C. Piorkowski

Reduction of radiation exposure during atrial fibrillation ablation using a novel fluoroscopy image integrated 3-dimensional electroanatomic mapping system: A prospective, randomized, single-blind, and controlled study

OBJECTIVE We explored whether the use of a novel fluoroscopy image integrated 3-dimensional electroanatomic mapping (F-EAM) system could result in a reduction of overall fluoroscopy time and radiation doses during the whole procedure of atrial fibrillation (AF) ablation. METHODS Eighty patients (44 men (55%); mean age 63 ± 10 years) who underwent catheter ablation due to paroxysmal AF were recruited consecutively in the present study. Patients were randomized (1:1) into 2 arms for AF ablation: one using a conventional 3-dimensional electroanatomical mapping (EAM) system and the other using the F-EAM system. RESULTS Fluoroscopy time (10:42 [interquartile range {IQR} 8:45-12:46] minutes:seconds vs 1:45 [IQR 1:05-2:22] minutes:seconds; P < .001) and radiation doses (2440 [IQR 1593-3091] cGy·cm(2) vs 652 [IQR 326-1489] cGy·cm(2); P < .001) in the EAM group were significantly greater than those in the F-EAM group. The majority of reduction of radiation exposure was achieved after transseptal puncture, which was near-zero fluoroscopic exposure. In total, approximately 84% of fluoroscopy time and 73% of radiation doses have been reduced during the AF ablation procedure using the F-EAM system compared to using the conventional EAM system. However, procedure time did not differ significantly (1:39 [IQR 1:18-2:10] hours:minutes vs 1:37 [IQR 1:17-1:50] hours:minutes; P = .362). During follow-up (5.9 ± 1.3 months), 61 patients (76.3%) had no recurrence of atrial arrhythmias. The recurrence rate between the 2 groups did not differ. CONCLUSION AF catheter ablation using the F-EAM system was safe and resulted in a significant reduction of radiation exposure to patients and staff without complicating the workflow of the procedure. A near-zero fluoroscopic catheter ablation procedure could be performed without compromising acute/mid-term efficacy and safety.

Early cerebral thromboembolic complications after radiofrequency catheter ablation of atrial fibrillation: Incidence, characteristics, and risk factors

BACKGROUND Thromboembolic complications remain one of the most severe adverse events associated with catheter ablation of atrial fibrillation (AF), but data on such events are limited. OBJECTIVE The purpose of this study was to evaluate the incidence, characteristics, and risk factors of thromboembolic complications after AF ablation. METHODS Cerebral thromboembolic complications occurring within 1 month of 3360 consecutive AF radiofrequency catheter ablations were assessed. Stroke was defined as a neurologic deficit lasting more than 24 hours or with imaging study showing new infarction. Transient ischemic attack (TIA) was defined as a deficit lasting less than 24 hours and without documented infarction. RESULTS There were 17 peri-interventional cerebral thromboembolic events (0.5%). Nine cases (53%) were diagnosed as strokes and 8 (47%) as TIAs. Sixty percent of the events occurred within 48 hours after the ablation; the rest occurred within 1 week. In univariate analysis, peri-interventional thromboembolism was associated with peripheral vascular disease (P = .010), impaired left ventricular ejection fraction (P = .040), periprocedural bridging with heparin (P = .007), and previous stroke (P = .026). Multivariable analysis demonstrated that peripheral vascular disease (odds ratio [OR] 8.81, confidence interval [CI] 1.61-48.31, P = .012) and previous stroke (OR 6.13, CI 1.18-31.91, P = .031) were independent predictors. In a different model, the CHA2DS2-VASc score was associated with thromboembolism (OR 1.35, CI 1.00-1.80, P = .049). CONCLUSION Cerebral thromboembolic complications after AF radiofrequency catheter ablation are rare. They mostly occur within 48 hours after the procedure and remain without lasting neurologic deficits in the majority of cases. Such complications are associated with peripheral vascular disease, previous stroke, and the CHA2DS2-VASc score.

[Non-fluoroscopic catheter tracking: the MediGuide™ system].

ZusammenfassungIn der Visualisierung von diagnostischen und therapeutischen EP-Kathetern standen bislang die konventionelle Durchleuchtung und 3-D-Mappingsysteme als unabhängige Modalitäten zur Verfügung. Eine neue technologische Plattform (MediGuide™) ermöglicht es nun, eine strahlungsfreie Katheterdarstellung projiziert auf kurze Fluoroskopie-Loops zu erreichen, wodurch die räumliche Auflösung der 3-D-Mappingsysteme mit einer fluoroskopischen Darstellung der Katheter kombiniert werden kann. Zudem kann durch Unterlegung mit Angiographien eine permanente Visualisierung der anatomischen Zielstruktur gewährleistet werden. Wir berichten über die Erfahrungen mit der weltweit ersten MediGuide™-Anlage für die verschiedenen Indikationsfelder in der Elektrophysiologie. Vom typischen Vorhofflattern über Vorhofflimmern bis hin zu ventrikulären Tachykardien und der Implantation von LV-Elektroden im Rahmen von CRT-Implantationen. In einem ersten Schritt konnte unter der Verwendung von diagnostischen Kathetern gezeigt werden, dass sich die Durchleuchtungszeiten bereits dramatisch reduzieren ließen. Die Prozedurdauer wurde nicht wesentlich erhöht und auch eine Zunahme der Komplikationsrate wurde nicht verzeichnet. Seit Mai 2012 sind auch Ablationskatheter mit der MediGuide™-Technologie verfügbar und erste vollständig nicht fluoroskopische Ablationsprozeduren sind erfolgt.AbstractConventional fluoroscopy is the main technology for intracardiac device tracking in interventional cardiovascular procedures. For therapy delivery it carries the advantage of being able to instantaneously localize the device and its spatial relationship with respect to the moving target organ. However, besides the associated X-ray exposure, fluoroscopy only provides 2D orientation. For treatment of complex cardiac anatomies and substrates such as in interventional electrophysiology, 3-D mapping technologies have been introduced to facilitate spatial, anatomic, and electrical orientation. A new technological platform (MediGuide™) offers the option to continuously display the catheter tip on a prerecorded cine-loop allowing better anatomic understanding of the underlying substrate. We describe our initial experience using the system with diagnostic catheters only and the first procedures with the MediGuide™ equipped ablation catheter (available since May 2012). We could show a significant decrease of fluoroscopy time in all types of procedures with comparable procedure times. No increase in complication rates was observed.Conventional fluoroscopy is the main technology for intracardiac device tracking in interventional cardiovascular procedures. For therapy delivery it carries the advantage of being able to instantaneously localize the device and its spatial relationship with respect to the moving target organ. However, besides the associated X-ray exposure, fluoroscopy only provides 2D orientation. For treatment of complex cardiac anatomies and substrates such as in interventional electrophysiology, 3-D mapping technologies have been introduced to facilitate spatial, anatomic, and electrical orientation. A new technological platform (MediGuide(™)) offers the option to continuously display the catheter tip on a prerecorded cine-loop allowing better anatomic understanding of the underlying substrate. We describe our initial experience using the system with diagnostic catheters only and the first procedures with the MediGuide(™) equipped ablation catheter (available since May 2012). We could show a significant decrease of fluoroscopy time in all types of procedures with comparable procedure times. No increase in complication rates was observed.

Prevalence and predictors of low voltage zones in the left atrium in patients with atrial fibrillation

Aims To describe the extent and distribution of low voltage zones (LVZ) in a large cohort of patients undergoing ablation for paroxysmal and persistent atrial fibrillation (AF), and to explore baseline predictors of LVZ in these patients. Methods and results Consecutive patients who underwent a bipolar voltage map guided AF ablation, were enrolled. Voltage maps were conducted for each patient using 3-dimensional electroanatomical mapping system and LVZ were defined as areas of bipolar voltage < 0.5 mV. A total of 539 patients (309 male, age 65 ± 10 years) were included. Low voltage zones was present in 58 out of 292 patients with paroxysmal and 134 out of 247 persistent AF (P < 0.001). The area of LVZ was larger in patients with persistent as compare to paroxysmal AF, 5 cm2 (IQR 3-18.6) vs. 12.1 cm2 (IQR 3.6-28.5), P = 0.026, respectively. In the multivariate analysis age (OR 1.07, 95%CI 1.05-1.10, P < 0.001), female gender (OR 2.18, 95%CI 1.38-3.43, P = 0.001), sinoatrial node dysfunction (OR 3.90, 95%CI 1.24-12.21, P = 0.020), larger surface area of left atrium pr. cm2 (OR 1.01, 95%CI 1.00-1.02, P = 0.016), and persistent AF (OR 5.03, 95%CI 3.20-7.90, P<0.001) were associated with presence of LVZ. Conclusion In a large cohort of patients undergoing ablation for AF, the prevalence of LVZ was higher and LVZ areas larger in patients with persistent as compared with paroxysmal AF. The most frequent localization of LVZ was anterior wall, septum and posterior wall. Presence of LVZ was associated with higher age, female gender, larger LA surface area, and sinoatrial node dysfunction.

Current rare indications and future directions for implantable loop recorders.

The scope of application for implantable loop recorders has shifted away from the evaluation of unclear palpitations and syncope episodes to more complex conditions. This article focuses on rare indications of growing importance such as rhythm monitoring after ablation of atrial fibrillation or after cryptogenic stroke. Furthermore, forthcoming applications in various clinical settings are described, e. g., arrhythmia detection after myocardial infarction, after catheter-based valve interventions, in heart failure, and in cardiomyopathies. Enhancement of the capabilities of implantable loop recorders could broaden their fields of use.ZusammenfassungDer Einsatzbereich für implantierbare Ereignisrekorder hat sich von der Abklärung unklarer Palpitationen und Synkopen zu komplexeren Zuständen verlagert. Der vorliegende Artikel setzt einen Schwerpunkt auf gegenwärtig noch seltene Indikationen, die zunehmend an Bedeutung gewinnen, wie beispielsweise Rhythmusüberwachung nach Ablation von Vorhofflimmern und nach kryptogenem Insult. Darüber hinaus werden zukünftige Anwendungen in verschiedenen klinischen Situationen beschrieben, z. B. Arrhythmiedetektion nach Myokardinfarkt, nach kathetergestützten Klappeninterventionen, bei Herzinsuffizienz und bei Kardiomyopathien. Weiterentwicklungen des Funktionsumfangs implantierbarer Ereignisrekorder könnten deren Anwendungsgebiete noch ausdehnen.

Telemedizin in der ICD-Therapie@@@Remote control in ICD therapy

ZusammenfassungDer Nutzen der ICD-Therapie bei der Behandlung maligner Rhythmusstörungen ist in zahlreichen Studien eindrucksvoll belegt worden. Mit der jährlich steigenden Zahl an Neuimplantationen wächst auch der Bedarf an ambulanten Nachsorgen, die derzeit ambulant in 3–6-monatlichen Abständen erfolgen. Die telemedizinische Übermittlung relevanter ICD-Daten stellt eine Möglichkeit dar, den Nachsorgeaufwand für den nachbetreuenden Kardiologen, die Anfahrtskosten für den Patienten und das Zeitintervall vom Auftreten technischer oder medizinischer Probleme bis zum Ergreifen adäquater Maßnahmen zu reduzieren. Es konnte in mehreren Studien belegt werden, dass die telemedizinische Nachsorge von ICD-Patienten sicher durchführbar ist und darüber hinaus den Zeitaufwand für Patient und Arzt relevant reduziert. In Zukunft wird die Frage zu beantworten sein, ob durch den Einsatz telemedizinischer Übertragungstechnologien über die alleinige Device-Nachsorge hinausgehende Diagnose- und Therapiemöglichkeiten geschaffen werden können, die ein weitaus komplexeres klinisches Management der überwiegend herzinsuffizienten Patientenpopulation der ICD-Träger ermöglichen könnten.AbstractIn several studies, ICD therapy has been shown to be an effective treatment option for patients suffering from or being at risk of malignant ventricular arrhythmias. Given the increasing rate of ICD implantations with the need for in-office interrogations at least twice a year, the number of follow-up visits is constantly growing. Remote transmission of relevant ICD data is a way to reduce follow-up burden for the physician, travel costs for the patient, and the time delay between onset of medical or device problems and an adequate physician response. In several studies, it has been demonstrated that remote ICD follow-up is safe and reduces follow-up resources for both the patient and the physician. With ongoing studies, the questions of whether remote ICD interrogations can offer additional diagnostic and therapeutic options that go beyond pure device follow-up and allow for a more complex management of ICD patients, who in fact represent a large percentage of the heart failure population, will have to be answered.In several studies, ICD therapy has been shown to be an effective treatment option for patients suffering from or being at risk of malignant ventricular arrhythmias. Given the increasing rate of ICD implantations with the need for in-office interrogations at least twice a year, the number of follow-up visits is constantly growing. Remote transmission of relevant ICD data is a way to reduce follow-up burden for the physician, travel costs for the patient, and the time delay between onset of medical or device problems and an adequate physician response. In several studies, it has been demonstrated that remote ICD follow-up is safe and reduces follow-up resources for both the patient and the physician. With ongoing studies, the questions of whether remote ICD interrogations can offer additional diagnostic and therapeutic options that go beyond pure device follow-up and allow for a more complex management of ICD patients, who in fact represent a large percentage of the heart failure population, will have to be answered.

Remote control in ICD therapy

ZusammenfassungDer Nutzen der ICD-Therapie bei der Behandlung maligner Rhythmusstörungen ist in zahlreichen Studien eindrucksvoll belegt worden. Mit der jährlich steigenden Zahl an Neuimplantationen wächst auch der Bedarf an ambulanten Nachsorgen, die derzeit ambulant in 3–6-monatlichen Abständen erfolgen. Die telemedizinische Übermittlung relevanter ICD-Daten stellt eine Möglichkeit dar, den Nachsorgeaufwand für den nachbetreuenden Kardiologen, die Anfahrtskosten für den Patienten und das Zeitintervall vom Auftreten technischer oder medizinischer Probleme bis zum Ergreifen adäquater Maßnahmen zu reduzieren. Es konnte in mehreren Studien belegt werden, dass die telemedizinische Nachsorge von ICD-Patienten sicher durchführbar ist und darüber hinaus den Zeitaufwand für Patient und Arzt relevant reduziert. In Zukunft wird die Frage zu beantworten sein, ob durch den Einsatz telemedizinischer Übertragungstechnologien über die alleinige Device-Nachsorge hinausgehende Diagnose- und Therapiemöglichkeiten geschaffen werden können, die ein weitaus komplexeres klinisches Management der überwiegend herzinsuffizienten Patientenpopulation der ICD-Träger ermöglichen könnten.AbstractIn several studies, ICD therapy has been shown to be an effective treatment option for patients suffering from or being at risk of malignant ventricular arrhythmias. Given the increasing rate of ICD implantations with the need for in-office interrogations at least twice a year, the number of follow-up visits is constantly growing. Remote transmission of relevant ICD data is a way to reduce follow-up burden for the physician, travel costs for the patient, and the time delay between onset of medical or device problems and an adequate physician response. In several studies, it has been demonstrated that remote ICD follow-up is safe and reduces follow-up resources for both the patient and the physician. With ongoing studies, the questions of whether remote ICD interrogations can offer additional diagnostic and therapeutic options that go beyond pure device follow-up and allow for a more complex management of ICD patients, who in fact represent a large percentage of the heart failure population, will have to be answered.In several studies, ICD therapy has been shown to be an effective treatment option for patients suffering from or being at risk of malignant ventricular arrhythmias. Given the increasing rate of ICD implantations with the need for in-office interrogations at least twice a year, the number of follow-up visits is constantly growing. Remote transmission of relevant ICD data is a way to reduce follow-up burden for the physician, travel costs for the patient, and the time delay between onset of medical or device problems and an adequate physician response. In several studies, it has been demonstrated that remote ICD follow-up is safe and reduces follow-up resources for both the patient and the physician. With ongoing studies, the questions of whether remote ICD interrogations can offer additional diagnostic and therapeutic options that go beyond pure device follow-up and allow for a more complex management of ICD patients, who in fact represent a large percentage of the heart failure population, will have to be answered.