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Iqbal AM, Li KY, Mahmood M, Gautam S. Safety of fluoroless radiofrequency catheter ablation for atrial fibrillation in patients with pre-existing cardiac implantable electronic device: A single-center study. Pacing Clin Electrophysiol 2023; 46:1387-1392. [PMID: 37713192 DOI: 10.1111/pace.14818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/27/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Radiofrequency catheter ablation (RFA) for atrial fibrillation (AF) is being increasingly performed without fluoroscopy. This study aims to determine the safety of fluoroless RFA for patients with pre-existing cardiac implantable electronic devices (CIED). METHODS This is a single-center, single-operator, retrospective, observational study of 225 consecutive fluoroless RFA procedures for AF from June 1, 2019 to June 1, 2022. All procedures were performed with intracardiac echocardiography (ICE) support. Patients with pre-existing CIED were extracted from the database. Each CIED was interrogated at the start and end of each procedure and at 30-day follow-up. Pre- and post-procedure CIED interrogations were compared for any change in device or lead parameters. Patients were tracked for any subsequent device malfunction. RESULTS Out of 225 fluoroless AF ablations, 25 (10.2%) had pre-existing CIED (14 dual-chamber pacemakers, three dual-chamber defibrillators, three single-chamber defibrillators, one single chamber pacemaker, and four biventricular devices). Mean patient age was 71 ± 6 years. The mean duration of indwelling CIED was 1804 ± 1645 days (range: 78-6267 days). One (4%) patient had lead-related fibrin on ICE imaging. There was no significant difference in lead(s) threshold, impedance, or sensing post procedure or at 30-day follow-up compared to pre procedure. None of the patients required lead revision. There were no intra- or post-op thromboembolic events or subsequent device infection. One patient underwent CIED extraction after 11 months for an unrelated secondary device infection. CONCLUSIONS Radiofrequency catheter ablation for AF can be safely performed without fluoroscopy in patients with pre-existing CIED.
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Affiliation(s)
- Arshad Muhammad Iqbal
- Department of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Kai Yu Li
- Department of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Mobasser Mahmood
- Department of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Sandeep Gautam
- Department of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
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Telishevska M, Lengauer S, Reents T, Kantenwein V, Popa M, Bahlke F, Englert F, Erhard N, Deisenhofer I, Hessling G. Long-Term Follow-Up of Empirical Slow Pathway Ablation in Pediatric and Adult Patients with Suspected AV Nodal Reentrant Tachycardia. J Clin Med 2023; 12:6532. [PMID: 37892670 PMCID: PMC10607303 DOI: 10.3390/jcm12206532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The aim of this study was to assess long-term efficacy and safety of empirical slow pathway (ESP) ablation in pediatric and adult patients with a special interest in patients without dual AV nodal physiology (DAVNP). METHODS A retrospective single-center review of patients who underwent ESP ablation between December 2014 and September 2022 was performed. Follow-up included telephone communication, letter questionnaire and outpatient presentation. Recurrence was based on typical symptoms. RESULTS 115 patients aged 6-81 years (median age 36.3 years, 59.1% female; 26 pts < 18 years) were included. A typical history was present in all patients (100%), an ECG documentation of narrow complex tachycardia in 97 patients (84%). Patients were divided into three groups: Group 1 without DAVNP (n = 23), Group 2 with AH jump (n = 30) and Group 3 with AH jump and at least one AV nodal echo beat (n = 62). No permanent AV block was observed. During a median follow-up of 23.6 ± 22.7 months, symptom recurrence occurred in 7/115 patients (6.1%) with no significant difference between the groups (p = 0.73, log-rank test). Symptom recurrence occurred significantly more often in patients without (5/18 patients; 27%) as compared to patients with ECG documentation (2/97 patients; 2.1%; p = 0.025). No correlation between age and success rate was found (p > 0.1). CONCLUSIONS ESP ablation is effective and safe in patients with non-inducible AVNRT. Overall, recurrence of symptoms during long-term follow-up is low, even if no DAVNP is present. Tachycardia documentation before the EP study leads to a significantly lower recurrence rate following ESP ablation.
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Affiliation(s)
- Marta Telishevska
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Lazarettstr. 36, 80636 Munich, Germany; (S.L.); (T.R.); (V.K.); (M.P.); (F.B.); (F.E.); (N.E.); (I.D.); (G.H.)
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Topalović M, Jan M, Kalinšek TP, Žižek D, Štublar J, Rus R, Kuhelj D. Zero-Fluoroscopy Catheter Ablation of Supraventricular Tachycardias in the Pediatric Population. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1513. [PMID: 37761474 PMCID: PMC10527735 DOI: 10.3390/children10091513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023]
Abstract
Catheter ablation (CA) of supraventricular tachycardias (SVTs) is conventionally performed with the aid of X-ray fluoroscopy. Usage of a three-dimensional (3D) electro-anatomical mapping (EAM) system and intracardiac echocardiography (ICE) enables zero-fluoroscopy ablation, eliminating the harmful effects of radiation. We retrospectively analyzed the feasibility, effectiveness and safety of zero-fluoroscopy radiofrequency and cryoablation of various types of SVTs in pediatric patients. Overall, in 171 consecutive patients (12.5 ± 3.9 years), 175 SVTs were diagnosed and 201 procedures were performed. The procedural success rate was 98% (193/197), or more precisely, 100% (86/86) for AVNRT, 95.8% (91/95) for AVRT, 94.1% (16/17) for AT and 100% (2/2) for AFL. No complications were recorded. Follow-up was complete in 100% (171/171) of patients. During the mean follow-up period of 488.4 ± 409.5 days, 98.2% of patients were arrhythmia-free with long-term success rates of 98.7% (78/79), 97.5% (78/80), 100% (13/13) and 100% (2/2) for AVNRT, AVRT, AT and AFL, respectively. Zero-fluoroscopy CA of various types of SVTs in the pediatric population is a feasible, effective and safe treatment option.
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Affiliation(s)
- Mirko Topalović
- Cardiology Department, Pediatric Clinic, University Medical Centre Ljubljana, Bohoriceva 20, 1000 Ljubljana, Slovenia
| | - Matevž Jan
- Cardiovascular Surgery Department, Surgical Clinic, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia (T.P.K.); (J.Š.)
| | - Tine Prolič Kalinšek
- Cardiovascular Surgery Department, Surgical Clinic, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia (T.P.K.); (J.Š.)
| | - David Žižek
- Cardiology Department, Internal Medicine Clinic, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia;
| | - Jernej Štublar
- Cardiovascular Surgery Department, Surgical Clinic, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia (T.P.K.); (J.Š.)
| | - Rina Rus
- Cardiology Department, Pediatric Clinic, University Medical Centre Ljubljana, Bohoriceva 20, 1000 Ljubljana, Slovenia
| | - Dimitrij Kuhelj
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia;
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Luani B, Basho M, Ismail A, Rauwolf T, Kaese S, Tobli N, Samol A, Pankraz K, Schmeisser A, Wiemer M, Braun-Dullaeus RC, Genz C. Catheter navigation by intracardiac echocardiography enables zero-fluoroscopy linear lesion formation and bidirectional cavotricuspid isthmus block in patients with typical atrial flutter. Cardiovasc Ultrasound 2023; 21:13. [PMID: 37537565 PMCID: PMC10398930 DOI: 10.1186/s12947-023-00312-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION One of the most helpful aspects of intracardiac echocardiography (ICE) implementation in electrophysiological studies (EPS) is the real-time visualisation of catheters and cardiac structures. In this prospective study, we investigated ICE-guided zero-fluoroscopy catheter navigation during radiofrequency (RF) ablation of the cavotricuspid isthmus (CTI) in patients with typical atrial flutter (AFL). METHODS AND RESULTS Thirty consecutive patients (mean age 72.9 ± 11.4 years, 23 male) with ongoing (n = 23) or recent CTI-dependent AFL underwent an EPS, solely utilizing ICE for catheter navigation. Zero-fluoroscopy EPS could be successfully accomplished in all patients. Mean EPS duration was 41.4 ± 19.9 min, and mean ablation procedure duration was 20.8 ± 17.1 min. RF ablation was applied for 6.0 ± 3.1 min (50W, irrigated RF ablation). Echocardiographic parameters, such as CTI length, prominence of the Eustachian ridge (ER), and depth of the CTI pouch on the ablation plane, were assessed to analyse their correlation with EPS- or ablation procedure duration. The CTI pouch was shallower in patients with an ablation procedure duration above the median (4.8 ± 1.1 mm vs. 6.4 ± 0.9 mm, p = 0.04), suggesting a more lateral ablation plane in these patients, where the CTI musculature is stronger. CTI length or ER prominence above the respective median did not correlate with longer EPS duration. CONCLUSIONS Zero-fluoroscopy CTI ablation guided solely by intracardiac echocardiography in patients with CTI-dependent AFL is feasible and safe. ICE visualisation may help to localise the optimal ablation plane, detect and correct poor tissue contact of the catheter tip, and recognise early potential complications during the ablation procedure.
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Affiliation(s)
- Blerim Luani
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany.
| | - Maksim Basho
- Department of Radiology, University Hospital Center Mother Teresa, Tirana, Albania
| | - Ammar Ismail
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Thomas Rauwolf
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | - Sven Kaese
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Ndricim Tobli
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Alexander Samol
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Katharina Pankraz
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Alexander Schmeisser
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | - Marcus Wiemer
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital Minden Ruhr-University Bochum, Hans-Nolte-Str. 1, Minden, 32429, Germany
| | - Rüdiger C Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | - Conrad Genz
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
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Randomized trial of intracardiac echocardiography-guided slow pathway ablation. J Interv Card Electrophysiol 2022; 63:709-714. [PMID: 35044581 DOI: 10.1007/s10840-022-01126-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. METHODS In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. RESULTS Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. CONCLUSIONS ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
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Purtell CS, Kipp RT, Eckhardt LL. Into a Fluoroless Future: an Appraisal of Fluoroscopy-Free Techniques in Clinical Cardiac Electrophysiology. Curr Cardiol Rep 2021; 23:28. [PMID: 33655436 PMCID: PMC7925460 DOI: 10.1007/s11886-021-01461-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
Purpose of Review There are risks to both patients and electrophysiology providers from radiation exposure from fluoroscopic imaging, and there is increased interest in fluoroscopic reduction. We review the imaging tools, their applications, and current uses to eliminate fluoroscopy. Recent Findings Multiple recent studies provide supporting evidence for the transition to fluoroscopy-free techniques for both ablations and device implantation. The most frequently used alternative imaging approaches include intracardiac echocardiography, cardiac MRI guidance, and 3D electroanatomic mapping systems. Electroanatomic mapping and intracardiac echocardiography originally used to augment fluoroscopy imaging are now replacing the older imaging technique. The data supports that the future of electrophysiology can be fluoroscopy-free or very low fluoroscopy for the vast majority of cases. Summary As provider and institution experience grows with these techniques, many EP labs may choose to completely forego the use of fluoroscopy. Trainees will benefit from early experience with these techniques.
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Affiliation(s)
- Christopher S Purtell
- Department of Medicine, Division of Cardiovascular Medicine, Electrophysiology Service, University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI, 53792, USA
| | - Ryan T Kipp
- Department of Medicine, Division of Cardiovascular Medicine, Electrophysiology Service, University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI, 53792, USA.,William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Lee L Eckhardt
- Department of Medicine, Division of Cardiovascular Medicine, Electrophysiology Service, University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI, 53792, USA. .,Cellular and Molecular Arrhythmia Research Program, Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin-Madison, Madison, WI, USA.
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Percell RL, Pike JL, Olmsted RK, Beideck JE, Nunes HL, Johnson KN, Schaffer M, Vachok LB, Sveen SM, Keim EJ, Mohr-Burt SO, Saalfeld RM, Beran CA, Allison TW, Stock JF. The Grand SANS FLUORO (SAy No Series to FLUOROsopy) Study: Examining Fluoroscopy Use in More than 1,000 Ablation Procedures. J Innov Card Rhythm Manag 2020; 11:4224-4232. [PMID: 32983591 PMCID: PMC7510468 DOI: 10.19102/icrm.2020.1100903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The majority of electrophysiologists routinely use fluoroscopy (FLUORO) during ablation procedures for common arrhythmias despite the known complications of radiation exposure and protective lead use. This study assessed the safety of catheter ablation (CA) with FLUORO versus without FLUORO (SANS FLUORO) in patients with the following common arrhythmias: atrial fibrillation (AF), atrial flutter, supraventricular tachycardia, and ventricular tachycardia. A total of 1,258 CA procedures were performed in 816 consecutive patients over a 53-month period (SANS FLUORO CA: 609 patients; FLUORO CA: 209 patients). The secondary outcome was the efficacy of AF ablation in FLUORO versus SANS FLUORO patients. Ultimately, there was no statistically significant difference found concerning the safety of CA in the SANS FLUORO and FLUORO groups in terms of procedure time, vascular complications, tamponade, stroke, or death. FLUORO patients had markedly increased FLUORO time, increased radiation exposure, and increased dose-area product (all p < 0.0001). AF development after SANS FLUORO CA of AF was not different from that after FLUORO CA regardless of the pulmonary vein isolation (PVI) modality used (cryoablation versus radiofrequency) at 24 months (p = 0.21). Additionally, women fared just as well as men after CA ablation for AF. At 36 months, 58% of SANS FLUORO AF device patients were free from AF. As such, SANS FLUORO CA of common arrhythmias appears to be as safe as FLUORO CA but with a markedly reduced level of radiation exposure. Also, SANS FLUORO CA remains as effective as FLUORO CA in the prevention of AF for up to 24 months.
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Affiliation(s)
- Robert L Percell
- SANS FLUORO Institute, Electrophysiology Department, Bryan Heart Institute, Lincoln, NE, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Casey A Beran
- Abbott Medical, Abbott Laboratories, Abbott Park, IL, USA
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