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McBride S, Avazzadeh S, Wheatley AM, O’Brien B, Coffey K, Elahi A, O’Halloran M, Quinlan LR. Ablation Modalities for Therapeutic Intervention in Arrhythmia-Related Cardiovascular Disease: Focus on Electroporation. J Clin Med 2021; 10:jcm10122657. [PMID: 34208708 PMCID: PMC8235263 DOI: 10.3390/jcm10122657] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023] Open
Abstract
Targeted cellular ablation is being increasingly used in the treatment of arrhythmias and structural heart disease. Catheter-based ablation for atrial fibrillation (AF) is considered a safe and effective approach for patients who are medication refractory. Electroporation (EPo) employs electrical energy to disrupt cell membranes which has a minimally thermal effect. The nanopores that arise from EPo can be temporary or permanent. Reversible electroporation is transitory in nature and cell viability is maintained, whereas irreversible electroporation causes permanent pore formation, leading to loss of cellular homeostasis and cell death. Several studies report that EPo displays a degree of specificity in terms of the lethal threshold required to induce cell death in different tissues. However, significantly more research is required to scope the profile of EPo thresholds for specific cell types within complex tissues. Irreversible electroporation (IRE) as an ablative approach appears to overcome the significant negative effects associated with thermal based techniques, particularly collateral damage to surrounding structures. With further fine-tuning of parameters and longer and larger clinical trials, EPo may lead the way of adapting a safer and efficient ablation modality for the treatment of persistent AF.
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Affiliation(s)
- Shauna McBride
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Sahar Avazzadeh
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Antony M. Wheatley
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
| | - Barry O’Brien
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 R6W6 Galway, Ireland; (B.O.); (K.C.)
| | - Ken Coffey
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 R6W6 Galway, Ireland; (B.O.); (K.C.)
| | - Adnan Elahi
- Translational Medical Device Lab (TMDL), Lamb Translational Research Facility, University College Hospital Galway, H91 V4AY Galway, Ireland; (A.E.); (M.O.)
- Electrical & Electronic Engineering, School of Engineering, National University of Ireland Galway, H91 HX31 Galway, Ireland
| | - Martin O’Halloran
- Translational Medical Device Lab (TMDL), Lamb Translational Research Facility, University College Hospital Galway, H91 V4AY Galway, Ireland; (A.E.); (M.O.)
| | - Leo R. Quinlan
- Physiology and Cellular Physiology Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human Biology Building, National University of Ireland (NUI) Galway, H91 W5P7 Galway, Ireland; (S.M.); (S.A.); (A.M.W.)
- CÚRAM, SFI Research Centre for Medical Devices, National University of Ireland Galway, H92 W2TY Galway, Ireland
- Correspondence:
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Bartel T, Rivard A, Jimenez A, Mestres CA, Müller S. Medical three-dimensional printing opens up new opportunities in cardiology and cardiac surgery. Eur Heart J 2019; 39:1246-1254. [PMID: 28329105 DOI: 10.1093/eurheartj/ehx016] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/11/2017] [Indexed: 11/12/2022] Open
Abstract
Advanced percutaneous and surgical procedures in structural and congenital heart disease require precise pre-procedural planning and continuous quality control. Although current imaging modalities and post-processing software assists with peri-procedural guidance, their capabilities for spatial conceptualization remain limited in two- and three-dimensional representations. In contrast, 3D printing offers not only improved visualization for procedural planning, but provides substantial information on the accuracy of surgical reconstruction and device implantations. Peri-procedural 3D printing has the potential to set standards of quality assurance and individualized healthcare in cardiovascular medicine and surgery. Nowadays, a variety of clinical applications are available showing how accurate 3D computer reformatting and physical 3D printouts of native anatomy, embedded pathology, and implants are and how they may assist in the development of innovative therapies. Accurate imaging of pathology including target region for intervention, its anatomic features and spatial relation to the surrounding structures is critical for selecting optimal approach and evaluation of procedural results. This review describes clinical applications of 3D printing, outlines current limitations, and highlights future implications for quality control, advanced medical education and training.
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Affiliation(s)
- Thomas Bartel
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates
| | - Andrew Rivard
- Imaging Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Alejandro Jimenez
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates
| | - Carlos A Mestres
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates
| | - Silvana Müller
- Department of Internal Medicine III, Cardiology Division, Innsbruck Medical University, Innsbruck, Austria
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Costet A, Wan E, Melki L, Bunting E, Grondin J, Garan H, Konofagou E. Non-invasive Characterization of Focal Arrhythmia with Electromechanical Wave Imaging in Vivo. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2241-2249. [PMID: 30093340 PMCID: PMC6163072 DOI: 10.1016/j.ultrasmedbio.2018.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 06/05/2018] [Accepted: 06/11/2018] [Indexed: 06/02/2023]
Abstract
There is currently no established method for the non-invasive characterization of arrhythmia and differentiation between endocardial and epicardial triggers at the point of care. Electromechanical wave imaging (EWI) is a novel ultrasound-based imaging technique based on time-domain transient strain estimation that can map and characterize electromechanical activation in the heart in vivo. The objectives of this initial feasibility study were to determine that EWI is capable of differentiating between endocardial and epicardial sources of focal rhythm and, as a proof-of-concept, that EWI could characterize focal arrhythmia in one patient with premature ventricular contractions (PVCs) before radiofrequency (RF) ablation treatment. First, validation of EWI for differentiation of surface of origin was performed in seven (n = 7) adult dogs using four epicardial and four endocardial pacing protocols. Second, one (n = 1) adult patient diagnosed with PVC was imaged with EWI before the scheduled RF ablation procedure, and EWI results were compared with mapping procedure results. In dogs, EWI was capable of detecting whether pacing was of endocardial or epicardial origin in six of seven cases (86% success rate). In the PVC patient, EWI correctly identified both regions and surface of origin, as confirmed by results from the electrical mapping obtained from the RF ablation procedure. These results reveal that EWI can map the electromechanical activation across the myocardium and indicate that EWI could serve as a valuable pre-treatment planning tool in the clinic.
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Affiliation(s)
- Alexandre Costet
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Elaine Wan
- Department of Medicine-Cardiology, Columbia University, New York, New York, USA
| | - Lea Melki
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Ethan Bunting
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Julien Grondin
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Hasan Garan
- Department of Medicine-Cardiology, Columbia University, New York, New York, USA
| | - Elisa Konofagou
- Department of Biomedical Engineering, Columbia University, New York, New York, USA; Department of Radiology, Columbia University, New York, New York, USA.
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Muser D, Castro SA, Liang JJ, Santangeli P. Identifying Risk and Management of Acute Haemodynamic Decompensation During Catheter Ablation of Ventricular Tachycardia. Arrhythm Electrophysiol Rev 2018; 7:282-287. [PMID: 30588317 DOI: 10.15420/aer.2018.36.3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/19/2018] [Indexed: 12/21/2022] Open
Abstract
Radiofrequency catheter ablation (CA) has an established role in the management of patients with structural heart disease presenting with recurrent ventricular tachycardia (VT). Due to the complex underlying substrate, high burden of comorbidities and concomitant heart failure (HF) status, these patients may be at higher risk of periprocedural complications. The prolonged low-output state related to VT induction and mapping, as well as the fluid overload due to irrigated CA and the use of general anaesthesia, may decompensate the HF status, leading to multiple-organ failure and increase in early post-procedural mortality. Proper identification of patients at high risk of periprocedural acute haemodynamic decompensation (AHD) has important implications in terms of procedural planning (i.e. prophylactic use of mechanical assistance devices) and pre-procedural management in order to optimise the HF status. In the present manuscript we focus on the clinical predictors of AHD and the strategies to improve pre-procedural risk stratification, as well as the evidence supporting the use of haemodynamic support during CA procedures.
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Affiliation(s)
- Daniele Muser
- Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania USA
| | - Simon A Castro
- Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania USA
| | - Jackson J Liang
- Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania USA
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Keramati AR, DeMazumder D, Misra S, Chrispin J, Assis FR, Raghuram C, Dey S, Calkins H, Tandri H. Anterior pericardial access to facilitate electrophysiology study and catheter ablation of ventricular arrhythmias: A single tertiary center experience. J Cardiovasc Electrophysiol 2017; 28:1189-1195. [PMID: 28727191 DOI: 10.1111/jce.13296] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/23/2017] [Accepted: 06/26/2017] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Epicardial ablation is becoming an important part of management in patients with ventricular tachycardia (VT). Posterior epicardial access via the Sosa or needle-in-needle (NIN) approach for epicardial VT ablation is considered to be the method of choice for most electrophysiologists. Anterior epicardial access as an alternative technique has recently been proposed, but there are limited data about its safety, efficacy, and the rate of immediate complications. In this study, we report our experience with anterior epicardial access between 2009 and 2016. METHODS Between 2009 and June 2016, 100 consecutive patients underwent epicardial VT ablation using an anterior approach. The success rate, epicardial bleeding, and other complications related to the epicardial access in these patients were compared to the previously reported rate of complications in patients whom epicardial access was performed using the NIN or Sosa techniques. RESULTS Anterior epicardial access was obtained successfully in 100% of patients in the first attempt. The success rate of the anterior approach was comparable with the reported success rate of the NIN technique (100% vs. 100%, P value not significant) but better than the Sosa technique (100% vs. 94%, P = 0.012). None of the patients in the anterior approach series suffered from significant pericardial bleeding (defined as greater than 80 mL of blood loss), RV puncture/damage, or need for an emergent cardiac surgery. CONCLUSION An anterior epicardial approach is feasible and appears to have an acceptable safety profile in comparison with other epicardial approaches.
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Affiliation(s)
- Ali R Keramati
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Deeptankar DeMazumder
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Division of Cardiology, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Satish Misra
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fabrizio R Assis
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Chava Raghuram
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Swati Dey
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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