Name: robotic ablation of atrial fibrillation
Uploaded: 2015-05-29T14:00:00.000+00:00
Duration: 11 min 21 s
Description: Watch this Scientific Journal Video about Robotic Ablation of Atrial Fibrillation at JoVE.com

The authors have no acknowledgements.

这里介绍的协议是机器人导管消融RCS的心内科，查理特的标准方法 - Universitätsmedizin柏林，校园魏尔啸。该协议与程序和患者的预后分析批准了查理特的当地伦理委员会 - Universitätsmedizin柏林。 1.远程导管系统（RCS）的<ol><li>附加的机器人臂以手术台，如前7（ 图1）中描述。 注:本RCS由一个远程导管操纵器，这是一个机器人臂可通过遥控器来移动的。 </li><li>将消融导管在RCS的基座。操纵与使用遥控器的导管，而操作医师撑出辐射场7。提前退出，旋转和偏转导管与使用RCS的。 </li></ol> 2。预消融准备<ol><li>放置在手术台上病人，诱导深度镇静咪唑安定（0.03毫克/千克丸）和丙泊酚（连续输液4毫克/公斤/小时）。 </li><li>放置一个温度探头在食管，测量食管的温度，防止食管损伤。 </li><li>附加3D-映射系统的12导联心电图和表面电极到患者的体内。 </li><li>在启动过程之前确保以下材料准备好。 <ol><li>经中隔针（71厘米）和8.5˚FSL0鞘导丝。 A 6 F和7 F25厘米护套。一个decapolar和一个圆形streerable诊断导管。开放式灌溉消融导管消融发生器。 </li><li>此外，确保造影剂针筒和心包托盘可用于急性并发症的治疗。 </li></ol></li><li>定位系统的机器人臂以无菌披盖，并准备使用。装上手持遥控续辊到所述机器人臂（ 图1）。 </li><li>通过获得双侧静脉穿刺的静脉通路与6楼7 F和8.5˚F鞘和放置decapolar诊断导管在冠状窦（CS）。 </li><li>使用8.5˚F长SLO鞘和71厘米穿刺针透视引导下进行间隔穿刺。 </li><li>经隔穿刺后，取出针，并通过在左上肺静脉的经隔鞘引入导丝。然后退了下腔静脉鞘。 </li><li>放置一个8.5˚F长SRO鞘与在左心房（LA）的导线，使用金属丝作为引导到卵圆窝和LA（"一次穿刺，双通路"-technique）。推进开放式灌溉消融导管，通过SR0护套洛杉矶3.5毫米尖端接触力的测量。 </li><li>以下的140国际单位/ kg的推注之间保持3活化凝血时间（ACT）施用肝素的15的UI /公斤/小时的速率00并在整个过程350秒。 </li><li>一旦消融导管已经进入了洛杉矶，引入鞘到洛杉矶为好。除去SLO护套的导丝和扩张器，并放置消融导管在左心室。同时使用消融导管用于高速率心室起搏以提高对比度混浊（LA造影示于图2A）执行LA造影在护套。 </li><li>通过长鞘进入LA（ 图2B中所示的圆形标测导管）推进圆形标测导管。 </li><li>与使用的映射系统的和圆形映射导管执行LA的三维解剖重建。通过移动LA，所有四个肺静脉和左心耳的内表面上的圆形导管，而相对于使用计算机化绘图系统的运动的登记到一个创建LA的三维解剖重建参比电极（COMPLETE 3-D-地图显示在图2C和D）。 </li><li>将圆标测导管在右上PV记录光伏潜力和PVI后确认传导阻滞。退消融导管从左心室到左心房（ 图2B中所示两个导管的目标位置）。 </li><li>悬垂的RCS用无菌盖。定位消融导管的手柄在AMIGO系统的机器人臂。 </li></ol> 3.消融过程<ol><li>执行消融宽胃窦周消融（WACA）采用43℃，最高温度为35 W（间隔）或25 W（后壁），最大功率分别为广告17毫升/分钟的流速。通过机器人臂与使用从辐射场之外的远程控制的操纵的消融导管。 </li><li>由左和右光伏窦口周围创建逐点病灶进行消融。测量接触力DUR荷兰国际集团消融。使用记录在消融导管，消除在环形导管和入口/出口块作为消融端点光伏电图或解离的尖端的局部电描幅值减少。 </li><li>马克在三维重建消融各点。 </li><li>通过记录对PV（入口块）内的环状标测导管的电位和由从PV内起搏而不心房（退出块）的捕获确认为每一个光伏传导阻滞。 </li></ol> 4.消融后程序和患者的恢复<ol><li>停止异丙酚，并删除所有导管。 </li><li>测量活化凝血时间（ACT）和去除笔杆的前施用3000的IE精蛋白如果ACT&gt; 300秒。除去护套和上穿刺部位10分钟，直到出血停止执行手动压缩。放置一个加压包扎在腹股沟，并建议病人静静地躺着8小时。 </li><li>传输不稳定型心绞痛患者核苷酸到一个降压单元和监视器4小时，直至完全反应。 </li><li>管理低分子肝素抗凝直至出院。开始在手术后一天口服抗凝药（华法令或直接口服抗凝血剂）。 </li><li>因为17日之前描述的过程后，在当天进行超声心动图。排除心包积液，并确定瓣膜功能及左室射血分数17。 </li></ol>

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Free access to this article was sponsored by Catheter Robotics, Inc. Alexander Wutzler has received moderate lecture fees from Biotronik and travel grants from Boston Scientific. Leif-Hendrik Boldt has received moderate lecture fees from Catheter Robotics, St. Jude Medical and Boston Scientific.

已经报道由组Haissaguerre那胃窦PVI是治愈性治疗阵发性AF 1,2,10。最近的数据相比，PVI与阵发性房颤药物治疗，结果发现房颤复发率较低PVI后相比，抗心律失常治疗2年后随访11。然而，随着RAAFT-2试验的作者得出结论，这两种类型的治疗后复发率高11。因此，改良的技术是必要的。 它已被讨论过，该手册导管控制可能会导致不准确的导管运动5,7。因此，临床意义，如果消融用机械臂是可行的，有效的。另一方面，增加的稳定性可能会导致严重的并发症，如心脏壁穿孔和邻近结构的伤害。在此前发表的研究报告中，结果表明，左心房映射和PVI与RCS是可行的，有效的。没有大的并发症发生7，确认在机器人消融12,13的安全先前公布的结果。操作透视曝光不降低手术成功率7显著降低。 第一个关键步骤是跨间隔穿刺。有心房壁穿孔和心包填塞一个显著风险以及伤到主动脉。穿刺应在卵圆窝透视引导下，用CS导管具有里程碑意义的风险降到最低执行。下一关键步骤是三维重建。三维图像的精度取决于患者的解剖结构，导管稳定性和病人固定化。因此，足够的耐心镇静关键的是要避免移动文物，并创建一个可靠的形象。第三关键步骤是消融病变的应用。 OPTIMA导管稳定性和壁接触应该是achieVED。 之一的RCS的主要优点（相比于其他机器人系统）是有可能在该过程并返回到机器人消融切换到手动消融。这可以是在壳体解剖学异常或难以结构非常有帮助的（ 例如，左肺静脉的一个共同的口）。操作者可以在困难的​​地区手动执行消融，并使用RCS为剩余的消融部位。因此，从机器人切换到手动消融可能是在手术过程中的困难情况下的解决方案。 如前所述，接触力的测量可以添加有价值的信息为操作7。在这里介绍的情况下，接触力和与使用该映射系统的导管组织接触进行评估。接触力映射可以进一步提高程序14疗效和安全性。 要注意的是很重要的，即尽管我们电子商务RCS某些步骤的程序仍然必须手动进行的，如经隔穿刺和肺静脉内部的环状标测导管的定位。然而，这些步骤通常可以快速进行，并没有必要长时间透视时间。 此外，触觉反馈是在机器人导管消融缺乏。医生必须依靠X线透视，三维重建和接触力的测量。有研究期间房颤消融使用接触力的测量显示，触觉反馈的接触力15的估计非常有限的价值。因此，接触力测量被认为优于触觉疗效方面的反馈。然而，出于安全端点触觉反馈的值（ 例如，预防心房壁穿孔），目前还不太清楚，因为穿孔的发生率较房颤复发发病率由于光伏重新连接要低得多。 Theoretically，接触力测量也应防止过高的力量和后壁穿孔。一个先前的研究发现食管病变的机器人AF消融后16发病率比较高。即使不同的机器人系统，使用和不接触力测定在研究通过Tilz 等人可以至少部分地适用于在我们的协议中使用的RCS的结果。大规模随机前瞻性研究缺失，但与RCS初步经验，大量的研究支持这种观点的机器人消融的RCS是安全的7-9。 在这里，我们提出了一个协议房颤消融机器人。相较于以前的研究中，我们使用的导管与接触力测量，以增加该过程的安全性和有效性。操作者透视曝光可以显著降低。导管的稳定性是最有可能增加，结果是媲美手动消融。此外，ROBO手动间切换抽动消融是容易的，这是RCS的一个独特的方面。总之，消融与使用的RCS可能在将来优化PVI程序，减少操作者暴露于辐射和增加的技术的准确性。因此，机器人消融的RCS是房颤的治疗有前途的方法。

AF是最常见的心律失常为1的患病率 - 2％，在普通人群。症状包括心悸，头晕，呼吸困难和运动能力降低。此外，中风的风险基本上是在房颤患者增多。在过去十年中，元太已成为患者从AF 1,2-患有既定疗效的治疗选择。 PVI的基本原理是PV口周围的圆形病变的应用与射频（RF）能量来创建PV和左心房之间的电传导阻断。这个传导阻滞防止心房纤颤，这是由不规则电活动从PV始发触发。然而，透病变需要达到传导阻滞和应用透病变可以是具有挑战性。再传导和复发导管消融发生在20房颤-的情况下，1,2 40％。 3,4-先决条件。许多技术和消融的方法已被开发，以改善导管的稳定性，streerability和导管 - 组织接触。其中，机器人系统是特别有意义的。的优点和机器人消融原则5-7之前已经讨论。这些系统不仅可以通过最大限度地减少手工导管操作的伪像改善导管的稳定性，而且还具有降低透视曝光的优点为操作，因为系统经由从辐射场外遥控操作。一种新型机器人系统具有远程导管操纵性最近已经出台。这个可行性系统PVI等电程序，如AV-结折返-tachcardia，配件途径或房扑和房颤或ventricula和功效ř心动过速已评估7-9。被示出的显著减少操作者透视曝光相比手册消融的，而所有其他程序参数和成功率在12个月的随访没有显著不同7。 左心房映射和PVI与使用这个新的远程导管系统的过程在这里被呈现。 获得经股静脉血管通路后，使用长经隔套和透视引导下一个经隔针进行式房经隔穿刺。经隔穿刺后，针是除去，导丝是通过在左上肺静脉的经隔鞘的地方。然后在抽回到下腔静脉和消融导管被定位在洛杉矶，使用金属丝作为引导到卵圆窝和LA（"一次穿刺，双通路"-technique）的护套。一旦ablatioÑ​​导管已进入LA，护套向前移动到洛杉矶为好，导丝被去除，消融导管被定位在左心室。被执行的左心房造影在鞘，而消融导管被用于高速率心室起搏来增强对比度混浊。后的LA造影完成后，一个圆形标测导管经由长鞘成LA和如果LA是与使用的映射系统的执行的3-D-解剖重建定位。圆形标测导管定位在右上PV录制光伏潜力和PVI后确认传导阻滞。消融导管绘制从左心室回左心房和消融导管的手柄被定位在AMIGO系统的机器人臂。在消融过程中，操作者操纵经由机器人臂与使用遥控器的消融导管。烧蚀由铬进行进食逐点病变的左和右的光伏窦口周围。传导阻滞是通过记录在圆形标测导管光伏潜力和起搏演习证实。 病例报告在病人有症状的药物难治性阵发性房颤，无严重合并症和没有事先心脏手术执行此过程。执行如下所述的预诊断测试。 诊断，评估和计划房颤的诊断是通过反复动态心电图记录，包括房颤相关性和症状证实（心悸，呼吸困难，运动能力降低）。如果AF被记录和症状报告尽管至少有1抗心律失常药物治疗，PVI被指示为根据实际准则对症药物治疗无效的自动对焦的处理。 PVI定和书面知情同意从患者获得。此前PVI physiCAL检查，实验室检测，经食管和经胸超声心动图被执行，以排除左心房血栓和严重的结构性心脏疾病。在空腹状态下进行下深度镇静PVI程序。维生素K拮抗剂停止消融前5天，低分子量肝素，开始时的国际标准化比率为&lt;2。

<table><tbody><tr><td>Amigo Remote Catheter System</td><td>Catheter Robotics/Boston Scientific</td><td></td><td>Robotic system</td></tr><tr><td>BRK transseptal needle (71 cm)</td><td>St Jude Medical</td><td></td><td>Needle for transseptal puncture</td></tr><tr><td>8.5 F SR0 sheath</td><td>Swartz/St Jude Medical</td><td></td><td>long sheath to access the left atrium and to provide stability for the ablation catheter</td></tr><tr><td>8.5 F SL0 sheath</td><td>Swartz/St Jude Medical</td><td></td><td>long sheath to access the left atrium and to provide stability for the LASSO catheter</td></tr><tr><td>LASSO catheter + cable</td><td>Biosense Webster</td><td></td><td>Circular mapping catheter (7 F) to measure electrical activity in the pulmonary veins</td></tr><tr><td>IBI inquiry decapolar catheter + cable</td><td>St Jude Medical</td><td></td><td>Coronary sinus catheter</td></tr><tr><td>Thermocool SmartTouch</td><td>Biosense Webster</td><td></td><td>open-irrigated ablation catheter (7,5 F) with a 3,5 mm tip and contact force measurement, the tip is heated to apply thermal lesions in the left atril myocardium</td></tr><tr><td>Heparin</td><td>Braun</td><td></td><td>1. heparinized irrgation solution for preparation of the sheath,2. intravenous unfractionated heparin for procedural anticoagulation</td></tr><tr><td>Propofol</td><td>Fresenius</td><td></td><td>Procedural sedation</td></tr><tr><td>Midazolam</td><td>Roche</td><td></td><td>Procedural sedation</td></tr><tr><td>NaCl solution</td><td>Braun</td><td></td><td>Irrigation solution for the ablation catheter</td></tr><tr><td>CARTO</td><td>Biosense Webster</td><td></td><td>Mapping System and contact force measurement; this system allows a 3-D- reconstrcution of the left atrium and navigation of the moving catheter</td></tr><tr><td>UHS-20</td><td>Biotronik</td><td></td><td>Electrical Stimulator for stimulation of cardiac tissue via catehetr tip of the LASSO-, CS- or ablation catheter</td></tr><tr><td>EP Shuttle</td><td>Stockert</td><td></td><td>Ablation Generator for application of energy and thermal lesion via the catheter tip</td></tr><tr><td>6 F sheath</td><td>Terumo</td><td></td><td>sheath to provide femoral access</td></tr><tr><td>Lifepack 15 defibrillator</td><td>Physio Control</td><td></td><td>Defibrillator/monitoring device</td></tr><tr><td>Pericardiocentesis set</td><td>variuous</td><td></td><td>Emergency set</td></tr></tbody></table>

robotic ablation of atrial fibrillation

背景:肺静脉电隔离（PVI）是一个既定的治疗房颤（AF）。在PVI肺静脉（PV）和左心房（LA）之间的电传导块创建。这个传导阻滞防止自动对焦，这是由不规则电活动从PV始发触发。然而，透心房病灶需要其可以是具有挑战性的。再传导和房颤复发发生在20 - 的情况下，40％。机器人导管系统，旨在提高操纵性导管。这里，以一个新的远程导管系统（RCS）的方法，提出了。这篇文章的目的是展示机器人房颤消融的可行性，以新颖的系统。材料和方法:在使用荧光透视引导下长期鞘和针进行式房经隔穿刺。针被移除，并且导丝放置在左上光伏。然后消融导管被定位在洛杉矶，使用鞘和导线作为导到洛杉矶。执行在鞘的LA造影。圆形标测导管通过长鞘进入LA定位并进行三维（3-D）解剖洛杉矶的重建。消融导管的手柄被定位在阿米戈系统的机器人臂和消融过程开始。在消融过程中，操作者操纵经由机器人臂与使用遥控器的消融导管。烧蚀由左和右光伏窦口周围创建逐点病变进行。接触力的测量是在导管尖端，以提供导管 - 组织接触的反馈。传导阻滞是通过记录在圆形标测导管光伏潜力和起搏演习证实。操作员保持了radiationfield消融过程中。结论:新型导管系统允许消融低运营透视暴露较高的稳定性。

该过程的终点是所有的PV完全电气隔离。最近它被证明在119名患者的研究，即程序的参数和结果是不与RCS（N = 40）相比，标准的手动方式（N = 79）的程序显著不同。统计分析（曼-惠特尼U检验）揭示了手术时间（159.1±45.4 与 146±30.1分钟，P = 0.19），总能量传递（78146.3±26992.4 与 87963.9±79202.1 Ws中，P = 0.57无显著差异）和总透视时间（21.2±8.6 与 23.9±5.4分钟，P = 0.15）。然而，操作者透视曝光在RCS组（13.4±6.1 对 23.9±5.4分钟，P &lt;0.001）7中显著降低。 另外，还进行了第一次21例PVI与RCS的分析。患者特征和临床数据在表1中被描绘</STRONG&gt;。此分析表示一个单中心的经验。数据是为一组20例PVI分析（从一个病人的数据是不可用的，由于技术原因）。使用曼 - 惠特尼U型试验进行了程序性参数的统计分析。结果以平均值±标准差（SD）的连续变量和数字和百分比离散变量。 总过程时间为137.3±24.2分钟，总透视时间为26.1±6.1分钟，运营商透视曝光为14.8±6.1分钟。肺静脉隔离（PV）的是在所有患者实现了与使用远程系统的。进行的手术时间，总透视时间和运营商之间的透视暴露时间比较分析的程序与改善成长的经验与技术。案件平均持续时间11 - 20是显著相比，减少案件1 - 10（125.5±18.1 主场迎战149±24.6分钟，P = 0.029），同时降低总透视时间（23.1±6.4 与 28.7±9.3分钟，P = 0.21）和运营商透视曝光时间（12.9±5.35 主场迎战 17±6.48分钟，P = 0.2 ）没有达到显着性（ 图3和4）。没有进行接触力测量。无并发症发生。 这些初步结果表明，左心房映射和PVI是可行和有效的。在肺静脉隔离是在所有的情况下实现的。学习曲线很短，在11-20的情况下一个显著减少手术时间。操作者透视曝光被显着减小。 <img alt="图1" src="/files/ftp_upload/52560/52560fig1.jpg" /> 图1.远程导管系统。附连到导管的表（A和B）和前机械臂（c）后插入消融catheter.Handheld遥控器（D和E）。 <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/52560/52560fig1large.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <img alt="图2" src="/files/ftp_upload/52560/52560fig2.jpg" /> 图左心房2.图像左心房造影左前斜观点与使用SLO鞘的血管造影和消融导管率高心室起搏（A）。环状标测导管定位在右上肺静脉（B）中 。 3-D重建左心房。圆形映射导管中示出的右上肺静脉。左心房示于前-后（C）和右横向（D）的图。 ABL =消融cathe之三，CS =冠状静脉窦导管，LAA =左心耳，LA =左心房，LIPV =左下肺静脉，LSPV =左上肺静脉，RIPV =右下肺静脉，RSPV =右上肺静脉。 <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/52560/52560fig2large.jpg" target="_blank">请点击这里查看该图的放大版本。</a> <img alt="图3" src="/files/ftp_upload/52560/52560fig3.jpg" width="500" /> 图3.程序数据过程1 - 10 与 11 - 20手术时间（A），总透视时间（B），和运营商透视曝光时间（C）的步骤1 - 10，11 - 20。*统计学显著。 <img alt="图4" src="/files/ftp_upload/52560/52560fig4.jpg" /> 图4.程序DUR通货膨胀和总透视时间步骤1 - 20。 <table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"> 基线特征 </td></tr><tr><td>患者数</td><td> 21 </td></tr><tr><td>年龄（年）（SD） </td><td> 64.1（8.5） </td></tr><tr><td>男（％） </td><td> 17（81） </td></tr><tr><td> BMI（SD） </td><td> 28.1（4.1） </td></tr><tr><td>阵发性房颤（％） </td><td> 14（66.7） </td></tr><tr><td>高血压（％） </td><td> 16（76.2） </td></tr><tr><td> CAD（％） </td><td> 5（23.8） </td></tr><tr><td>射血分数（％）（SD） </td><td> 56.9（4.6） </td></tr><tr><td> LA直径（mm）（SD） </td><td> 42.4（4.9） </td></tr></tbody></table> 表1.患者的特征和临床数据的特点及前20例患者的临床资料进行消融房颤与远程cathetER系统在我们的中心。 AF =心房颤动，CAD =冠状动脉疾病，LA =左房，左室射血分数=左心室射血分数

Watch this Scientific Journal Video about Robotic Ablation of Atrial Fibrillation at JoVE.com

Robotic Ablation of Atrial Fibrillation

Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

房颤消融机器人

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

19.5K 次观看.  Charité — Universitätsmedizin Berlin, Campus Virchow. Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

视频: Robotic Ablation of Atrial Fibrillation

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

This report provides a detailed description of a new remote navigation system based on magnetic driven forces, which has been recently introduced as a new robotic tool for human cardiac electrophysiology procedures.

遥控磁导航导管定位准确，实时和心脏电生理消融程序

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

科研

医学

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6.
Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8.
The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16.
Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 18. This device received the Conformit&eacute; Europ&eacute;enne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy 19.
Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding 20 or other warfarin-associated problems.
The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1 21. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.

Catheter ablation is combined with placement of the WATCHMAN Left Atrial Appendage Closure Device to prevent ischemic stroke in a patient with non-valvular atrial fibrillation.

结合消融房颤左心耳封堵

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and ...

Direct Pressure Monitoring Accurately Predicts Pulmonary Vein Occlusion During Cryoballoon Ablation

Cryoballoon ablation (CBA) is an established therapy for atrial fibrillation (AF). Pulmonary vein (PV) occlusion is essential for achieving antral contact and PV isolation and is typically assessed by contrast injection. We present a novel method of direct pressure monitoring for assessment of PV occlusion.
Transcatheter pressure is monitored during balloon advancement to the PV antrum. Pressure is recorded via a single pressure transducer connected to the inner lumen of the cryoballoon. Pressure curve characteristics are used to assess occlusion in conjunction with fluoroscopic or intracardiac echocardiography (ICE) guidance. PV occlusion is confirmed when loss of typical left atrial (LA) pressure waveform is observed with recordings of PA pressure characteristics (no A wave and rapid V wave upstroke). Complete pulmonary vein occlusion as assessed with this technique has been confirmed with concurrent contrast utilization during the initial testing of the technique and has been shown to be highly accurate and readily reproducible.
We evaluated the efficacy of this novel technique in 35 patients. A total of 128 veins were assessed for occlusion with the cryoballoon utilizing the pressure monitoring technique; occlusive pressure was demonstrated in 113 veins with resultant successful pulmonary vein isolation in 111 veins (98.2%). Occlusion was confirmed with subsequent contrast injection during the initial ten procedures, after which contrast utilization was rapidly reduced or eliminated given the highly accurate identification of occlusive pressure waveform with limited initial training.
Verification of PV occlusive pressure during CBA is a novel approach to assessing effective PV occlusion and it accurately predicts electrical isolation. Utilization of this method results in significant decrease in fluoroscopy time and volume of contrast.

Effective pulmonary vein isolation utilizing a cryoballoon depends on complete pulmonary vein occlusion. The point of occlusion can be effectively predicted by direct analysis of pulmonary vein pressure waveform analysis during balloon inflation using a simple and reproducible technique.

直接压力监测准确预测在Cryoballoon消融肺静脉阻塞

Cryoballoon  ablation (CBA) is an established therapy for atrial fibrillation (AF).  Pulmonary vein (PV) occlusion is essential for achieving antral ...

Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that the application of this non-fluoroscopic catheter visualization system (NFCV) reduces fluoroscopy time and dose by 90-95% in a variety of electrophysiology (EP) procedures. This can be of relevance not only to the patients, but also to the nurses and physicians working in the EP lab. Furthermore, in a subset of indications such as supraventricular tachycardias, NFCV enables a fully non-fluoroscopic procedure and allows the lab staff to work without wearing lead aprons. With this protocol, we demonstrate that even complex procedures such as ablations of atrial fibrillation, that are typically associated with fluoroscopy times of &#62;30 min in conventional settings, can safely be performed with a reduction of &#62;90% in fluoroscopy exposure by the additional use of NFCV.

Radiation exposure is an underestimated risk in complex ablation procedures. Here, we describe a protocol to significantly decrease fluoroscopy time and dosage for both the patient and the lab staff by using a novel non-fluoroscopic catheter visualization system.

非透视导管跟踪透视减少介入电

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that ...

Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) &#8211; the atrial septum&#8217;s thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P &#60;0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a &#8220;cryoballoon only&#8221; technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

The goal of this study is to demonstrate the preferential location of transseptal puncture during a cryoballoon catheter ablation procedure for the treatment of atrial fibrillation.

与前伪劣间隔穿刺网站减少医源性房间隔缺损操作Cryoballoon消融导管时，

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical ...

Ablation of Ischemic Ventricular Tachycardia Using a Multipolar Catheter and 3-dimensional Mapping System for High-density Electro-anatomical Reconstruction

Ventricular tachycardia (VT) in patients with ischemic cardiomyopathy mainly results from endocardial scars after myocardial infarction; those scars represent zones of slow conduction that allow the occurrence and maintenance of reentrant circuits. Catheter ablation enables substrate modification of those low voltage areas and thus can help to alter the scar tissue in such a way that arrhythmias cannot appear anymore. Hospitalizations of concerned patients decrease, quality of life and outcome rise. Consequently, VT ablation represents a growing field in electrophysiology, especially for patients with endocardial scars in ischemic heart disease after myocardial infarction. However, ablation of ventricular tachycardia remains one of the most challenging procedures in the electrophysiology lab. Precise scar definition and localization of abnormal potentials are critical for ablation success. The following manuscript describes the use of a multipolar mapping catheter and 3-dimensional (3D) mapping system to create a high density electro-anatomical map of the left ventricle including a precise scar representation as well as mapping of fractionated and late potentials in order to allow a highly accurate substrate modification.

With the following protocol, we provide an approach to Ventricular Tachycardia (VT) ablation using high density mapping with a multipolar catheter and 3D mapping system enhancing the success of the procedure.

采用多极导管三维测图系统进行缺血性室性心动过速的高密度电解剖重建

Ventricular tachycardia (VT) in patients with ischemic cardiomyopathy mainly results from endocardial scars after myocardial infarction; those scars ...

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.

The goal of this protocol is to describe the use of esophageal temperature modulation to counteract esophageal thermal injury from left atrial ablation for the treatment of atrial fibrillation.

在心房颤动治疗中，为食道冷却或加热，以减少左心房消融期间的食管损伤

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most ...

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the esophagus from inadvertent thermal injury. Active esophageal cooling is increasingly being used over traditional luminal esophageal temperature (LET) monitoring, and each approach may influence procedure times and the variability around those times. The objective of this study is to measure the effects on procedure time and variability in procedure time of two different esophageal protection strategies utilizing advanced informatics techniques to facilitate data extraction. Trained clinical informaticists first performed a contextual inquiry in the catheterization laboratory to determine laboratory workflows and observe the documentation of procedural data within the electronic health record (EHR). These EHR data structures were then identified in the electronic health record reporting database, facilitating data extraction from the EHR. A manual chart review using a REDCap database created for the study was then performed to identify additional data elements, including the type of esophageal protection used. Procedure duration was then compared using summary statistics and standard measures of dispersion.&#160;A total of 164 patients underwent radiofrequency PVI over the study timeframe; 63 patients (38%) were treated with LET monitoring, and 101 patients (62%) were treated with active esophageal cooling. The mean procedure time was 176 min (SD of 52 min) in the LET monitoring group compared to 156 min (SD of 40 min) in the esophageal cooling group (P = 0.012). Thus, active esophageal cooling during PVI is associated with reduced procedure time and reduced variation in procedure time when compared to traditional LET monitoring.

This study utilized advanced informatics techniques to compare procedure duration in patients undergoing radiofrequency atrial ablation treated with active esophageal cooling to those treated with traditional luminal esophageal temperature monitoring. Contextual inquiry, workflow analysis, and data mapping were utilized. The findings demonstrated reduced procedure time and variability with active cooling.

通过主动食管冷却减少心房颤动射频消融术的手术时间和可变性

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the ...

Benefits of Cardiac Resynchronization Therapy in an Asynchronous Heart Failure Model Induced by Left Bundle Branch Ablation and Rapid Pacing

It is now well recognized that heart failure (HF) patients with left bundle branch block (LBBB) derive substantial clinical benefits from cardiac resynchronization therapy (CRT), and LBBB has become one of the important predictors for CRT response. The conventional tachypacing-induced HF model has several major limitations, including absence of stable LBBB and rapid reversal of left ventricular (LV) dysfunction after cessation of pacing. Hence, it is essential to establish an optimal model of chronic HF with isolated LBBB for studying CRT benefits. In the present study, a canine model of asynchronous HF induced by left bundle branch (LBB) ablation and 4 weeks of rapid right ventricular (RV) pacing is established. The RV and right atrial (RA) pacing electrodes via the jugular vein approach, together with an epicardial LV pacing electrode, were implanted for CRT performance. Presented here are the detailed protocols of radiofrequency (RF) catheter ablation, pacing leads implantation, and rapid pacing strategy. Intracardiac and surface electrograms during operation were also provided for a better understanding of LBB ablation. Two-dimensional speckle tracking imaging and aortic velocity time integral (aVTI) were acquired to validate the chronic stable HF model with LV asynchrony and CRT benefits. By coordinating ventricular activation and contraction, CRT uniformed the LV mechanical work and restored LV pump function, which was followed by reversal of LV dilation. Moreover, the histopathological study revealed a significant restoration of cardiomyocyte diameter and collagen volume fraction (CVF) after CRT performance, indicating a histologic and cellular reverse remodeling elicited by CRT. In this report, we described a feasible and valid method to develop a chronic asynchronous HF model, which was suitable for studying structural and biologic reverse remodeling following CRT.

The establishment of a chronic asynchronous heart failure (HF) model by rapid pacing combined with left bundle branch ablation is presented. Two-dimensional speckle tracking imaging and aortic velocity time integral are applied to validate this stable HF model with left ventricular asynchrony and the benefits of cardiac resynchronization therapy.

心脏再同步治疗在左束分支消融和快速起搏诱发的异步心力衰竭模型中的益处

It is now well recognized that heart failure (HF) patients with left bundle branch block (LBBB) derive substantial clinical benefits from cardiac ...

生物学

评估食管冷却肺静脉隔离的连续性指数 

Determination of Continuity Index Values in Atrial Fibrillation Ablation with Proactive Esophageal Cooling

Radiofrequency (RF) ablation to perform pulmonary vein isolation (PVI) for the treatment of atrial fibrillation involves some risk to collateral structures, including the esophagus. Proactive esophageal cooling using a dedicated device has been granted marketing authorization by the Food and Drug Administration (FDA) to reduce the risk of ablation-related esophageal injury due to RF cardiac ablation procedures, and more recent data also suggest that esophageal cooling may contribute to improved long-term efficacy of treatment. A mechanistic underpinning explaining these findings exists through the quantification of lesion placement contiguity defined as the Continuity Index (CI). Kautzner et al. quantified the CI by the order of lesion placement, such that whenever a lesion is placed non-adjacent to the prior lesion, the CI is incremented by the number of segments the catheter tip has moved over. 
To facilitate real-time calculation of the CI and encourage further adoption of this instrument, we propose a modification in which the placement of non-adjacent lesions increments the CI by only one unit, avoiding the need to count potentially nebulous markers of atrial segmentation. The objective of this protocol is to describe the methods of calculating the CI both prospectively during real-time PVI cases and retrospectively using recorded case data. A comparison of the results obtained between cases that utilized proactive esophageal cooling and cases that used luminal esophageal temperature (LET) monitoring is then provided.

作者聚焦:通过主动食管冷却改善肺静脉隔离中的病变连续性

This protocol describes the methods used to determine the continuity index in patients undergoing pulmonary vein isolation procedures using radiofrequency ablation and demonstrates the differences in continuity index between ablation procedures using proactive esophageal cooling as compared to procedures using traditional luminal esophageal temperature monitoring.