Ulrike Wetzel

Electromagnetic Versus Fluoroscopic Mapping of the Inferior Isthmus for Ablation of Typical Atrial Flutter A Prospective Randomized Study

BackgroundRadiofrequency catheter ablation within the tricuspid annulus–inferior caval vein isthmus can cure typical atrial flutter. The target for ablation, nonetheless, is relatively wide, and standard ablation procedures may require significant exposure to radiation. Methods and ResultsA total of 50 patients (mean age, 58±11 years) with typical atrial flutter were prospectively randomized to receive isthmus ablation using conventional fluoroscopy for catheter navigation (group I, n=24) or electromagnetic mapping (group II, n=26). Complete bidirectional isthmus block was verified with double potential mapping. If complete isthmus block could not be achieved after 20 radiofrequency pulses or 25 minutes of fluoroscopy, the patients were switched to the other group. Eight patients from group I (33%) but only 1 patient from group II (4%) were switched. Overall, complete isthmus block was achieved in 47 of 50 patients (94%). The overall fluoroscopy time, including the placement of the diagnostic catheters, was 22.0±6.3 minutes in group I and 3.9±1.5 minutes in group II (P <0.0001). The fluoroscopy time needed for isthmus mapping was 17.7±6.5 minutes in group I and 0.2±0.3 minutes in group II (P <0.0001). ConclusionsElectromagnetic mapping during the induction of linear lesions for the ablation of atrial flutter permitted a highly significant reduction in exposure to fluoroscopy while maintaining high efficacy, and it allowed the time required for fluoroscopy to be reduced to levels anticipated for diagnostic electrophysiological studies.

Catheter ablation of ventricular tachycardia in remote myocardial infarction: substrate description guiding placement of individual linear lesions targeting noninducibility.

Introduction: The aim of this study was to describe the arrhythmogenic substrate in postinfarction patients with ventricular tachycardia (VT) guiding the placement of individual strategic linear lesions transecting all potential isthmuses using target area maps with limited mapping points to allow short procedure times.

Steerable Versus Nonsteerable Sheath Technology in Atrial Fibrillation Ablation A Prospective, Randomized Study

Background— Steerable sheath technology is designed to facilitate catheter access, stability, and tissue contact in target sites of atrial fibrillation (AF) catheter ablation. We hypothesized that rhythm control after interventional AF treatment is more successful using a steerable as compared with a nonsteerable sheath access. Methods and Results— One hundred thirty patients with paroxysmal or persistent drug-refractory AF undergoing their first ablation procedure were prospectively included in a randomized fashion in 2 centers. Ablation was performed by 10 operators with different levels of clinical experience. Treatment outcome was measured with serial 7-day Holter ECGs and additional symptom-based arrhythmia documentation. Single procedure success (freedom from AF and/or atrial macroreentrant tachycardia) was significantly higher in patients ablated with a steerable sheath (78% versus 55% after 3 months, P=0.005; 76% versus 53% after 6 months, P=0.008). Rate of pulmonary vein isolation, procedure duration, and radiofrequency application time did not differ significantly, whereas fluoroscopy time was lower in the steerable sheath group (33±14 minutes versus 45±17 minutes, P<0.001). Complication rates showed no significant difference (3.2% versus 5%, P=0.608). On multivariable analysis, steerable sheath usage remained the only powerful predictor for rhythm outcome after 6 months of follow-up (hazard ratio, 2.837 [1.197 to 6.723]). Conclusions— AF catheter ablation using a manually controlled, steerable sheath for catheter navigation resulted in a significantly higher clinical success rate, with comparable complication rates and with a reduction in periprocedural fluoroscopy time. Clinical Trial Registration— URL: http://clinicaltrials.gov. Unique identifier: NCT00469638.

Catheter ablation of atrial fibrillation using remote magnetic catheter navigation: a case–control study

AIMS To compare the acute and the 6 month outcome of catheter ablation of atrial fibrillation (AF) using irrigated tip magnetic catheter and remote magnetic cathter navigation (RMN) with manual catheter navigation (MCN) in patients with paroxysmal and persistent AF. METHODS AND RESULTS In this retrospective analysis 356 patients (235 male, mean age: 57.9 ± 10.9 years) with AF (70.5%, paroxysmal) who underwent catheter ablation between August 2007 and May 2008 using either RMN (n = 70, 46 male, mean age: 57.9 ± 10.1 years, 50% paroxysmal) or MCN (n = 286, 189 male, mean age: 58.0 ± 13.9 years, 75.5% paroxysmal) were included. All patients completed an intensive follow-up strategy. Complete pulmonary vein isolation was achieved in 87.6 and 99.6% of patients in RMN and MCN groups, respectively (P < 0.05). The procedure, fluoroscopy, and radiofrequency application times were 223 ± 44 vs. 166 ± 52 min (P < 0.0001), 13.7 ± 7.8 vs. 34.5 ± 15.1 min (P < 0.0001), and 75.4 ± 20.9 vs. 53.2 ± 21.4 min (P < 0.0001) in RMN and MCN groups, respectively. Seven (10.0%) and 28 (9.8%) patients in RMN and MCN groups received antiarrhythmic medications during the follow-up (P = 0.96). All the patients completed the 6 month follow-up. Freedom from AF at 6 months was achieved in 57.8 and 66.4% of the patients in RMN and MCN groups, respectively (P = 0.196). In patients without previous AF catheter ablation procedure the freedom from AF at 6 months were 68.2 and 60.5% in the MCN and RMN groups, respectively (P = 0.36). CONCLUSION Catheter ablation using irrigated tip magnetic catheter and RMN is an effective and safe method for catheter ablation of AF. Compared to manual catheter navigation, the procedure and radiofrequency application times were longer and fluoroscopy time was shorter in the RMN group compared with the MCN group.

Color-coded three-dimensional entrainment mapping for analysis and treatment of atrial macroreentrant tachycardia

BACKGROUND Mapping and ablation of atrial macroreentrant tachycardia focus on activation mapping with identification of the area of slow conduction. OBJECTIVE The purpose of this study was to evaluate a new concept for analysis and treatment of macroreentrant tachycardia based on color-coded three-dimensional (3D) entrainment mapping and subsequent placement of strategic lesion lines. METHODS Twenty-six patients presented with macroreentrant tachycardia (cycle length 329 +/- 70 ms). Using nonfluoroscopic systems (CARTO 12, NavX 14), sequential mapping of the target atrium was performed. On each mapping point, the 3D location was paired with color-coded entrainment information so that the reentrant circuit could be directly visualized. RESULTS Procedural duration, fluoroscopy time, and radiofrequency time measured 181 +/- 58, 37 +/- 19, and 31 +/- 17 minutes, respectively. Thirty-nine macroreentrant tachycardias were ablated: perimitral 9, around pulmonary vein ostium 6, through left atrial roof 5, around left atrial appendage 3, right atrial cavotricuspid isthmus dependent 6, around right atrial scar 2, around superior vena cava 1, within the septum 5, and within the coronary sinus 2. Tachycardia termination and noninducibility of any macroreentrant tachycardia was the procedural end-point. In case of left atrial macroreentrant tachycardia, pulmonary vein isolation was completed. Follow-up with serial 7-day Holter covered 302 +/- 82 days. Two (8%) patients experienced recurrences of a pretreated macroreentrant tachycardia. CONCLUSION In patients with macroreentrant tachycardia, color-coded 3D entrainment mapping is feasible to accurately determine and visualize the 3D location of the reentrant circuit and to plan a strategic ablation line concept. That approach, not targeting the area of slow conduction of the circuit, resulted in excellent procedural success (100%), with long-term freedom from any tachycardia recurrences in 88% of patients.

Long‐Term Efficacy of Single Procedure Remote Magnetic Catheter Navigation for Ablation of Ischemic Ventricular Tachycardia: A Retrospective Study

Long‐Term Efficacy of Single Procedure Remote Magnetic Catheter Navigation.

Catheter Ablation of Scar-Related Ventricular Tachycardia in Patients with Electrical Storm Using Remote Magnetic Catheter Navigation

Background: A remote magnetic navigation system (MNS) has been used for ablation of ventricular arrhythmias. However, irrigated tip catheter has not been evaluated in large series of patients.

Radiofrequency ablation of accessory pathways. Contemporary success rates and complications in 323 patients.

Das Ziel dieser Studie war es, 17 Jahre nach der ersten Hochfrequenzstrom (HF)-Katheterablation einer akzessorischen Bahn, die gegenwärtig erreichten Erfolgsraten der HF-Ablation akzessorischer Leitungsbahnen zusammen mit den Prozedurdaten und Komplikationsraten zu analysieren. Da bisherige Untersuchungen über die Lokalisation akzessorischer Leitungsbahnen noch auf der alten Nomenklatur basieren, war es ein weiteres Ziel, die Verteilung akzessorischer atrioventrikulärer Leitungsbahnen unter Gebrauch der 1999 von ESC und NASPE eingeführten neuen Nomenklatur zu analysieren. Es wurden die Daten aller Patienten, bei denen zwischen dem 1. 1. 2000 und dem 31. 12. 2003 am Herzzentrum Leipzig eine akzessorische Bahn abladiert wurde, retrospektiv analysiert. Über einen Zeitraum von 4 Jahren wurden an unserem Zentrum insgesamt 336 akzessorische Bahnen bei 323 Patienten abladiert. Gemäß der neuen Nomenklatur wurden die Bahnen eingeteilt in links gelegene, rechts gelegene, septale und paraseptale akzessorische Bahnen. 188 der Bahnen (56%) lagen links, 41 (12%) rechts, 64 (19%) (infero-)paraseptal und 31 (9%) septal oder parahissär. 12 Bahnen (4%) zeigten atypische Verläufe und/oder Eigenschaften und konnten somit nicht klar zugeordnet werden. Die mittlere Prozedurdauer betrug 68±37 Minuten. Die Erfolgsrate betrug insgesamt 98%. Bei 289 der Patienten (89%) konnte die akzessorische Bahn in einer einzigen Untersuchung erfolgreich abladiert werden. Komplikationen traten bei weniger als 2% der behandelten Patienten auf. 17 Jahre nach Durchführung der ersten HF-Katheterablation einer akzessorischen Leitungsbahn hat sich diese als hocheffektive und komplikationsarme kurative Behandlungsmethode etabliert. Die Erfolgsraten sind in den letzten 10 Jahren weiter gestiegen und die Komplikationsraten konnten weiter gesenkt werden. Mit der Einführung der neuen Nomenklatur ist es für den interventionellen Elektrophysiologen leichter geworden, die Lokalisation einer akzessorischen Bahn gemäß der realen anatomischen Lage im Körper festzulegen. 17 years ago the first radiofrequency catheter ablation of an accessory pathway (AP) was performed. The aim of this study was to describe the contemporary success rates and procedure related complication rates of radiofrequency (RF) ablation of accessory pathways (APs). In addition, the present study describes the anatomical distribution of APs according to the new nomenclature introduced by NASPE and ESC in 1999. The analysis included all patients, who underwent RF ablation of an AP in the Heart Center Leipzig between January 2000 and December 2003. Over a 4 year period 336 APs were ablated in 323 patients. 201 APs (60%) presented with antegrade and retrograde conduction and showed preexcitation on ECG. For the remaining 135 APs (40%), only retrograde conduction over the AP was documented. According to the new nomenclature APs were classified as left-sided, right sided, septal and paraseptal APs. 188 APs (56%) were located on the left, 41 (12%) on the right, 64 (19%) in the paraseptal space and 31 APs (9%) presented with a septal or parahissian localization, respectively. Because of atypical course and/or characteristics 12 APs (4%) could not be classified. Ablation of all pathways were successful in 315 patients (98%). In 289 patients (89%) success was achieved within a single ablation session. The left-sided pathways had a re-intervention rate of 5%, which was significantly lower compared to the remaining localizations. The highest re-intervention rate was observed in the septal APs (23%). Complications were observed in less than 2% of all treated patients. 17 years after the first RF catheter ablation of an AP this therapy is established as a highly effective procedure. The success rate has improved to 98% and the complication rate has been minimized to less than 2%. The most frequent localization of APs is left posterior. Left sided APs also presented with the lowest re-intervention rate. The introduction of the new nomenclature in 1999 by NASPE and ESC has simplified the description of the exact anatomical localization of an AP.

Radiofrequency ablation of accessory pathways

Das Ziel dieser Studie war es, 17 Jahre nach der ersten Hochfrequenzstrom (HF)-Katheterablation einer akzessorischen Bahn, die gegenwärtig erreichten Erfolgsraten der HF-Ablation akzessorischer Leitungsbahnen zusammen mit den Prozedurdaten und Komplikationsraten zu analysieren. Da bisherige Untersuchungen über die Lokalisation akzessorischer Leitungsbahnen noch auf der alten Nomenklatur basieren, war es ein weiteres Ziel, die Verteilung akzessorischer atrioventrikulärer Leitungsbahnen unter Gebrauch der 1999 von ESC und NASPE eingeführten neuen Nomenklatur zu analysieren. Es wurden die Daten aller Patienten, bei denen zwischen dem 1. 1. 2000 und dem 31. 12. 2003 am Herzzentrum Leipzig eine akzessorische Bahn abladiert wurde, retrospektiv analysiert. Über einen Zeitraum von 4 Jahren wurden an unserem Zentrum insgesamt 336 akzessorische Bahnen bei 323 Patienten abladiert. Gemäß der neuen Nomenklatur wurden die Bahnen eingeteilt in links gelegene, rechts gelegene, septale und paraseptale akzessorische Bahnen. 188 der Bahnen (56%) lagen links, 41 (12%) rechts, 64 (19%) (infero-)paraseptal und 31 (9%) septal oder parahissär. 12 Bahnen (4%) zeigten atypische Verläufe und/oder Eigenschaften und konnten somit nicht klar zugeordnet werden. Die mittlere Prozedurdauer betrug 68±37 Minuten. Die Erfolgsrate betrug insgesamt 98%. Bei 289 der Patienten (89%) konnte die akzessorische Bahn in einer einzigen Untersuchung erfolgreich abladiert werden. Komplikationen traten bei weniger als 2% der behandelten Patienten auf. 17 Jahre nach Durchführung der ersten HF-Katheterablation einer akzessorischen Leitungsbahn hat sich diese als hocheffektive und komplikationsarme kurative Behandlungsmethode etabliert. Die Erfolgsraten sind in den letzten 10 Jahren weiter gestiegen und die Komplikationsraten konnten weiter gesenkt werden. Mit der Einführung der neuen Nomenklatur ist es für den interventionellen Elektrophysiologen leichter geworden, die Lokalisation einer akzessorischen Bahn gemäß der realen anatomischen Lage im Körper festzulegen. 17 years ago the first radiofrequency catheter ablation of an accessory pathway (AP) was performed. The aim of this study was to describe the contemporary success rates and procedure related complication rates of radiofrequency (RF) ablation of accessory pathways (APs). In addition, the present study describes the anatomical distribution of APs according to the new nomenclature introduced by NASPE and ESC in 1999. The analysis included all patients, who underwent RF ablation of an AP in the Heart Center Leipzig between January 2000 and December 2003. Over a 4 year period 336 APs were ablated in 323 patients. 201 APs (60%) presented with antegrade and retrograde conduction and showed preexcitation on ECG. For the remaining 135 APs (40%), only retrograde conduction over the AP was documented. According to the new nomenclature APs were classified as left-sided, right sided, septal and paraseptal APs. 188 APs (56%) were located on the left, 41 (12%) on the right, 64 (19%) in the paraseptal space and 31 APs (9%) presented with a septal or parahissian localization, respectively. Because of atypical course and/or characteristics 12 APs (4%) could not be classified. Ablation of all pathways were successful in 315 patients (98%). In 289 patients (89%) success was achieved within a single ablation session. The left-sided pathways had a re-intervention rate of 5%, which was significantly lower compared to the remaining localizations. The highest re-intervention rate was observed in the septal APs (23%). Complications were observed in less than 2% of all treated patients. 17 years after the first RF catheter ablation of an AP this therapy is established as a highly effective procedure. The success rate has improved to 98% and the complication rate has been minimized to less than 2%. The most frequent localization of APs is left posterior. Left sided APs also presented with the lowest re-intervention rate. The introduction of the new nomenclature in 1999 by NASPE and ESC has simplified the description of the exact anatomical localization of an AP.

Individually tailored left ventricular lead placement: lessons from multimodality integration between three-dimensional echocardiography and coronary sinus angiogram

AIMS Non-responder rates for cardiac resynchronization therapy (CRT) vary from 11% to 46%. Retrospective data imply a better outcome with stimulation of the latest contracting left ventricular (LV) region. Our study analysed the feasibility, safety and clinical outcome of prospectively planned LV lead placement at the site of latest mechanical activation. METHODS AND RESULTS Thirty-eight heart failure patients with CRT indication were assessed by three-dimensional (3D) transoesophageal echocardiography and rotation angiography of the coronary sinus (CS). Both images were merged into a single 3D-model to identify CS target veins close to the site of latest mechanical activation. Subsequently, LV lead deployment was attempted at the desired target position. Patients were clinically and echocardiographically evaluated at baseline, after 3 and 6 months. The area of latest mechanical activation covered 6 ± 2 segments (38 ± 13% of LV surface) and was found lateral in 24 of 37 (65%), anterior in 11 of 37 (30%), inferior in 2 of 37 (5%), and septal in 1 of 37 (3%) patients. In 36 of 37 (97%) patients an appropriate target vein was identified and successful implantation could be performed in 34 of 37 (92%) patients. Among those patients clinical and echocardiographic response was observed in 91% and 81%, respectively. CONCLUSION Individualized lead placement at the latest contracting LV site can be performed safely and successfully in the majority of patients. Initial clinical outcome data are encouraging. Identification of target sites requires multimodality integration between LV wall motion data and CS anatomy. Future developments need to improve those technologies and require randomized data on clinical outcome parameters.