Near Zero Fluoroscopic Implantation of BIV ICD Using Electro-anatomical Mapping

Zero to minimal fluoroscopy for cardiac electronic device implantation: A systematic review and meta-analysis

Background

Fluoroscopy is conventionally performed for cardiac implantable electronic device (CIED) therapy and carries radiation drawback for both patients and medical workers. Recently, zero to minimal fluoroscopy (ZMF) approach is introduced to reduce radiation exposure of fluoroscopy. This study compares the feasibility and safety of ZMF approach to fluoroscopy for CIEDs therapy in adults.

Method

A systematic literature search was conducted on PubMed, ScienceDirect, and Web of Science in March 2023. All observational or experimental studies comparing ZMF approach to fluoroscopy for adult CIEDs therapy were included. Reviews, case report/series, animal studies, and non-English articles were excluded. The success rate, procedural time, fluoroscopy time, radiation dose, and complications rate were compared for each approach.

Results

Seven articles for permanent and three articles for temporary CIEDs were included for analysis. The success rate of ZMF for permanent CIEDs was similar to fluoroscopy method (OR: 0.77, 95% CI: 0.33-4.15). The procedural time of ZMF was similar to fluoroscopy for both permanent and temporary CIEDs (standardized mean difference [SMD]: 0.10, 95% CI: -0.35 to 0.55 and SMD: -0.71, 95% CI: -1.87-0.44, respectively). However, ZMF approach markedly reduced the fluoroscopy time and radiation exposure for permanent CIEDs (SMD: -1.80, 95% CI: -2.49 to -1.12 and SMD: -1.26, 95% CI: -2.24 to -0.29). The complication rate was similar for permanent CIEDs (OR: 1.08, 95% CI: 0.41-2.84), yet lowered for temporary CIEDs (OR: 0.34, 95% CI: 0.20-0.59).

Conclusion

ZMF had similar success rate, procedural time, and sum complication rate for permanent CIEDs implantation with a significant reduction of fluoroscopy time and radiation exposure.

Electroanatomical mapping- and CT scan image integration-guided pacing lead implantation: A case series and review of the recent literature

Background

We present a case series and short review of electroanatomical mapping (EAM)–guided pacing lead implantation. The cases illustrate different aspects of EAM use in special circumstances and summarizes our experience with EAM-guided His lead implantation in 32 consecutive patients. Advantages and caveats encountered when using EAM in device procedures are discussed.

Objective

To illustrate usefulness of EAM-guided lead implantation and computed tomography (CT) image integration in a case series.

Methods

Lead implantation was performed targeting different anatomically defined regions using EAM for mapping and lead navigation, as well as using the system for image integration for 2 cardiac resynchronization therapy implantations.

Results

For His bundle pacing lead implantation, a steep learning curve for successful His bundle lead placement seems obtainable (91%) for new implanters using EAM-guided implantation. Successful lead placements in other locations guided by anatomical or physiologically defined positions are demonstrated in individual cases. However, map shifts are frequently encountered and should be recognized and corrected.

Conclusion

EAM-guided His bundle lead implantation seems to be a useful tool for arriving at high success rates for new His lead implanters with a steep learning curve, if appropriate precautions are undertaken. In selected cases EAM and CT scan image integration can be of benefit in lead implantation in other locations. Knowledge of specific problems in using EAM for device procedures should be recognized.

High efficiency and workflow of His bundle pacing and atrioventricular node ablation guided by three-dimensional mapping system

BACKGROUND

Atrioventricular node (AVN) ablation combined with His bundle pacing is an effective strategy for permanent atrial fibrillation (AF) with rapid ventricular rate refractory to pharmacological therapy. We aimed to access the feasibility and efficiency of His bundle pacing and AVN ablation guided by three-dimensional (3-D) mapping system throughout the procedure.

METHODS

Eighteen patients with permanent AF with refractory rate and symptoms were referred for His bundle pacing and AVN ablation guided by 3-D mapping (CARTO3). Electroanatomic 3-D mapping of the right atrium and right ventricle was performed by the ablation catheter with CARTO 3 system, followed by the visualization of the leads for implantation and AVN ablation.

RESULTS

Implantation of His bundle and ventricular leads and AVN ablation were achieved successfully with the help of 3-D mapping in 17 patients. Selective His bundle pacing was achieved in five patients (29.4%), and the other (70.6%) were nonselective His bundle pacing. The mean procedure duration was 99.4 ± 16.4 minutes. The mean fluoroscopy time was 7.0 ± 2.6 minutes. The time spent on His lead implantation was 6.1 ± 3.2 minutes. One patient experienced AVN ablation from left side under aortic valves due to no effect of ablation in right atrium.

CONCLUSION

His bundle pacing and AVN ablation guided by throughout real-time 3-D mapping system are of high-efficiency and feasibility.

Implantation of BIV ICD with Near Zero Contrast Use in Patients with Advanced Renal Insufficiency Using Three Dimensional Electro-anatomical Mapping

Background

Biventricular (BIV) ICD implantations are traditionally performed using contrast and fluoroscopic guidance. Contrast use in patient with advanced renal disease can cause deterioration of renal function and even lead to dialysis.

Objective

To evaluate the feasibility of utilizing 3 D mapping technique in reducing or eliminating contrast use in patient with advanced renal disease.

Methods and Results

The study consisted of 30 consecutive adult patients, in which BIV implantation was accomplished in advanced renal disease (stage III and IV GFR 15 to 59) by electroanatomical 3D mapping (EAM).Acute procedural success was 96% and only one patient LV lead implantation was unsuccessful due to unsuitable anatomy.47 % of patients had BIV ICD implantation with zero contrast. Average contrast exposure for the group was 4.3 ml only. Average ratio of contrast use to GFR (glomerular filtration rate) was only 0.1. Improved mean GFR was observed from 42 to 50 post procedure (P value<0.01), and continued to improve to 48 at 3 and 6 month (P value<0.01) and improvement decreased to 45 and 44 beyond 6 month and 1 year (P value NS). There was no single case of contrast induced acute renal insufficiency (CI-ARI) due to minimal use of contrast.69 % of the patients experienced an improvement in their functional class. A decrease in QRS duration was seen from 159 to 136 milliseconds (86% of patients had improved QRS duration); P value = <0.001. The average pre procedure ejection fraction (EF) for the group was 23%. The average EF post procedure for the group was 35%; P values = <0.001 (72% of patient had EF improvement).93% of patient had either EF and/or GFR improvement suggesting substantial clinical benefit from the procedure.There was no minor or major complications.

Conclusions

Implantation of BiV ICD using EAM with near zero contrast is feasible, safe and effective in patients with moderate to severe renal insufficiency. There is an added renal protection and benefit from procedure in this group of patients.

How to perform electroanatomic mapping-guided cardiac resynchronization therapy using Carto 3 and ESI NavX three-dimensional mapping systems

AIMS 

To examine the feasibility and safety of a novel protocol for low fluoroscopy, electroanatomic mapping (EAM)-guided Cardiac resynchronization therapy with a defibrillator (CRT-D) implantation and using both EnSite NavX (St. Jude Medical, St. Paul, MN, USA) and Carto 3 (Biosense Webster, Irvine, CA, USA) mapping systems.

METHODS AND RESULTS

Twenty consecutive patients underwent CRT implantation using either a conventional fluoroscopic approach (CFA) or EAM-guided lead placement with Carto 3 and EnSite NavX mapping systems. We compared fluoroscopy and procedural times, radiopaque contrast dose, change in QRS duration pre- and post-procedure, and complications in all patients. Fluoroscopy time was 86% lower in the EAM group compared to the conventional group [mean 37.2 min (CFA) vs. 5.5 min (EAM), P = 0.00003]. There was no significant difference in total procedural time [mean 183 min (CFA) vs. 161 min (EAM), P = 0.33] but radiopaque contrast usage was lower in the EAM group [mean 16 mL (CFA) vs. 4 mL (EAM), P = 0.006]. Likewise, there was no significant change in QRS duration with BiV pacing between the groups [mean -13 (CFA) vs. -25 ms (EAM), P = 0.09].

CONCLUSION 

Electroanatomic mapping-guided lead placement using either Carto or ESI NavX mapping systems is a feasible alternative to conventional fluoroscopic methods for CRT-D implantation utilizing the protocol described in this study.

Impact of cardiac resynchronisation therapy on cardiologists' exposure to radiation during implantation of pacemakers and implantable cardioverter-defibrillators

Cardiologists are among the health professionals that are most exposed to ionizing radiation, but there is no recent study quantifying overexposure of physicians during cardiac resynchronisation therapy (CRT) procedures compared to 'classical' implantation of pacemakers (PMs) or implantable cardioverter-defibrillators (ICDs). We aimed to measure and compare operator exposure to radiation during implantation of PM and ICD with or without CRT. The study population comprised all PMs and ICDs implanted in a large referral centre over a six months period. The endpoint was operator radiation exposure, assessed using a personal electronic dosimeter located on operator's chest. In total, 169 PM/ICD implantations were analysed, 19 of which included CRT. Compared with 'classical' implantation, cardiologist radiation exposure was 9-fold greater during CRT procedures (p < 0.001). Physician exposure was related to dose-area product (R² = 0.21 during 'classical' implantations and R² = 0.57 during CRT procedures). Our study shows that cardiologists' exposure to radiation during CRT implantation was 9-fold greater than during procedures without CRT.

Role of cardiovascular imaging in cardiac resynchronization therapy: a literature review

: Cardiac resynchronization therapy (CRT) is an established treatment in patients with symptomatic drug-refractory heart failure and broad QRS complex on the surface ECG. Despite the presence of either mechanical dyssynchrony or viable myocardium at the site where delivering left ventricular pacing being necessary conditions for a successful CRT, their direct assessment by techniques of cardiovascular imaging, though feasible, is not recommended in clinical practice by the current guidelines. Indeed, even though there is growing body of data providing evidence of the additional value of an image-based approach as compared with routine approach in improving response to CRT, these results should be confirmed in prospective and large multicentre trials before their impact on CRT guidelines is considered.

Zero x-ray cardiac resynchronization therapy device implantation guided by a nonfluoroscopic mapping system: A pilot study

BACKGROUND

Fluoroscopic guidance is the standard tool used in device implantation. This means that both the patient and the operator are exposed to radiation, which may sometimes be high. The possibility of single-lead permanent pacemaker implantation without fluoroscopy has already been demonstrated.

OBJECTIVE

The aim of our study was to investigate the feasibility and reliability of biventricular device implantation guided only by an electroanatomic navigation system.

METHODS

Sixty-one patients with heart failure underwent implantation of a cardiac resynchronization therapy (CRT) device with or without defibrillator (CRT-D; CRT-P). The procedure was performed with or without fluoroscopy guidance (Rx+; Rx0). In the latter case, the EnSite Velocity system was used; this system is able to reconstruct the anatomy and activation of the cardiac chambers by simultaneously collecting a "cloud" of anatomical points from multiple electrodes.

RESULTS

Lead positioning was achieved in 24 of 26 patients undergoing CRT implantation without fluoroscopy (92% success). No complications were observed during the procedure and no catheter dislodgment occurred the day after the implantation or during 1-month follow-up. Procedure time progressively decreased from 136 minutes in the first case to 59 minutes in the last one, suggesting that operators gradually gained confidence while using the new technique.

CONCLUSION

Our study demonstrates the feasibility, efficacy, and safety of lead positioning guided only by the nonfluoroscopic EnSite Velocity mapping system without the use of fluoroscopy in CRT-P or CRT-D implantation. The benefits in terms of significantly reduced fluoroscopy exposure are associated with technical and clinical advantages.