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The target ablation index values for electrical isolation of the superior vena cava. J Interv Card Electrophysiol 2022; 64:687-694. [PMID: 35112239 DOI: 10.1007/s10840-021-01112-w] [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: 08/17/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The ablation index (AI), developed as a radiofrequency (RF) catheter ablation composite component endpoint, which incorporates contact force (CF), time, and power in a weighted formula, has been reported to be useful for a durable pulmonary vein isolation (PVI) to treat atrial fibrillation (AF). No study has reported the target AI value for the SVC isolation (SVCI). In this study, we aimed to investigate the target AI for the SVCI. METHODS Thirty-six AF patients who underwent an initial SVCI were enrolled. Ablation was performed at 556 points. The sites where dormant conduction was induced or additional ablation was needed were defined as touch up sites (n = 36). We compared the energy deliver time, power, generator impedance (GI) drop, local bipolar voltage, contact force (CF), force-time integral (FTI), and AI between the touch up sites and the no touch up sites (n = 520). RESULTS The FTI and AI were significantly lower at the touch up sites (touch up sites vs. no touch up sites; FTI, 126.5 [99.3-208.8] vs. 244 [184-340.8], p < 0.0001; AI, 350.1 ± 43.6 vs. 277.2 ± 21.8, p < 0.0001). The median value of the AI at the no touch up sites was 350, and no reconnections were seen where the minimum AI value was more than 308. Most of the touch up sites were located in the anterior wall and lateral wall (anterior wall, 20/36 sites [55.6%]; lateral wall, 10/36 sites [27.8%]; septal wall, 6/36 sites [16.7%]; posterior wall, 0/36sites [0.0%]). CONCLUSION The target AI value for the SVCI should be 350, and at least 308 would be needed.
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Smith A, Amin AK, El‐Zein R, Billakanty SR, Chopra N. Relationship between Surpoint Tag Index, a Radiofrequency Ablation lesion quality indicator, and Atrial wall thickness in Cavotricuspid isthmus Ablations exhibiting bidirectional block. J Arrhythm 2021; 38:118-125. [PMID: 35222758 PMCID: PMC8851572 DOI: 10.1002/joa3.12662] [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: 07/09/2021] [Revised: 10/28/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022] Open
Abstract
Background An RFA lesion quality indicator, Surpoint Tag Index® (TI) incorporates key factors: power, time, and contact force, impacting lesion quality. TI accurately estimates lesion depth in animal studies. However, the relationship between TI and in‐vivo atrial wall thickness in patients exhibiting bidirectional block remains unknown. Objective To describe the relationship between atrial wall thickness and TI in CTI exhibiting bidirectional block. Methods Data from 492 RFA lesions from 25 patients undergoing PVI and CTI ablations in SR with point‐by‐point RF lesions (<45 W) utilizing a Thermocool Smarttouch® SF ablation catheter and CARTO‐3 mapping were retrospectively analyzed. Operators were blinded to TI data and CTI thickness. CTI thickness was obtained using ICE images on Cartosound pre‐ablation. Durable lesions were defined as part of a lesion set exhibiting bidirectional block of >30 min. Results In lesions exhibiting bidirectional block, the thinnest (1–2 mm; 5% lesions) and thickest (8–10 mm; 6% lesions) portions of the CTI correlated with the lowest (429 ± 75) and highest (516 ± 64) TI. The bulk of thickness (2–6 mm; 80%) correlated with a TI of 455 ± 72 (p = 0.001). There was a weak but positive correlation between TI and CTI thickness (r = 0.2; p ≤ 0.01). Examined in sectors, the anterior 1/3rd CTI was the thickest (4.8 ± 1.9 mm) but correlated with a similar TI value (479 ± 75 vs. 471 ± 70; p = 0.34) as the thinner middle 1/3rd (3.8 ± 1.7 mm; p ≤ 0.0001). Conclusion A mean TI value of 455 correlates with bidirectional block across the bulk of CTI with lower and higher values needed for the thinner and thicker portions, respectively. Tissue composition, aside from wall thickness, influences TI values for the creation of the bidirectional block.
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Affiliation(s)
- Alexander Smith
- Department of Internal Medicine Riverside Methodist Hospital Columbus Ohio USA
| | - Anish K. Amin
- Section of Cardiac Electrophysiology Department of Cardiology OhioHealth Heart and Vascular PhysiciansRiverside Methodist Hospital Columbus Ohio USA
| | - Rayan El‐Zein
- Department of Internal Medicine OhioHealth Doctors Hospital Columbus Ohio USA
| | - Sreedhar R. Billakanty
- Section of Cardiac Electrophysiology Department of Cardiology OhioHealth Heart and Vascular PhysiciansRiverside Methodist Hospital Columbus Ohio USA
| | - Nagesh Chopra
- Section of Cardiac Electrophysiology Department of Cardiology OhioHealth Heart and Vascular PhysiciansRiverside Methodist Hospital Columbus Ohio USA
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Khakpour H, Mori S, Bradfield JS, Shivkumar K. How to Use Intracardiac Echocardiography to Recognize Normal Cardiac Anatomy. Card Electrophysiol Clin 2021; 13:273-283. [PMID: 33990266 DOI: 10.1016/j.ccep.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article reviews cardiac anatomy as it pertains to commonly used intracardiac echocardiography segments and views.
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Affiliation(s)
- Houman Khakpour
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Kautzner J, Haskova J, Lehar F. Intracardiac Echocardiography to Guide Non-fluoroscopic Electrophysiology Procedures. Card Electrophysiol Clin 2021; 13:399-408. [PMID: 33990278 DOI: 10.1016/j.ccep.2021.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intracardiac echocardiography (ICE) is the most practical method for online imaging during electrophysiological procedures. It allows guiding of complex catheter ablation procedures together with electroanatomical mapping systems, either with minimal or with zero fluoroscopy exposure. Besides safe and reproducible transseptal puncture, ICE helps to assess location and contact of the tip of the ablation catheter relative to specific anatomical structures. Another option is visualization of the arrhythmogenic substrate in patients with ventricular arrhythmias. This article describes the clinical utility of ICE in non-fluoroscopic electrophysiology procedures more in detail.
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Affiliation(s)
- Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Palacky University Medical School, Olomouc, Czech Republic.
| | - Jana Haskova
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Frantisek Lehar
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Internal Medicine 1-Cardioangiology, St Anne's University Hospital, Brno, Czech Republic
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Tscholl V, Kamieniarz P, Nagel P, Landmesser U, Attanasio P, Huemer M. The use of a high-power (50 W), ablation index-guided protocol for ablation of the cavotricuspid isthmus. J Arrhythm 2020; 36:1045-1050. [PMID: 33335623 PMCID: PMC7733584 DOI: 10.1002/joa3.12443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/30/2020] [Accepted: 09/18/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND High-power (HP) ablation protocols are increasingly used for ablation procedures to shorten procedural times and improve short- and long-term success. The ablation index (AI) combines contact force, power settings, and ablation time. It can be used in combination with HP protocols to guide operators toward standardized lesions. The purpose of this study was to evaluate both a HP and AI-guided strategy for ablation of the cavotricuspid isthmus (CTI) in patients with typical atrial flutter (AFL). METHODS In this single-center study, consecutive patients with typical AFL (n = 52, mean age 68.7 ± 8.3 years, 21/52 [40.4%] female) underwent AI-guided HP radiofrequency (RF) ablation of the CTI. Ablation was performed with 50 W and AI target values of 550 with a maximum ablation duration of 25 seconds per lesion. Target interlesion distance was ≤6 mm. Ablation was performed with a 3.5 mm porous tip Smarttouch SF catheter. RESULTS Acute CTI block was achieved in 52 of 52 patients (100%), and first-pass conduction block was achieved in 41 of 52 patients (80.4%). Spontaneous reconduction after 30 minutes waiting time occurred in 1 of 52 (1.9%) patient. Average ablation time until CTI block was 3:51 ± 1:40; 2:33 ± 1:01 minutes of bonus ablation pulses were applied after CTI block. An audible steam pop was noted in one patient (1.9%). No major complications occurred. After a mean follow-up of 193.7 ± 152.2 days, no patient showed recurrence of typical AFL. CONCLUSION In this pilot study, AI-guided HP ablation of the CTI was fast, safe, and effective.
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Affiliation(s)
- Verena Tscholl
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Paul Kamieniarz
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Patrick Nagel
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Ulf Landmesser
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Philipp Attanasio
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Martin Huemer
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
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Enriquez A, Saenz LC, Rosso R, Silvestry FE, Callans D, Marchlinski FE, Garcia F. Use of Intracardiac Echocardiography in Interventional Cardiology: Working With the Anatomy Rather Than Fighting It. Circulation 2019; 137:2278-2294. [PMID: 29784681 DOI: 10.1161/circulationaha.117.031343] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The indications for catheter-based structural and electrophysiological procedures have recently expanded to more complex scenarios, in which an accurate definition of the variable individual cardiac anatomy is key to obtain optimal results. Intracardiac echocardiography (ICE) is a unique imaging modality able to provide high-resolution real-time visualization of cardiac structures, continuous monitoring of catheter location within the heart, and early recognition of procedural complications, such as pericardial effusion or thrombus formation. Additional benefits are excellent patient tolerance, reduction of fluoroscopy time, and lack of need for general anesthesia or a second operator. For these reasons, ICE has largely replaced transesophageal echocardiography as ideal imaging modality for guiding certain procedures, such as atrial septal defect closure and catheter ablation of cardiac arrhythmias, and has an emerging role in others, including mitral valvuloplasty, transcatheter aortic valve replacement, and left atrial appendage closure. In electrophysiology procedures, ICE allows integration of real-time images with electroanatomic maps; it has a role in assessment of arrhythmogenic substrate, and it is particularly useful for mapping structures that are not visualized by fluoroscopy, such as the interatrial or interventricular septum, papillary muscles, and intracavitary muscular ridges. Most recently, a three-dimensional (3D) volumetric ICE system has also been developed, with potential for greater anatomic information and a promising role in structural interventions. In this state-of-the-art review, we provide guidance on how to conduct a comprehensive ICE survey and summarize the main applications of ICE in a variety of structural and electrophysiology procedures.
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Affiliation(s)
- Andres Enriquez
- Section of Cardiac Electrophysiology (A.E., D.C., F.E.M., F.G.)
| | - Luis C Saenz
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia. Instituto de Cardiologia. Centro Internacional de Arritmias "Andrea Natale," Fundacion Cardioinfantil, Bogota, Colombia (L.C.S.)
| | - Raphael Rosso
- Cardiac Eletrophysiology, Cardiology Division, Tel-Aviv Souraski Medical Center, Israel (R.R.)
| | | | - David Callans
- Section of Cardiac Electrophysiology (A.E., D.C., F.E.M., F.G.)
| | | | - Fermin Garcia
- Section of Cardiac Electrophysiology (A.E., D.C., F.E.M., F.G.)
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Intra-procedural evaluation of the cavo-tricuspid isthmus anatomy with different techniques: comparison of angiography and intracardiac echocardiography. Heart Vessels 2019; 34:1703-1709. [PMID: 30953137 DOI: 10.1007/s00380-019-01394-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
Cavo-tricuspid isthmus (CTI) anatomies are highly variable, and specific anatomies lead to a difficult CTI ablation. This study aimed to compare the clinical utility of angiography and intracardiac echocardiography (ICE) in evaluating CTI anatomies, and to investigate the impact of the CTI anatomy on the procedure when the ablation tactic was adjusted to the anatomy. This study included 92 consecutive patients who underwent a CTI ablation. The CTI morphology was assessed with both right atrial angiography and ICE before the ablation, and the ablation tactic was adjusted to the anatomy. The mean CTI length was 34 ± 9 mm. On ICE imaging, 21 (23%) patients had a flat CTI, while 41 (45%) had a concave CTI with a mean depth of 5.6 ± 2.7 mm. The remaining 30 (32%) had a distinct pouch with a mean depth of 6.4 ± 2.3 mm, located at the posterior, middle, and anterior isthmus in 15, 14, and 1 patients, respectively. The Eustachian ridge (ER) was visualized in 46 (50%) patients. On angiography, a pouch and ER were detected in 22 and 15 patients, but not in the remaining 8 and 31, respectively. A complete CTI block line was created in all patients without any complications. The CTI anatomy did not significantly impact any procedural parameters. ICE was superior to angiography in evaluating the detailed CTI anatomy, especially pouches and the ER. An adjustment of the ablation tactic to the anatomy could overcome the procedural difficulties of the CTI ablation in cases with specific anatomies.
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8
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Shimizu Y, Yoshitani K, Murotani K, Kujira K, Kurozumi Y, Fukuhara R, Taniguchi R, Toma M, Miyamoto T, Kita Y, Takatsu Y, Sato Y. The deeper the pouch is, the longer the radiofrequency duration and higher the radiofrequency energy needed-Cavotricuspid isthmus ablation using intracardiac echocardiography. J Arrhythm 2018; 34:410-417. [PMID: 30167012 PMCID: PMC6111476 DOI: 10.1002/joa3.12075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/25/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this study was to explore whether the pouch depth influenced the radiofrequency (RF) duration and total delivered RF energy for cavotricuspid isthmus (CTI) ablation and define the cutoff value for a deep pouch-specified ablation strategy. METHODS This study included 94 atrial fibrillation (AF) patients (56 males, age 68 ± 8.0 years). With intracardiac echocardiography, the isthmus length and pouch depth were precisely measured. After a standard AF ablation, all patients underwent the CTI ablation along the lateral isthmus. If bidirectional block could not be achieved, the ablation catheter was deflected more than 90 degrees to ablate inside the pouch (knuckle-curve ablation). RESULTS Seventy-two patients (76.6%) had a sub-Eustachian pouch. Bidirectional block could be achieved in all patients. By a univariate logistic regression analysis, only the pouch depth was significantly correlated with the RF duration (P = .005) and RF energy (P = .006). A multivariate logistic regression analysis also revealed the pouch depth was the sole factor that influenced the RF duration (P = .001) and RF energy (P = .001). Among the 72 patients, 21 patients needed a knuckle-curve ablation. Using a receiver operating characteristic curve, the optimal cutoff value of the pouch depth for a knuckle-curve ablation was 3.7 mm with a sensitivity of 90% and specificity of 69%. CONCLUSIONS The sub-Eustachian pouch depth was the sole factor that influenced the RF duration and energy in the CTI ablation. If the pouch was deeper than 3.7 mm, a deep pouch-specified ablation strategy would be needed.
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Affiliation(s)
- Yukiko Shimizu
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Kazuyasu Yoshitani
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Kenta Murotani
- Center for Clinical ResearchAichi Medical UniversityNagakuteJapan
| | - Kazuto Kujira
- Department of Cardiovascular MedicineToyohashi Heart CenterToyohashiJapan
| | - Yuma Kurozumi
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Rei Fukuhara
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Ryoji Taniguchi
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Masanao Toma
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Tadashi Miyamoto
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Yoshio Kita
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Yoshiki Takatsu
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Yukihito Sato
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
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9
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Saygi S, Bastani H, Drca N, Insulander P, Wredlert C, Schwieler J, Jensen-Urstad M. Impact of cavotricuspid isthmus morphology in CRYO versus radiofrequency ablation of typical atrial flutter. SCAND CARDIOVASC J 2016; 51:69-73. [DOI: 10.1080/14017431.2016.1259496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Serkan Saygi
- All Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Hamid Bastani
- All Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Nikola Drca
- All Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Per Insulander
- All Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Christer Wredlert
- All Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Schwieler
- All Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Jensen-Urstad
- All Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Bencsik G. Novel strategies in the ablation of typical atrial flutter: role of intracardiac echocardiography. Curr Cardiol Rev 2015; 11:127-33. [PMID: 25308811 PMCID: PMC4356719 DOI: 10.2174/1573403x10666141013121843] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 09/25/2013] [Accepted: 04/05/2014] [Indexed: 11/22/2022] Open
Abstract
Radiofrequency ablation (RFA) of the cavo-tricuspid isthmus (CTI) is one of the most frequently performed procedures in electrophysiology. Despite a high success rate, ablation of the CTI can be unusually difficult in some cases. Multiple tools like angiography, 3D mapping, remote navigation and intracardiac echocardiography (ICE) have been introduced to facilitate typical flutter ablation. This review article summarizes the clinical value of different strategies and tools used for CTI ablation focusing on the importance of approaches utilizing ICE.
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Affiliation(s)
- Gábor Bencsik
- 2nd Department of Internal Medicine and Cardiology Centre, University of Szeged, Korányi fasor 6. 6724 Szeged, Hungary.
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KUMAR SAURABH, MORTON JOSEPHB, LEE GEOFFREY, HALLORAN KAREN, KISTLER PETERM, KALMAN JONATHANM. High Incidence of Low Catheter-Tissue Contact Force at the Cavotricuspid Isthmus During Catheter Ablation of Atrial Flutter: Implications for Achieving Isthmus Block. J Cardiovasc Electrophysiol 2015; 26:826-831. [DOI: 10.1111/jce.12707] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/16/2015] [Accepted: 04/24/2015] [Indexed: 11/29/2022]
Affiliation(s)
- SAURABH KUMAR
- Department of Cardiology, The Royal Melbourne Hospital, and Department of Medicine; University of Melbourne; Parkville Victoria Australia
- Department of Medicine; University of Melbourne; Victoria Australia
| | - JOSEPH B. MORTON
- Department of Cardiology, The Royal Melbourne Hospital, and Department of Medicine; University of Melbourne; Parkville Victoria Australia
- Department of Medicine; University of Melbourne; Victoria Australia
| | - GEOFFREY LEE
- Department of Cardiology, The Royal Melbourne Hospital, and Department of Medicine; University of Melbourne; Parkville Victoria Australia
- Department of Medicine; University of Melbourne; Victoria Australia
| | - KAREN HALLORAN
- Department of Medicine; University of Melbourne; Victoria Australia
| | - PETER M. KISTLER
- Department of Medicine; University of Melbourne; Victoria Australia
- Department of Cardiology; Alfred Hospital and Baker IDI; Prahran Victoria Australia
| | - JONATHAN M. KALMAN
- Department of Cardiology, The Royal Melbourne Hospital, and Department of Medicine; University of Melbourne; Parkville Victoria Australia
- Department of Medicine; University of Melbourne; Victoria Australia
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Vitulano N, Pazzano V, Pelargonio G, Narducci ML. Technology update: intracardiac echocardiography - a review of the literature. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2015; 8:231-9. [PMID: 26060415 PMCID: PMC4454216 DOI: 10.2147/mder.s49567] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The development of new imaging tools helps in better investigation of cardiac structures and function by showing detailed images during interventional procedures. Intracardiac echocardiography plays a pivotal role as an intraoperative real-time imaging tool during invasive cardiac procedures. Initially, this echocardiographic technique was particularly useful when transthoracic image quality was insufficient and to avoid general anesthesia for transesophageal imaging. Nowadays, intracardiac echocardiography is routinely used in several cardiac invasive laboratories to support several types of procedures, such as extraction and implantation of cardiac devices, electrophysiological mapping, ablation, and endomyocardial biopsies. This review gives an overview of the basic principles of intracardiac echocardiography and examines its applications in the different settings of invasive cardiology.
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Affiliation(s)
- Nicola Vitulano
- Institute of Cardiology, Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Vincenzo Pazzano
- Institute of Cardiology, Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Gemma Pelargonio
- Institute of Cardiology, Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Maria Lucia Narducci
- Institute of Cardiology, Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Kuwahara T. Intracardiac Echocardiography in Catheter Ablation for Atrial Fibrillation: It Is Better to See What You Are Doing? J Atr Fibrillation 2015; 7:1215. [PMID: 27957164 DOI: 10.4022/jafib.1215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/19/2015] [Accepted: 03/20/2015] [Indexed: 11/10/2022]
Abstract
Current advanced technology allows the accurate three-dimensional reconstruction of cardiac structures using multiple images from two-dimensional intracardiac echocardiography (ICE). This technology is applicable to atrial fibrillation (AF) ablation and provides real-time anatomical information on relevant atrial structures and myocardial thickness as well as suitable sites for transseptal puncture. ICE allows radiofrequency to be delivered away from structures resistant to ablation and the monitoring of possible complications during AF ablation. Visualization of the inside of both atria during the procedure may contribute to safe and effective AF ablation. The purpose of this review was to elucidate the utility of ICE in AF ablation.
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Affiliation(s)
- Taishi Kuwahara
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
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Brooks AG, Wilson L, Chia NH, Lau DH, Alasady M, Leong DP, Laborderie J, Roberts-Thomson KC, Young GD, Kalman JM, Sanders P. Accuracy and clinical outcomes of CT image integration with Carto-Sound compared to electro-anatomical mapping for atrial fibrillation ablation: A randomized controlled study. Int J Cardiol 2013; 168:2774-82. [DOI: 10.1016/j.ijcard.2013.03.130] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 03/19/2013] [Accepted: 03/26/2013] [Indexed: 11/28/2022]
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15
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Marcos-Alberca P, Sánchez-Quintana D, Cabrera JA, Farré J, Rubio JM, de Agustín JA, Almería C, Pérez-Isla L, Macaya C. Two-dimensional echocardiographic features of the inferior right atrial isthmus: the role of vestibular thickness in catheter ablation of atrial flutter. Eur Heart J Cardiovasc Imaging 2013; 15:32-40. [PMID: 23751506 DOI: 10.1093/ehjci/jet112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to examine the feasibility of transthoracic two-dimensional (2D)-echocardiography in defining the cavo-tricuspid isthmus (CTI) anatomy and its value concerning the ease of catheter ablation of isthmic atrial flutter (AF). METHODS CTI analysis was accomplished in 39 cases: 16 necropsy specimens and 23 patients. Sixteen were patients with isthmus-dependent AF and seven controls with other supraventricular re-entrant tachycardias. Two-dimensional transthoracic echocardiography and a right atrium angiogram were performed before radiofrequency catheter ablation (RFCA). RESULTS The measurements of the CTI with angiography were compared with those taken with echocardiography and correlation was excellent (r= 0.91; P < 0.0001). In normal patients, the dimension of the vestibular thickness was successfully compared and validated with the histological examination of the necropsy specimens: histology median 6.8 mm, range 4.4-10.5 vs. echo median 6.2 mm, range 5.4-8.7; P: NS. Vestibular thickness was greater in complex than in simple RFCA (13.6 ± 1.9 mm vs. 10.0 ± 2.3 mm; P = 0.01). When vestibular thickness ≥11.5 mm, the ablation prone to be complex (sensitivity 83.3%, specificity 80%, positive predictive value 71.4%, and negative predictive value 88.9%). CONCLUSIONS Two-dimensional transthoracic echocardiography clearly depicts the inferior isthmus and, displaying the thickness of the tricuspid vestibule, it was related with complexity of the ablation procedure in isthmus-dependent AF.
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Affiliation(s)
- Pedro Marcos-Alberca
- Cardiology Department, Instituto Cardiovascular, Hospital Clínico San Carlos, c/ Prof. Martín Lagos s/n. 28040 Madrid, Spain
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BENCSIK GÁBOR, PAP RÓBERT, MAKAI ATTILA, KLAUSZ GERGELY, CHADAIDE SZÁMI, TRAYKOV VASSIL, FORSTER TAMÁS, SÁGHY LÁSZLÓ. Randomized Trial of Intracardiac Echocardiography During Cavotricuspid Isthmus Ablation. J Cardiovasc Electrophysiol 2012; 23:996-1000. [DOI: 10.1111/j.1540-8167.2012.02331.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Kottkamp H. Catheter ablation of cavotricuspid isthmus dependent atrial flutter: manual skills or technology or both? J Cardiovasc Electrophysiol 2012; 23:1001-2. [PMID: 22587662 DOI: 10.1111/j.1540-8167.2012.02358.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Hans Kottkamp
- Department of Electrophysiology, Clinic Hirslanden, Zurich, Switzerland.
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Chen JY, Lin KH, Liou YM, Chang KC, Huang SKS. Usefulness of pre-procedure cavotricuspid isthmus imaging by modified transthoracic echocardiography for predicting outcome of isthmus-dependent atrial flutter ablation. J Am Soc Echocardiogr 2011; 24:1148-55. [PMID: 21764555 DOI: 10.1016/j.echo.2011.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Anatomic characteristics of the cavotricuspid isthmus (CTI) have been reported to be related to the outcome of atrial flutter ablation therapy. However, preprocedural evaluation of CTI anatomy using modified transthoracic echocardiography to guide atrial flutter ablation has not been well described. METHODS Transthoracic echocardiography was prospectively performed before atrial flutter ablation in 42 patients with typical CTI-dependent atrial flutter. A modified apical long-axis view was designed to visualize and evaluate anatomic characteristics of the CTI and Eustachian ridge (ER). A prominent ER, extending from the inferior vena cava to the interatrial septum, is defined as an extensive ER. RESULTS Twenty-eight patients had straightforward ablation procedures, and 14 patients had difficult ablation procedures. Two patients with difficult procedures had unsuccessful ablation. Multivariate analysis (using CTI length, the presence of a pouch or recess, ER morphology, and significant tricuspid regurgitation as variables) showed that the presence of extensive ER was the only independent predictor of a difficult ablation procedure. The ablation time in patients with extensive ER (n = 13) was significantly longer than in those patients with nonextensive ER (n = 29) (1,638.4 ± 1,548.3 vs 413.8 ± 195.5 sec, P = .015). The incidence of difficulty in achieving bidirectional isthmus block was also higher in patients with extensive ER (10 of 13 vs four of 29, P < .001). CONCLUSION Preprocedural transthoracic echocardiography using a modified apical long-axis view is useful to characterize the morphology of the CTI and the ER. An extensive ER is a strong predictor for difficult ablation of CTI-dependent atrial flutter.
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Affiliation(s)
- Jan-Yow Chen
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
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Yokokawa M, Tada H, Koyama K, Ino T, Naito S, Oshima S, Taniguchi K. The change in the tissue characterization detected by magnetic resonance imaging after radiofrequency ablation of isthmus-dependent atrial flutter. Int J Cardiol 2011; 148:30-5. [DOI: 10.1016/j.ijcard.2009.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Accepted: 10/09/2009] [Indexed: 11/26/2022]
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Cosio FG, Perea J. The continuing challenge of typical atrial flutter ablation: it is the anatomy! (Again). Europace 2010; 12:1518-9. [DOI: 10.1093/europace/euq375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ozgun M, Kirchhof P, Bunck AC, Heindel W, Eckardt L, Maintz D. MRI of right atrial function after catheter ablation of atrial flutter. Acad Radiol 2010; 17:856-61. [PMID: 20471870 DOI: 10.1016/j.acra.2010.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Revised: 03/15/2010] [Accepted: 03/17/2010] [Indexed: 10/19/2022]
Abstract
RATIONALE AND OBJECTIVES Catheter ablation of the cavotricuspid isthmus (CTI) is an effective treatment of right atrial flutter. The objective of this study was to evaluate the changes in CTI length and right atrial (RA) function after radiofrequency ablation of isthmus-dependent atrial flutter (isthmus ablation). MATERIALS AND METHODS Magnetic resonance imaging was obtained in 14 patients (2 female, mean age 59 +/- 9) before and after isthmus ablation (mean delay 80 +/- 175 days) using steady-state free precession cine magnetic resonance imaging in right anterior oblique view orientation. Right atrial function (maximum/minimum right atrial volumes, stroke volume, ejection fraction) and maximum/minimum length of the CTI were measured. RESULTS After isthmus ablation, maximum RA volume decreased by 13% (P = .02) and minimum RA volume by 22% (P = .01), whereas stroke volume and ejection fraction did not increase significantly (P = .4 and .2, respectively). After ablation, the maximum length of the CTI showed a significant decrease of 19% (P < .001) and the minimum length a decrease of 24% (P < .001). A linear correlation between change in CTI length and number of energy applications during ablation could not be observed (r = .605, P = .22 for minimum length; r = .384, P = .18 for maximum length). After eliminating the outliers in the number of energy applications, a significant correlation between energy applications and change in CTI systolic length was found (r = .808, P = .008). CONCLUSION Magnetic resonance imaging to visualize right atrial size and function in right anterior oblique orientation was successfully performed and easy to evaluate for volumetric analysis and determination of CTI length. Scarring of the CTI with the use of catheter ablation leads to a significant and linear decrease in its length and to a subsequent reduction of right atrial volumes, whereas functional parameters such as stroke volume/ejection fraction did not change significantly.
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Intracardiac echocardiography in complex cardiac catheter ablation procedures. J Interv Card Electrophysiol 2010; 28:167-84. [DOI: 10.1007/s10840-010-9474-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 02/01/2010] [Indexed: 11/25/2022]
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GAMI APOORS, EDWARDS WILLIAMD, LACHMAN NIRUSHA, FRIEDMAN PAULA, TALREJA DEEPAK, MUNGER THOMASM, HAMMILL STEPHENC, PACKER DOUGLASL, ASIRVATHAM SAMUELJ. Electrophysiological Anatomy of Typical Atrial Flutter: The Posterior Boundary and Causes for Difficulty with Ablation. J Cardiovasc Electrophysiol 2010; 21:144-149. [DOI: 10.1111/j.1540-8167.2009.01607.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Takatsuki S, Extramiana F, Hayashi M, Haggui A, Messali A, Milliez P, Leenhardt A, Cauchemez B. High take-off left inferior pulmonary vein as an obstacle in creating a conduction block at the lateral mitral isthmus. Europace 2009; 11:910-6. [PMID: 19546188 DOI: 10.1093/europace/eup151] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
AIMS Creation of complete linear lesions in the lateral mitral isthmus (LMI) by catheter ablation for treating atrial fibrillation remains technically challenging. We aimed to clarify whether a high take-off left inferior pulmonary vein (LIPV) can hamper the creation of a complete block at the LMI. METHODS AND RESULTS We included 81 consecutive patients who underwent linear ablation at the LMI and cardiac computed tomography (CT) before ablation. We defined a high take-off LIPV when the level of the lower edge of the LIPV ostium was higher than that of the top of mitral annulus on CT. The clinical backgrounds, parameters, and long-term follow-up were then compared between the success (successful creation of a complete LMI block) and failure groups. A complete LMI block was obtained in 60/81 (76%) patients. In the failure group, a high take-off LIPV was noted more commonly and the LMI tended to be longer than the success group. Multivariate analysis revealed that a high take-off LIPV was an independent predictor of failure to achieve a complete LMI block. The sinus rhythm maintenance rate was not different between the success and failure groups. CONCLUSION A high take-off LIPV hampered the creation of complete linear lesions in the LMI.
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Affiliation(s)
- Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo 160-8582, Japan.
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Kim SS, Hijazi ZM, Lang RM, Knight BP. The use of intracardiac echocardiography and other intracardiac imaging tools to guide noncoronary cardiac interventions. J Am Coll Cardiol 2009; 53:2117-28. [PMID: 19497437 DOI: 10.1016/j.jacc.2009.01.071] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 01/06/2009] [Accepted: 01/19/2009] [Indexed: 10/20/2022]
Abstract
The limitations of standard fluoroscopy have led to the development of improved imaging techniques to guide noncoronary cardiac interventions. Imaging tools that are used in the interventional laboratory can be categorized as invasive and noninvasive. Noninvasive cardiac imaging tools include ultrasound, computed tomography, and magnetic resonance imaging. These modalities can generate high-resolution images of the heart and are increasingly being used to guide cardiac interventions. Despite these advances, there remains a strong role for invasive imaging tools in the interventional laboratories. Such invasive imaging tools include transesophageal echocardiography, intracardiac echocardiography, intracardiac endoscopy, and electroanatomic mapping systems. Despite the risks inherent to the invasive nature of these tools, these modalities can provide excellent real-time, detailed images that can be invaluable in guiding certain cardiac interventions. This review will propose the features of an ideal intracardiac imaging tool, summarize the intracardiac imaging tools that are currently available or under development to guide noncoronary cardiac interventional procedures, and suggest opportunities for improvement. One opportunity in this field is to couple imaging systems directly with the interventional devices themselves. The use of intracardiac imaging to guide select cardiac procedures including transseptal catheterization, catheter ablation procedures for arrhythmias, and percutaneous placement of cardiac valves and closure devices will also be discussed. Most of this review will be devoted to intracardiac echocardiography, which currently has the broadest number of applications.
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Affiliation(s)
- Susan S Kim
- Department of Internal Medicine, University of Chicago, Illinois, USA
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Silvestry FE, Kerber RE, Brook MM, Carroll JD, Eberman KM, Goldstein SA, Herrmann HC, Homma S, Mehran R, Packer DL, Parisi AF, Pulerwitz T, Seward JB, Tsang TSM, Wood MA. Echocardiography-guided interventions. J Am Soc Echocardiogr 2009; 22:213-31; quiz 316-7. [PMID: 19258174 DOI: 10.1016/j.echo.2008.12.013] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A major advantage of echocardiography over other advanced imaging modalities (magnetic resonance imaging, computed tomographic angiography) is that echocardiography is mobile and real time. Echocardiograms can be recorded at the bedside, in the cardiac catheterization laboratory, in the cardiovascular intensive care unit, in the emergency room-indeed, any place that can accommodate a wheeled cart. This tremendous advantage allows for the performance of imaging immediately before, during, and after various procedures involving interventions. The purpose of this report is to review the use of echocardiography to guide interventions. We provide information on the selection of patients for interventions, monitoring during the performance of interventions, and assessing the effects of interventions after their completion. In this document, we address the use of echocardiography in commonly performed procedures: transatrial septal catheterization, pericardiocentesis, myocardial biopsy, percutaneous transvenous balloon valvuloplasty, catheter closure of atrial septal defects (ASDs) and patent foramen ovale (PFO), alcohol septal ablation for hypertrophic cardiomyopathy, and cardiac electrophysiology. A concluding section addresses interventions that are presently investigational but are likely to enter the realm of practice in the very near future: complex mitral valve repairs, left atrial appendage (LAA) occlusion devices, 3-dimensional (3D) echocardiographic guidance, and percutaneous aortic valve replacement. The use of echocardiography to select and guide cardiac resynchronization therapy has recently been addressed in a separate document published by the American Society of Echocardiography and is not further discussed in this document. The use of imaging techniques to guide even well-established procedures enhances the efficiency and safety of these procedures.
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Affiliation(s)
- Frank E Silvestry
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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DA COSTA ANTOINE, ROMEYER-BOUCHARD CÉCILE, JAMON YANN, BISCH LAURENCE, ISAAZ KARL. Radiofrequency Catheter Selection Based on Cavotricuspid Angiography Compared with a Control Group with an Externally Cooled-Tip Catheter: A Randomized Pilot Study. J Cardiovasc Electrophysiol 2009; 20:492-8. [DOI: 10.1111/j.1540-8167.2008.01367.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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LO LIWEI, TAI CHINGTAI, LIN YENNJIANG, CHANG SHIHLIN, WONGCHAROEN WANWARANG, TUAN TACHUAN, UDYAVAR AMEYAR, HU YUFENG, UENG KUOCHANG, TSAI WENCHIN, CHANG CHIENJUNG, TSAO HSUANMING, HIGA SATOSHI, CHEN SHIHANN. Characteristics of the Cavotricuspid Isthmus in Predicting Recurrent Conduction in the Long-Term Follow-Up. J Cardiovasc Electrophysiol 2009; 20:39-43. [DOI: 10.1111/j.1540-8167.2008.01269.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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ASIRVATHAM SAMUELJ. Correlative Anatomy and Electrophysiology for the Interventional Electrophysiologist:. J Cardiovasc Electrophysiol 2009; 20:113-22. [DOI: 10.1111/j.1540-8167.2008.01344.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Feuchtner GM, Dichtl W, DeFrance T, Stühlinger M, Klauser A, Berger T, Junker D, Spuller K, Pachinger O, zur Nedden D, Hintringer F. Fusion of multislice computed tomography and electroanatomical mapping data for 3D navigation of left and right atrial catheter ablation. Eur J Radiol 2008; 68:456-64. [PMID: 17913424 DOI: 10.1016/j.ejrad.2007.08.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Revised: 08/28/2007] [Accepted: 08/28/2007] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess whether fusion of multislice computed tomography (CT) images with electroanatomical (EA)-mapping data using a new image integration module (CartoMerge) is feasible and accurate to navigate ablation catheters in right and left atrial catheter ablation. MATERIAL AND METHODS Twenty-four patients were examined with ECG-gated cardiac multislice CT (64 mm x 0.6mm, 0.33 s) 1 day before left atrial (LA) (15 patients) radiofrequency or right atrial cavotricuspid isthmus ablation (9 patients). CT data were fused with the non-fluoroscopic EA-mapping data by using dedicated software (CartoMerge) and the value of CT was analysed. RESULTS In 23/24 (96%) patients, CT images could be fused with the EA-map. The alignment error was 2.16+/-0.35 mm. In 15/15 (100%) patients, CT added relevant anatomical information regarding the course of the esophagus or the pulmonary veins before LA-ablation. CT added useful information in only 3/8 (37.5%) of patients undergoing right atrial cavotricuspid isthmus ablation. CONCLUSION 3D-navigation of RF-ablation catheters in the atria assisted by image fusion of multislice CT with EA-mapping data is feasible and accurate. CT added relevant anatomical information about the left atrium and the pulmonary veins before LA-ablation, CT also provided information about the course of the esophagus which might help to avoid thermal injury. CT image fusion might be of minor value before right atrial cavotricuspid isthmus catheter ablation.
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Affiliation(s)
- Gudrun M Feuchtner
- Department of Radiology II, Innsbruck Medical University, Anichstr. 35, Innsbruck A-6020, Austria.
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Oginosawa Y, Nogami A, Kurosaki K, Sugiyasu A, Kubota S, Kowase S, Yamasaki T, Takada S, Suzuki J, Sakamaki M, Aoki H, Yumoto K, Tamaki T, Kato K. Cavotricuspid isthmus conduction split by pouch-like recesses during typical atrial flutter. Circ J 2008; 73:179-82. [PMID: 19001745 DOI: 10.1253/circj.cj-07-1038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 58-year-old man had typical cavotricuspid-isthmus-dependent atrial flutter (AFL). Right atrial angiography and multidetector computed tomography revealed a deep pouch-like recess in the mid-isthmus region. Linear ablation from the pouch to the edge of the inferior vena cava resulted in widely split double potentials without any change in the AFL cycle length. This observation suggested that the pouch played an electrophysiological role by dividing the flutter wavefront into 2 parallel conduction wave fronts through both sides of the pouch along the isthmus during typical AFL. When a widely split potential is created on 1 side of the pouch, the other side of the pouch should be targeted.
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Affiliation(s)
- Yasushi Oginosawa
- Division of Cardiology, Yokohama Rosai Hospital, Kohoku-ku, Yokohama, Japan
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Cabrera JA, Ho SY, Sanchez-Quintana D. How anatomy can guide ablation in isthmic atrial flutter. Europace 2008; 11:4-6. [DOI: 10.1093/europace/eun340] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Saremi F, Pourzand L, Krishnan S, Ashikyan O, Gurudevan SV, Narula J, Kaushal K, Raney A. Right Atrial Cavotricuspid Isthmus: Anatomic Characterization with Multi–Detector Row CT. Radiology 2008; 247:658-68. [DOI: 10.1148/radiol.2473070819] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Multidetector 16-slice CT scan evaluation of cavotricuspid isthmus anatomy before radiofrequency ablation. J Interv Card Electrophysiol 2007; 20:29-35. [DOI: 10.1007/s10840-007-9159-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2007] [Accepted: 08/20/2007] [Indexed: 11/29/2022]
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Kautzner J, Peichl P. Intracardiac echocardiography in electrophysiology. Herzschrittmacherther Elektrophysiol 2007; 18:140-6. [PMID: 17891490 DOI: 10.1007/s00399-007-0574-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 06/23/2007] [Indexed: 05/17/2023]
Abstract
Intracardiac echocardiography (ICE) broadens the spectrum of echocardiographic techniques. Modern 10F sector echocardiographic catheters introduced into the right atrium allow high quality imaging of all cardiac structures, including pulse and continuous wave Doppler and/or color Doppler. The main indication for ICE appears to be monitoring of catheter ablation of complex arrhythmic substrates such atrial fibrillation, postincisional tachycardias and ventricular tachycardias. The other important role of ICE is the early diagnosis and prevention of complications during ablation procedures. These include those occurring during transseptal catheterization, damage to cardiac structures, left atrial thrombus formation, pulmonary venous stenosis, esophageal injury and pericardial effusion.
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Affiliation(s)
- J Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Vídenská 1958/9, 140 21 Prague 4, The Czech Republic.
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Parvez B, Goldberg SM, Pathak V, Schubert CM, Wood MA. Time to Electrode Rewarming After Cryoablation Predicts Lesion Size. J Cardiovasc Electrophysiol 2007; 18:845-8. [PMID: 17553073 DOI: 10.1111/j.1540-8167.2007.00871.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There are no methods in clinical use to assess tissue cooling during catheter cryoablation. Cryoablation electrode temperature may be a poor predictor of lesion size. The purpose of this study was to determine whether the time necessary for the cryoablation electrode to cool to target temperature or to rewarm after cryoablation can predict lesion size. METHODS AND RESULTS Cryoablation was performed on live porcine left ventricle in a saline bath (37 degrees C) using 8-mm-tip catheter. Cryoablation was given for 300 seconds under all permutations of the following conditions: electrode orientation vertical or horizontal, contact pressure 6 or 20 g, superfusate flow over electrode-tissue interface at 0.2 or 0.4 m/s (N = 10 each condition set, total 80 experiments). The time intervals necessary to cool the electrode to the target temperature of -75 degrees C and to rewarm to + 30 degrees C after termination of cryoablation were recorded. Lesion volume was predicted best by the time necessary to rewarm the electrode to +30 degrees C (r2 = 0.65, P < 0.0001), followed by electrode temperature (r2 = 0.28, P < 0.0001) and time to cool the electrode to -75 degrees C (r2 = 0.24, P < 0.0001). Time to +30 degrees C and time to -75 degrees C were associated with superfusate flow rate, contact pressure, and electrode orientation (r2 = 0.80 and 0.61, respectively, both P < 0.0001). Superfusate flow rate, contact pressure, and orientation were also highly predictive of lesion volume (r2 = 0.93, P < 0.0001). CONCLUSIONS Time to cryoablation electrode rewarming is a better predictor of cryoablation lesion size than is electrode temperature. Time to cryoablation electrode rewarming reflects important determinants of cryoablation lesion formation--convective warming, contact pressure, and electrode orientation--that are not ascertainable during clinical ablation procedures.
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Affiliation(s)
- Babar Parvez
- Division of Cardiology and Department of Biostatistics, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0053, USA
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Sacher F, O'Neill MD, Jais P, Huffer LL, Laborderie J, Derval N, Deplagne A, Takahashi Y, Jonnson A, Hocini M, Clementy J, Haissaguerre M. Prospective Randomized Comparison of 8-mm Gold-Tip, Externally Irrigated-Tip and 8-mm Platinum-Iridium Tip Catheters for Cavotricuspid Isthmus Ablation. J Cardiovasc Electrophysiol 2007; 18:709-13. [PMID: 17537205 DOI: 10.1111/j.1540-8167.2007.00861.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Radiofrequency (RF) ablation of the cavotricuspid isthmus (CTI) can be performed using different types of ablation catheter. Gold tip electrodes have the theoretical advantage of creating bigger lesions than standard platinum-iridium electrode. This prospective, randomized study compares the clinical efficacy of 8-mm gold tip catheter, externally irrigated and 8-mm platinum-iridium tip (Pt tip) catheters. METHODS AND RESULTS Sixty consecutive patients (51 men, 60 +/- 10 years) undergoing de novo CTI ablation for documented typical atrial flutter were randomized to one of the following ablation catheters: 8-mm gold tip catheter, an externally irrigated-tip (Irr. tip) catheter, or an 8-mm Pt tip catheter. The procedural endpoint was achievement of bidirectional isthmus conduction block with < or = 20 minutes of RF energy application. The latter was achieved equally with the 3 catheters (95% for gold tip, 100% for irrigated tip, 95% for Pt tip) and the durations of RF (10 +/- 6, 10 +/- 4, 13 +/- 8 minutes), fluoroscopy (12 +/- 6, 12 +/- 7, 15 +/- 12 minutes) and the procedure (34 +/- 23, 38 +/- 24, 40 +/- 30 minutes) were similar in all groups. The maximal targeted power could not be reached in at least one location in 40% of patients with gold tip and in 35% of patients with Pt tip catheters whereas it was always achieved with an Irr. tip catheter (P = 0.003, P = 0.008). The reduction in impedance during RF delivery was greater with Irr. tip (11 +/- 7 ohms) than with gold (7 +/- 4 ohms, P = 0.02) or Pt tip (5 +/- 3 ohms, P = 0.001) catheters. CONCLUSION This study demonstrates equivalent efficacies of gold, platinum-iridium and externally Irr. tip catheters for successful de novo ablation of the CTI.
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Affiliation(s)
- Frédéric Sacher
- Université Bordeaux II-Hôpital Cardiologique du Haut-Lévêque, Bordeaux-Pessac, France.
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Lee PC, Hwang B, Chen SA, Tai CGT, Chen YJ, Chiang CE, Meng CCL. The Results of Radiofrequency Catheter Ablation of Supraventricular Tachycardia in Children. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:655-61. [PMID: 17461876 DOI: 10.1111/j.1540-8159.2007.00727.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Radiofrequency (RF) catheter ablation represents a major advance in the management of children with cardiac arrhythmias and has rapidly become the standard of care for the first-ling therapy of supraventricular tachycardias (SVTs). The purpose of this study was to investigate the results of the RF catheter ablation of SVTs in pediatric patients. METHODS From December 1989 to August 2005, a total of 228 pediatric patients (age: 9 +/- 7 years, range: 5-18 years; male:female = 117:111) with clinically documented SVT underwent an electrophysiologic study and RF catheter ablation at our institution. RESULTS The arrhythmias included atrioventricular reentrant tachycardia (AVRT; n = 140, 61%), atrioventricular nodal reentrant tachycardia (AVNRT; n = 66, 29%), atrial tachycardia (AT; n = 11, 5%), and atrial flutter (AFL; n = 11, 5%). The success rate of the RF catheter ablation was 92% for AVRT, 97% for AVNRT, 82% for AT, and 91% for AFL, respectively. Procedure-related complications were infrequent (8.7%; major complications: high grade AV block (2/231, 0.9%); minor complications: first degree AV block (6/231, 2.6%), reversible brachial plexus injury (2/231, 0.9%), and local hematomas or bruises (10/231, 4.3%)). The recurrence rate was 4.7% (10/212) during a follow-up period of 86 +/- 38 months (0.5-185 months). CONCLUSIONS The RF catheter ablation was a safe and effective method to manage children with paroxysmal and incessant tachycardia. The substrates of the arrhythmias differed between the pediatric and adult patients. However, the success rate of the ablation, complications, and recurrence during childhood were similar to those of adults.
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Affiliation(s)
- Pi-Chang Lee
- Department of Pediatrics, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan.
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Da Costa A, Jamon Y, Romeyer-Bouchard C, Thévenin J, Messier M, Isaaz K. Catheter selection for ablation of the cavotricuspid isthmus for treatment of typical atrial flutter. J Interv Card Electrophysiol 2007; 17:93-101. [PMID: 17333369 DOI: 10.1007/s10840-006-9064-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2006] [Accepted: 11/25/2006] [Indexed: 11/29/2022]
Abstract
Radiofrequency catheter ablation (RFA) represents the first line therapy of the cavotricuspid isthmus-dependent atrial flutter (CTI-AFL) with a high efficacy and low secondary effects. RFA of CTI-dependent AFL can be performed by using various types of ablation catheters. Recent evaluations comparing externally cooled tip RFA (ecRFA) catheters and large-tip (8 mm) catheters have revealed that these catheters have a higher efficacy for CTI-AFL ablation compared to 4-mm catheters. The reliability of RFA catheters for AFL is variable and an optimal catheter selection may enhance the RFA effectiveness. The main goal of this article is to review the elements that improve the management of CTI RFA. Preliminary examinations of histopathologic and anatomical elements that may interfere with conventional CTI RFA are presented. Experimental studies concerning the electrobiology of large-tip and cooled-tip catheters are compared. The different catheter designs between cooled-tip and 8-mm-tip catheters are examined (size of the deflectable curve, rotation stability, and size of the distal nonsteerable catheter part) because of their critical role in CTI RFA results. A thorough review of clinical trials of each catheter is presented, and comparison of both catheters in this clinical setting is analyzed. In addition, the role of CTI morphology on AFL RF duration is underlined such as the value of right atrial angiography as an adjunct tool for CTI RFA catheter selection. Based on randomized studies, 8-mm-tip catheters seem to be more effective for ablation in case of straight angiographic isthmus morphology. On the other hand, ecRFA catheters appear to be more effective in cases of complex CTI anatomy or difficult CTI RFA. To reduce X-ray exposition and RFA application time, few studies report that CTI angiographic evaluation before RFA allows a catheter selection based on both CTI morphology and length. Moreover, preliminary data of randomized studies showed that an angiographic isthmus evaluation may predict both the effectiveness of a RFA catheter and the risk of an expensive catheter crossover.
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Affiliation(s)
- Antoine Da Costa
- Department of Cardiology, Faculty of Medicine J. Lisfranc, Jean Monnet University, Saint-Etienne Cedex 2, France.
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Lim KT, Murray C, Liu H, Weerasooriya R. Pre-ablation magnetic resonance imaging of the cavotricuspid isthmus. ACTA ACUST UNITED AC 2007; 9:149-53. [PMID: 17255147 DOI: 10.1093/europace/eul187] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS In this prospective pilot study, pre-procedural MRI was performed on patients undergoing radiofrequency ablation of the cavotricuspid isthmus (CTI) to assess variation in isthmus anatomy and its impact on catheter ablation. METHODS In 41 patients, 34 males, mean age 56 +/- 11.5 years, pre-procedural MRI was performed prior to ablation. On the basis of the magnetic resonance imaging (MRI), isthmus length and description of isthmus morphology was determined. Catheter ablation of the CTI was then performed using a standard technique by an experienced operator without prior knowledge of the MRI findings. RESULTS The following morphological variants of isthmus morphology were demonstrated: long isthmus, concave isthmus shape, simple pouches, and eccentric septally directed pouches distinct from the coronary sinus. There was a trend towards longer RF times for long and concave shaped CTI. Eccentric septally directed pouches were associated with significantly longer radiofrequency energy delivery times (29.5 +/- 24.5 min RF versus 14.5 +/- 12.9 min RF; P = 0.037). CONCLUSION The anatomy of the CTI is highly variable. Ablation difficulty can be predicted by the presence or absence of morphological variants and the length of CTI demonstrated by cardiac MRI.
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Affiliation(s)
- Kang-Teng Lim
- Department of Cardiology, Royal Perth Hospital, GPO Box X2213, Perth, Western, Australia
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Chang SL, Tai CT, Lin YJ, Ong MG, Wongcharoen W, Lo LW, Chang SH, Hsieh MH, Chen SA. The Electroanatomic Characteristics of the Cavotricuspid Isthmus: Implications for the Catheter Ablation of Atrial Flutter. J Cardiovasc Electrophysiol 2007; 18:18-22. [PMID: 17081213 DOI: 10.1111/j.1540-8167.2006.00647.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Radiofrequency ablation (RFA) of typical AFL is sometimes difficult because of the poor electroanatomic approach to the cavotricuspid isthmus (CTI). The aim of this study was to correlate the anatomy of the CTI between contact mapping (NavX) and right atrial angiography (RAG), and to investigate the impact of the electroanatomic characteristics of the CTI on the RFA of typical atrial flutter (AFL). METHODS One hundred patients with typical AFL undergoing RFA were studied. The image-guided group consisted of 50 consecutive patients with the guidance of NavX. NavX geometry and RAG were performed to investigate the morphology of the CTI. The bipolar voltages of the CTI were collected during sinus rhythm by a NavX. The control group consisted of 50 consecutive patients with the guidance of conventional fluoroscopy. RESULTS There was a good correlation between the angiography and NavX for the anatomy of the CTI. The pouch type had a longer length of CTI than the flat type (33.4 +/- 5.0 vs 22.6 +/- 8.4 mm, P < 0.0001) and deeper depth than the concave type (6.5 +/- 2.2 vs 3.7 +/- 0.8 mm, P < 0.0001) on the angiography. The pouch-type CTI had a longer ablation time and larger pulses of RFA than the other two types. The control group had a longer ablation time, fluoroscopy time, and larger pulses of RFA than image-guided group. CONCLUSIONS The 3-D mapping system provided a good reconstruction of CTI, which may help in the RFA in patients with a complex anatomy of the CTI.
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Affiliation(s)
- Shih-Lin Chang
- Division of Cardiology, Department of Medicine, National Yang-Ming University School of Medicine, and Taipei Veterans General Hospital, Taipei, Taiwan
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Knight BP, Burke MC, Hong TE, McAuley A, Amundson D, Hanlin J, Blankenship L, Ferguson TB, Nazarian S, Berger RD. Direct imaging of transvenous radiofrequency cardiac ablation using a steerable fiberoptic infrared endoscope. Heart Rhythm 2005; 2:1116-21. [PMID: 16188593 DOI: 10.1016/j.hrthm.2005.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2005] [Accepted: 07/12/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Direct imaging through blood has been achieved in vivo using fiberoptics and infrared wavelength technology. OBJECTIVES The purpose of this study was to determine the feasibility of using a percutaneous, steerable, fiberoptic infrared endoscope to identify and characterize the electrode-tissue interface during transvenous cardiac ablation. METHODS Infrared endoscopy was performed during 24 catheter ablation attempts in 10 mongrel dogs. Infrared imaging was performed through a transparent dome located at the tip of a 7Fr steerable endoscope using an imaging wavelength of 1,620 nm. Radiofrequency ablation was performed using a 4-mm-tip electrode catheter. Attempts were made to identify the electrode-endocardial interface at each ablation site and to characterize any signal changes during ablation. RESULTS The electrode-tissue interface could be identified at 19 of the 24 ablation sites. Changes at the electrode-tissue interface were observed during ablation at 14 sites, which included a gradual increase in the tissue signal intensity at 12 sites. Small lucencies near the ablation electrode were observed at six sites. There was no interference during energy delivery. Endocardial features identified by endoscopy correlated with the postmortem appearance. CONCLUSION Direct imaging of intracardiac structures and the electrode-tissue interface can be achieved through blood during transvenous catheter ablation with infrared endoscopy using a steerable, fiberoptic, infrared endoscopic catheter. Ablation lesion formation can be seen as a gradual increase in signal intensity. Fiberoptic infrared endoscopy appears to be a promising new tool for guiding catheter ablation.
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Affiliation(s)
- Bradley P Knight
- Division of Cardiology, Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA.
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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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Ventura R, Klemm H, Lutomsky B, Demir C, Rostock T, Weiss C, Meinertz T, Willems S. Pattern of Isthmus Conduction Recovery Using Open Cooled and Solid Large‐Tip Catheters for Radiofrequency Ablation of Typical Atrial Flutter. J Cardiovasc Electrophysiol 2004; 15:1126-30. [PMID: 15485433 DOI: 10.1046/j.1540-8167.2004.04125.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Open cooled-tip and solid 8-mm-tip catheters have demonstrated safety and effectiveness for radiofrequency current (RFC) ablation of typical atrial flutter (AFL). However, data from prospective and randomized studies in this setting are lacking. METHODS AND RESULTS One hundred thirty consecutive patients (104 men; 61 +/- 11 years) with AFL were randomized to undergo RFC catheter ablation either using a solid 8-mm-tip catheter (group A, 65 degrees C, 70 W, 60 s) or an open irrigated-tip catheter (group B, 65 degrees C, 50 W, 60 s, 17 mL/min flow). Endpoint was bidirectional conduction isthmus block. In cases of repeated (two times) transient isthmus block, the catheter was changed (crossed over) to the catheter used in the other randomization arm, but patients remained in the original group following intention-to-treat analysis. The selected endpoint could be achieved in all patients after 12 +/- 6 RFC pulses in group A and 10 +/- 7 RFC pulses in group B (P = 0.11). Procedure times were longer (159 +/- 38 min vs 138 +/- 37 min, P = 0.002) and x-ray exposures higher in group A (fluoroscopy time 25 +/- 17 min vs 21 +/- 10 min, P = 0.08; x-ray dosage 3,133 +/- 2,576 cGy.cm2 vs 2,326 +/- 1,405 cGy.cm2, P = 0.03). Transient isthmus block was observed in 23 group A patients and 12 group B patients (P = 0.03). Onset time of transient isthmus block ranged from 0.5 to 27 minutes. Repeated transient isthmus block occurred in 8 of the 23 patients in group A after 19 +/- 3 RFC applications. After crossover to the cooled-tip catheter, the endpoint was reached another 5 +/- 1 RFC pulses. In group B, all patients could be treated without change of ablation catheter. After a follow-up of 14 +/- 2 months, 2 patients (3%) in group A and 1 patient (1.5%) in group B presented with AFL recurrence. CONCLUSION Open cooled-tip catheters are more effective than solid large-tip catheters for AFL ablation. The greater effectiveness is evident in cases showing repeated conduction recovery within the cavotricuspid isthmus. Primary use of open irrigated-tip catheters should be considered for AFL ablation.
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Affiliation(s)
- Rodolfo Ventura
- Department of Cardiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Ventura R, Rostock T, Klemm HU, Lutomsky B, Demir C, Weiss C, Meinertz T, Willems S. Catheter Ablation of Common‐Type Atrial Flutter Guided by Three‐Dimensional Right Atrial Geometry Reconstruction and Catheter Tracking Using Cutaneous Patches:. J Cardiovasc Electrophysiol 2004; 15:1157-61. [PMID: 15485440 DOI: 10.1046/j.1540-8167.2004.04064.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION EnSite NavX (NavX) is a novel mapping and navigation system that allows visualization of conventional catheters for diagnostic and ablative purposes and uses them to create a three-dimensional (3D) geometry of the heart. NavX is particularly suitable for ablation procedures utilizing an anatomic approach, as in the setting of common-type atrial flutter (AFL). The aim of this study was to compare NavX-guided and conventional ablation procedures for AFL. METHODS AND RESULTS Forty consecutive patients (32 male, 59 +/- 12 years) with documented AFL were randomized to undergo fluoroscopy-guided (group I, 20 patients) or NavX-guided (group II, 20 patients) ablation, including 3D isthmus reconstruction. The same catheter setup was used in both groups. The endpoint of bidirectional isthmus block was obtained in all patients. Compared to conventional approaches, NavX-guided procedures significantly reduced fluoroscopy time (5.1 +/- 1.4 min vs 20 +/- 11 min, P < 0.01) and total x-ray exposure (5.1 +/- 3.1 Gycm2 vs 24.9 +/- 1.6 Gycm2, P < 0.01). Isthmus geometry reconstruction could be performed in all patients of group II. In 4 patients (20%) of group II, anatomic isthmus variations were detected by NavX. No significant differences in radiofrequency current applications and procedural times were found between the two groups. CONCLUSION NavX technology allows geometry reconstruction of the cavotricuspid isthmus. NavX-guided ablation of AFL reduces total x-ray exposure compared to the fluoroscopy-guided approach but does not prolong procedure time.
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Affiliation(s)
- Rodolfo Ventura
- Department of Cardiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Da Costa A, Faure E, Thévenin J, Messier M, Bernard S, Abdel K, Robin C, Romeyer C, Isaaz K. Effect of Isthmus Anatomy and Ablation Catheter on Radiofrequency Catheter Ablation of the Cavotricuspid Isthmus. Circulation 2004; 110:1030-5. [PMID: 15326078 DOI: 10.1161/01.cir.0000139845.40818.75] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Cavotricuspid isthmus (CTI) characteristics are rarely documented when comparing catheters in radiofrequency ablation (RFA) of atrial flutter (AFL). Our objectives were (1) to evaluate the impact of CTI morphology and length on ablation procedures and (2) to compare the efficacy of an 8-mm-tip catheter with an irrigated cooled-tip RFA in the subgroup presumed to be more difficult to treat (with a long CTI, >35 mm).
Methods and Results—
Over a period of 17 months, 185 patients accepted the protocol and underwent an isthmogram in preparation for RFA. Groups were classified according to CTI length and CTI morphology. RFA was performed with an 8-mm-tip catheter for patients with a short CTI, ≤35 mm (n=123), whereas randomization between an 8-mm-tip and a cooled-tip catheter applied to patients with a longer CTI, >35 mm (n=62). For long CTI, 32 patients were assigned to an 8-mm catheter and 30 patients to the cooled-tip RFA ablation group. In this subset, RF application (18.2±17 versus 19±13 minutes) and x-ray exposure (20.8±18 versus 18±13 minutes) did not differ between the 8-mm-tip and the cooled-tip procedures. Number of applications (9.9±11 versus 18.6±15 minutes;
P
<0.0001) and x-ray exposure (11.7±11 versus 19.5±16 minutes,
P
=0.0001) differed significantly between patients with short and long CTIs. Patients with short and straight CTIs required 3 times fewer RFA applications and shorter x-ray exposure compared with other CTI morphologies (pouch-like recesses and concave characteristics).
Conclusions—
The number of RF applications required for a complete isthmus block in long CTIs is not influenced by the choice between an 8-mm or cooled-tip catheter. Procedure parameters, however, are significantly influenced by CTI length and morphology. Pouch-like recesses and concave characteristics account for much longer ablation times at all CTI lengths.
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Affiliation(s)
- Antoine Da Costa
- University Hospital Jean Monnet, Division of Cardiology, Saint-Etienne, France.
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Affiliation(s)
- Fred Morady
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan 48109-0311, USA.
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