Raffaella Marazzi

Reduced fluoroscopy exposure during ablation of atrial fibrillation using a novel electroanatomical navigation system: a multicentre experience.

AIMSnCatheter ablation of atrial fibrillation (AF) focuses on pulmonary vein (PV) ablation with or without additional atrial substrate modification. These procedures require significant fluoroscopy exposure. A new 3D non-fluoroscopic navigation system (CARTO(®) 3 System, Biosense Webster, CA, USA) that allows precise location visualization of diagnostic and ablation catheters was evaluated for its impact on fluoroscopic exposure during AF ablation procedures.nnnMETHODS AND RESULTSnTwo groups of patients were treated by our centres for drug refractory AF. One group was treated using the new CARTO(®) 3 system to guide catheter ablation (Group A, 117 patients). The other group was treated using the CARTO(®) XP system (Biosense Webster) 3 months previously (Group B, 123 patients). For both groups, circumferential PV ostia ablation was performed; PV isolation was validated using a circular catheter placed at each ostium. There was no difference in any clinical characteristics (age, sex, AF type, left atrium diameter and volume, and heart disease) among the two study groups. The mean number of PVs identified and isolated per patient was similar in both groups, as were the mean procedural duration and radiofrequency time. However, mean fluoroscopic time was significantly reduced in Group A (15.9±12.3 min) as compared with Group B (26±15.1 min) (P < 0.001).nnnCONCLUSIONnThis multicentre observational study demonstrates a significant reduction of fluoroscopy exposure using a new 3D non-fluoroscopic mapping system to guide AF catheter ablation.

Superiority of Simulator-Based Training Compared With Conventional Training Methodologies in the Performance of Transseptal Catheterization

OBJECTIVESnThis study aims to compare the performance of electrophysiology fellows in transseptal catheterization (TSP-C) after conventional (Conv-T) or simulator training (Sim-T).nnnBACKGROUNDnCurrent training for TSP-C, an increasingly used procedure, relies on performance on patients with supervision by an experienced operator. Virtual reality, a new training option, could improve post-training performance.nnnMETHODSnFellows inexperienced in TSP-C were enrolled and randomly assigned to Conv-T or Sim-T. The post-training performance of each fellow was evaluated and scored in 3 consecutive patient-based procedures by an experienced operator blinded to the fellows training assignment.nnnRESULTSnFourteen fellows were randomized to Conv-T (n = 7) or to Sim-T (n = 7) and, after training, performed 42 TSP-Cs independently. Training time was significantly longer for Conv-T than for Sim-T (median 30 days vs. 4 days; p = 0.0175). The Conv-T fellows had significantly lower post-training performance scores (median 68 vs. 95; p = 0.0001) and a higher number of recurrent errors (median 3 vs. 0; p = 0.0006) when compared with Sim-T fellows.nnnCONCLUSIONSnThe TSP-C training with virtual reality results in shorter training times and superior post-training performance.

Simulator training reduces radiation exposure and improves trainees' performance in placing electrophysiologic catheters during patient-based procedures

BACKGROUNDnCurrently, training in interventional electrophysiology is based on conventional methodologies, and a paucity of data on the usefulness of simulation in this field is available.nnnOBJECTIVEnThe purpose of this study was to evaluate the impact of simulator training on trainees performance in electrophysiologic catheter placement during the early phase of their learning curve.nnnMETHODSnInexperienced electrophysiology fellows were considered. A hybrid high-fidelity simulator (Procedicus VIST, version 7.0, Mentice AB Gothenburg, Sweden for Biosense Webster) was used. The following parameters were evaluated in 3 consecutive patient-based procedures before and after two training sessions of at least 1.5 hours on the simulator: (1) ability to place catheters in conventional recording/pacing sites (coronary sinus, His-bundle area, high right atrium, and right ventricular apex); (2) amount of help provided by the supervisor (scale from 1-3; 3 for maximal help); (3) fluoroscopy time; and (4) positioning time.nnnRESULTSnSeven fellows performed 168 catheter placements during 42 patient-based procedures with no complications. Comparing parameters before and after simulator training, there was a significant reduction in the mean amount of help and in fluoroscopy and positioning times per placement: from 1.71 ± 1.24 to 0.42 ± 0.68 (P <.001), from 121 ± 88 seconds to 76 ± 54 seconds (P <.001), and from 175 ± 138 seconds to 102 ± 74 seconds (P <.001), respectively. Overall fluoroscopy time per patient decreased from 567 ± 220 seconds to 305 ± 111 seconds (P <.0001). Improvement appeared to be related to simulator training alone and not to the previously performed patient-based procedures.nnnCONCLUSIONnDuring the early phase of the trainees learning curve, simulator training significantly improves the independent trainees performance with reduction in radiation exposure.

Use of a novel sharp-tip, J-shaped guidewire to facilitate transseptal catheterization.

AIMSnTransseptal catheterization (TSP-C) is a demanding procedure and at the same time one of the key points of atrial fibrillation ablation, an increasingly diffused procedure. This study prospectively evaluates the usefulness of a novel sharp-tip, J-shaped 0.014 transseptal guidewire (TSP-GW) to facilitate TSP-C in case of resistant atrial septum (AS).nnnMETHODS AND RESULTSnConsecutive patients undergoing TSP-C for arrhythmia ablation in a single centre were considered for the study. TSP-C was performed according to a standardized technique. The criterion to use the TSP-GW was a resistant AS, defined as inability to perforate the fossa ovalis by applying moderate pressure to a standard Brockenbrough needle. The TSP-GW was inserted in the needle lumen and advanced to puncture the AS and enter the left atrium; subsequently, the transseptal assembly was advanced over the TSP-GW. Double transseptal puncture was routinely performed for ablation of atrial fibrillation. Eighty-one patients (54 males, 27 females; mean age 54 +/- 17 years, range 12-81) undergoing TSP-C were enrolled; 132 TSP-C procedures were planned and accomplished. Nineteen patients (23%) in 27 procedures showed a resistant AS. In all these procedures, the TSP-GW was safely and successfully used to accomplish the TSP-C. In patients with a resistant AS, only a significantly lower prevalence of structural heart disease was observed when compared with controls. No complication related to TSP-C was observed.nnnCONCLUSIONnThe TSP-GW facilitates TSP-C in 23% of the patients, in whom a resistant AS is encountered. In this population, there was no clinical predictor of such anatomy.

Role of three-dimensional imaging integration in atrial fibrillation ablation

Atrial fibrillation is the most common arrhythmia and in symptomatic patients with a drug-refractory form, catheter ablation aimed at electrically disconnecting the pulmonary veins (PVs) has proved more effective than use of antiarrhythmic drugs in maintaining sinus rhythm during follow-up. On the other hand, this ablation procedure is complex, requires specific training and adequate clinical experience. A main challenge is represented by the need for accurate sequential positioning of the ablation catheter around each veno-atrial junction to deliver point-by-point radiofrequency energy applications in order to achieve complete and persistent electrical disconnection of the PVs. Imaging integration is a new technology that enables guidance during this procedure by showing a three-dimensional, pre-acquired computed tomography or magnetic resonance image and the relative real-time position of the ablation catheter on the screen of the electroanatomic system. Reports in the literature suggest that imaging integration provides accurate visual information with improvement in the procedure parameters and/or clinical outcomes of the procedure.

Successful Selective Ablation of Fast Atrioventricular Node Pathway by Cryothermal Energy Application

This paper reports the experience of successful cryoablation of fast atrioventricular nodal pathway in a patient with recurrent atrioventricular nodal reentrant tachycardia after previous unsuccessful attempts of slow pathway ablation. Slow formation of a permanent lesion by cryothermal energy application allowed precise modulation of atrioventricular nodal conduction until the endpoints of complete fast pathway ablation were met with long‐term cure of the arrhythmia.

The effects of gender on electrical therapies for the heart: procedural considerations, results and complications: A report from the XII Congress of the Italian Association on Arrhythmology and Cardiostimulation (AIAC)

Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects.

Optimization of catheter/tissue contact during pulmonary vein isolation: the impact of atrial rhythm

AimsnDuring pulmonary vein isolation (PVI), even if operators are aware of the contact force (CF), its values may greatly vary and the impact of cardiac rhythm has not been thoroughly investigated yet. This study aims at assessing the actual values of CF, the applications with suboptimal CF, and the impact of cardiac rhythm on CF during PVI.nnnMethods and resultsnTwenty patients undergoing point-by-point PVI with a CF-sensing catheter were considered. CF target was between 6 and 40u2009g. The mean CF per application (mCF) was evaluated and considered suboptimal ifu2009≤5u2009g. The real-time graphic of CF was also evaluated and classified as pulsatile if regular variations synchronous with the atrial rate were seen; otherwise it was irregular. To achieve PVI, 1458 applications were delivered; 287 (19.68%) had suboptimal mCF. A great variability of mCF was seen according to anatomy, operators and patients. Compared to applications in atrial fibrillation (AF), those in sinus rhythm (SR) showed a higher median value of mCF (11 vs. 9u2009g; Pu2009=u20090.0099) and a lower percentage of suboptimal mCF (17.95% vs. 25.15%; Pu2009=u20090.0051). Compared to the irregular, the pulsatile pattern, almost exclusively observed in SR, was associated with higher mCF (14.69u2009±u20098.77 vs. 10.79u2009±u20097.89u2009g; Pu2009<u20090.0001) and fewer suboptimal applications (8.02% vs. 27.73%; Pu2009<u20090.0001).nnnConclusionnDuring PVI, several factors influence CF, which, despite optimization attempts, can be suboptimal in ∼20% of the applications. However, CF is higher in SR than in AF and this is strictly associated with a pulsatile pattern of instant CF values.

The effects of gender on electrical therapies for the heart: Procedural considerations, results and complications

Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects.

Validation of a High-Fidelity Electrophysiology Simulator and Development of a Proficiency-Based Simulator Training Program.

Introduction Simulator training can potentially provide high-intensity training in electrophysiology (EP) without compromising patient safety. We assessed the construct validity of a novel EP simulator (ANGIO Mentor; Simbionix) and developed proficiency-based scores for clinical EP simulator training. Methods Two European training centers participated. Participants were grouped on the basis of years of EP experience and (for a subset) subjectively scored clinical catheter manipulation skills. Each participant attempted the simulators 5 modules 3 times. These modules focus on catheter manipulation in 3-dimensional models, ranging from geometric shapes to fluoroscopic contracting cardiac models, with performance scored by the system on the basis of attainment of preset targets. Using these scores, targets were formulated for basic EP training. Results Twenty-eight participants were included (13 with subjectively scored catheter manipulation). Scores for participants with less than 1-year EP experience (group 1) were significantly lower for each of the attempts at the modules (P < 0.002). For group 1 only, scores improved with subsequent attempts (P < 0.005). In 4 of the 5 modules, scores of group 1 were significantly lower than the more experienced groups (P < 0.0005). Participants with subjectively scored above-average catheter manipulation skills also had higher scores in 4 of the 5 modules (P < 0.05). Target scores for a proficiency-based training program were generated from the median scores for each module for those with 1-year experience or more. Conclusions Scores attained in the simulator can distinguish those with less than 1-year EP experience and those with above-average catheter manipulation skills. Consequently, target scores have been generated for a proficiency-based training program.