Feasibility of Transseptal Puncture Using a Nonfluoroscopic Catheter Tracking System

Anesthetic Choice for Percutaneous Transcatheter Closure of the Left Atrial Appendage: A National Anesthesia Clinical Outcomes Registry Analysis

CONTEXT

Left atrial appendage closure (LAAC) was developed as a novel stroke prevention alternative for patients with atrial fibrillation, particularly for those not suitable for long-term oral anticoagulant therapy. Traditionally, general anesthesia (GA) has been more commonly used primarily due to the necessity of transesophageal echocardiography.

AIMS

Compare trends of monitored anesthesia care (MAC) versus GA for percutaneous transcatheter LAAC with endocardial implant and assess for independent variables associated with primary anesthetic choice.

SETTINGS AND DESIGN

Multi-institutional data collected from across the United States using the National Anesthesia Clinical Outcomes Registry.

MATERIAL AND METHODS

Retrospective data analysis from 2017-2021.

STATISTICAL ANALYSIS USED

Independent-sample t tests or Mann-Whitney U tests were used for continuous variables and Chi-square tests or Fisher's exact test for categorical variables. Multivariate logistic regression was used to assess patient and hospital characteristics.

RESULTS

A total of 19,395 patients underwent the procedure, and 352 patients (1.8%) received MAC. MAC usage trended upward from 2017-2021 (P < 0.0001). MAC patients were more likely to have an American Society of Anesthesiologists (ASA) physical status of≥ 4 (33.6% vs 22.89%) and to have been treated at centers in the South (67.7% vs 44.2%), in rural locations (71% vs 39.5%), and with lower median annual percutaneous transcatheter LAAC volume (102 vs 153 procedures) (all P < 0.0001). In multivariate analysis, patients treated in the West had 85% lower odds of receiving MAC compared to those in the Northeast (AOR: 0.15; 95% CI 0.03-0.80, P = 0.0261).

CONCLUSIONS

While GA is the most common anesthetic technique for percutaneous transcatheter closure of the left atrial appendage, a small, statistically significant increase in MAC occurred from 2017-2021. Anesthetic management for LAAC varies with geographic location.

3D mapping for the identification of the fossa ovalis in left atrial ablation procedures: a pilot study of a first step towards an electroanatomic-guided transseptal puncture

AIMS

Transseptal puncture (TP) for left atrial (LA) catheter ablation procedures is routinely performed under fluoroscopic guidance. To decrease radiation exposure and increase safety alternative techniques are desirable. The aim of this study was to assess whether right atrial (RA) electroanatomic 3D mapping can reliably identify the fossa ovalis (FO) in preparation of TP.

METHODS AND RESULTS

Between May 2019 and August 2019, electroanatomic RA mapping was performed before TP in 61 patients with paroxysmal or persistent atrial fibrillation. Three electroanatomic methods for FO identification, mapping catheter-induced FO protrusion, electroanatomic-guided analysis, and voltage mapping, were evaluated and compared with transoesophageal echocardiography (TOE). Mapping catheter-induced FO protrusion was feasible in 60 patients (98%) with a mean displacement of 6.8 ± 2.5 mm, confirmed by TOE, and proofed to be the most valuable and easiest marker for FO identification. Electroanatomic-guided analysis localized the FO midpoint consistently in the lower half (43 ± 7%) and posterior (18.2 ± 4.4 mm) to a line between coronary sinus and vena cava superior. Analysis of RA voltage maps during sinus rhythm (n = 40, low-voltage cut-off value 1.0 and 1.5 mV) allowed secure FO recognition in 33% and 18%, only. A step-by-step approach, combining FO protrusion (first step) with anatomy criteria in case of protrusion failure (second step) would have allowed for the correct localization of a TP site within the FO in all patients.

CONCLUSION

Right atrial electroanatomic 3D mapping prior to TP proofed to be a simple tool for FO identification and may potentially be of use in the safe and radiation-free performance of TP prior to LA ablation procedures.

Comprehensive strategies to minimize radiation exposure during Interventional electrophysiology procedures: state-of-the-art review

INTRODUCTION

Cardiac electrophysiology (EP) procedures are frequently performed in patients with cardiac arrhythmias, chronic heart failure, and sudden cardiac death. Most EP procedures involve fluoroscopy, which results in radiation exposure to physicians, patients, and EP lab staff. Accumulated radiation exposure is a known health detriment to patients and physicians.

AREA COVERED

This review will summarize radiation exposure, dose metrics, complications of radiation exposure, factors affecting radiation exposure, minimizing radiation exposure, zero or near-zero fluoroscopy strategies, and up-to-date research in the area of reducing radiation exposure and best practices.

EXPERT COMMENTARY

Comprehensive strategies should be implemented in EP laboratories to minimize radiation exposure with standard fluoroscopy. There are routine techniques that can mitigate significant amounts of radiation exposure using standard equipment within the EP lab. The operators need to emphasize that EP practices routinely incorporate non-ionizing radiation sources for cardiac imaging (e.g. magnetic resonance imaging, advanced electroanatomical mapping systems, intracardiac ultrasonography) in addition to other novel technologies to mitigate radiation exposure to patients and physicians.

Catheter ablation of atrial fibrillation with nonfluoroscopic catheter visualization-a prospective randomized comparison

PURPOSE

The application of a novel platform for nonfluoroscopic catheter sensor tracking within pre-recorded x-ray loops in the context of catheter ablation of atrial fibrillation (AF) demonstrated significant potential for reduction of fluoroscopy. We sought to provide the first prospective randomized comparison of fluoroscopy needs, procedure times, and complications in AF catheter ablation with or without additional use of nonfluoroscopic catheter visualization (NFCV).

METHODS

Patients with AF were randomized into two groups before scheduled radiofrequency ablation: (1) using established mapping systems and fluoroscopy as needed (CONV group) or (2) with additional NFCV (NFCV group). All procedures were performed in the same lab using the same ablation catheter tip technology and the same mapping and ablation strategies. Primary endpoints were radiation time and dose. Secondary endpoints were procedural parameters, complications, and long-term success.

RESULTS

A total of 80 patients (48 male patients, mean age 60 years, 46 patients with paroxysmal AF) were randomized into the two groups. Clinical parameters between both groups were similar. NFCV use reduced mean fluoroscopy time (1.9 vs. 13.2 min, p < 0.001) and mean dose (510 vs. 1549 Gycm², p < 0.001) significantly. Procedural parameters were similar in the two groups. One conservatively treated groin complication occurred (1.3%).

CONCLUSIONS

Radiation exposure can be significantly reduced by using the novel NFCV technology in addition to standard AF ablation technologies without negative effects on procedure durations, success rates, or complication rates. With the use of the technology, abandonment of lead protection for EP staff is possible following transseptal puncture.