubio JM, Ho SY. The Inferior Right Atrial Isthmus: Further Architectural Insights for Current and Coming Ablation Technologies. J Cardiovasc Electrophysiol 2005; 16:402-8. [PMID: 15828885 DOI: 10.1046/j.1540-8167.2005.40709.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although linear ablation of the right atrial isthmus in patients with isthmus-dependent atrial flutter can be highly successful, recurrences and complications occur in some patients. Our study provides further morphological details for a better understanding of the structure of the isthmus. METHODS AND RESULTS We examined the isthmic area in 30 heart specimens by dissection, histology, and scanning electron microscopy. This area was bordered anteriorly by the hinge of the tricuspid valve and posteriorly by the orifice of the inferior caval vein. With the heart in attitudinal orientation, we identified and measured the lengths of three levels of isthmus: paraseptal (24 +/- 4 mm), central (19 +/- 4 mm), and inferolateral (30 +/- 3 mm). Comparing the three levels, the central isthmus had the thinnest muscular wall and the paraseptal isthmus the thickest wall. At all three levels, the anterior part was consistently muscular whereas the posterior part was composed of mainly fibro-fatty tissue in 63% of hearts. The right coronary artery was less than 4 mm from the endocardial surface of the inferolateral isthmus in 47% of hearts. Inferior extensions of the atrioventricular node were present in the paraseptal isthmus in 10% of hearts, at 1-3 mm from the endocardial surface. CONCLUSIONS The thinner wall and shorter length of the central isthmus together with its distance from the right coronary artery, and nonassociation with the atrioventricular node or its arterial supply, should make it the preferred site for linear radiofrequency ablation.
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Affiliation(s)
- José Angel Cabrera
- Servicio de Cardiología, Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Spain
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Okishige K, Kawabata M, Yamashiro K, Ohshiro C, Umayahara S, Gotoh M, Sasano T, Isobe M. Clinical Study Regarding the Anatomical Structures of the Right Atrial Isthmus Using Intra-Cardiac Echocardiography: Implication for Catheter Ablation of Common Atrial Flutter. J Interv Card Electrophysiol 2005; 12:9-12. [PMID: 15717146 DOI: 10.1007/s10840-005-5835-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Accepted: 10/21/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND The construction of complete bi-directional block in the isthmus (ITH) between the tricuspid annulus and inferior vena cava by radiofrequency energy (RF) applications is sometimes hampered due to anatomical problems such as a thick isthmus or aneurysmal pouch in patients with common atrial flutter (AFL). METHODS AND RESULTS Fifteen patients were referred for RF ablation of AFL. The anatomical thickness of the right atrial ITH, diameter of the right atrium and thickness of the right atrial free wall were determined using intracardiac echocardiography (ICE), along with the endocardial electrogram recordings at the ITH. RF was applied at the ITH to create a transmural incision to treat the AFL. A significant parallel relationship between the maximum amplitude of the atrial electrogram and the thickness of the ITH, was observed. When the maximum amplitude of the atrial electrogram at the ITH exceeded 1.5 mV, the thickness at the ITH was approximately larger than 5 mm. CONCLUSIONS Using ICE, the precise measurement of the anatomical structures in the heart, including the ITH, was feasible. From the amplitude of the atrial electrogram, a deduction of the thickness at the ITH was possible, which is indispensable information for the appropriate selection of the RF devices.
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Affiliation(s)
- Kaoru Okishige
- Cardiac Electrophysiology Laboratory, Yokohama Red Cross Hospital, Japan.
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Peng J, Madrid AH, Palmeiro A, Rebollo JMG, Limón L, Nannini S, Marín I, Bernal E, Escobar C, Viana M, Moro C. Saline Irrigated Catheter Ablation for Pulmonary Vein Isolation in Pigs:. An Experimental Model. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:495-501. [PMID: 15078404 DOI: 10.1111/j.1540-8159.2004.00470.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Focal AF is amenable to radical cure by RF ablation within the PV. The primary purpose of this study was to compare lesion characteristics for irrigated versus standard ablation using three power settings for PV isolation in pigs. Secondary analyses were the comparisons of ablation time and temperature characteristics, and evaluation of short-term safety in the pig model. In 20 pigs from 25 to 35 kg in weight, transseptal catheterization was performed and then the ablation catheter was advanced into the PV. RF energy was delivered to the ostium of the PV until its isolation was achieved. The animals were euthanized 1 week after ablation for pathological examination. Electrophysiological isolation of the PV was achieved, although it was difficult to achieve a complete circumferencial lesion in the ostium of the PV. Both of these catheters can produce transmural necrosis, even using 15 W of power. The authors did not see any stenosis of the PV. This might be due to the low energy delivery and the short follow-up. Pulmonary hemorrhage was present in two animals with 50 W of power, high energy output is dangerous for the ablation of the PV.
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Affiliation(s)
- Jian Peng
- Arrhythmia Unit, Ramón y Cajal Hospital, Department of Medicine, Alcalá University, Madrid, Spain
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Cabeza P, Hernández Madrid A, Palmeiro A, Rebollo JM, Peña G, Escobar C, Bueno MG, Correa C, Chércoles A, Marín I, Bernal E, Peng J, Nannini S, Limón L, Viana M, Moro C. [Lesions produced by radiofrequency ablation of the cavotricuspid isthmus in an experimental model]. Rev Esp Cardiol 2003; 56:963-70. [PMID: 14563290 DOI: 10.1016/s0300-8932(03)76993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES Experimental studies have shown that deeper and wider lesions (up to 10 mm long or deep) can be safely created using an 8 mm or irrigated tip catheter for ablation to treat atrial flutter. However, potential damage to the tricuspid valve or inferior cava vein has not been systematically evaluated. PATIENTS AND METHOD The cavotricuspid isthmus was ablated in 26 pigs (body weight 26-52 kg), with a total of 187 radiofrequency pulses. Standard 4 mm, 8 mm and irrigated tip catheters were used at random. For each ablation, energy, impedance and temperature were recorded continuously. RESULTS The lesions were larger with irrigated tip and 8-mm catheters than with standard ones. In 7 animals (1 with an irrigated tip, 4 with an 8-mm, and 2 with a standard tip) the tricuspid valve was damaged. The tricuspid valve was severely damaged in 3 pigs and lesions were moderate in 4. In animals with tricuspid valve lesions, maximal energy was higher (59 +/- 27 vs. 51 +/- 24 W; p=0,03) and higher temperatures were reached (63 +/- 4 vs. 55 +/- 11 degrees C; p<0.001). Low energy pulses measured before ablation were also more intense in animals in which damage was produced (0.55 +/- 0.24 vs. 0.35 +/- 0.29; p=0.001), indicating greater contact pressure. CONCLUSIONS The tricuspid valve may be severely damaged during the ablation of the cavotricuspid isthmus for atrial flutter: damage was seen most often with high energy pulses and with 8-mm catheters, but can also occur with usual energy levels and standard catheters. To minimize damage this technique should not be used from the inside of the right ventricle just above the tricuspid valve.
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Affiliation(s)
- Pedro Cabeza
- Servicio de Cardiología, Unidad de Arritmias, Departamento de Medicina, Hospital Ramón y Cajal, Universidad de Alcalá, Madrid, España
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