Name: reduction of iatrogenic atrial septal defects with an anterior and inferior transseptal puncture site when operating the cryoballoon ablation catheter
Uploaded: 2015-06-15T14:00:00.000+00:00
Duration: 8 min
Description: Watch this Scientific Journal Video about Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter at JoVE

该研究发表在美国心脏协会会议:摘要17990 AHA 2013年赞助的开放获取视频是由美敦力PLC部分支持。

伦理声明:在这些检查执行的所有方法和程序是典型的和标准的护理中的数据收集的这个时间段。知情同意从所有病人获得的，和当地机构审查委员会的批准被授予两项研究。 1.房间隔访问注意:程序的方法和技术现在已经在一些出版物6-11得到很好的描述，并且这里使用的cryoballoon消融策略是类似于出版的描述。 <ol><li>检查患者的房颤消融手术当天经食管超声心动图。使用超声心动图经食管成像评估LA血栓存在或形成。 </li><li>重新计划消融与LA血栓存在任何病人，并纠正患者抗凝治疗策略。 </li><li>建立病人的镇静与使用全身麻醉（用剂如异丙酚）或清醒镇静（含剂如静脉注射芬太尼和谙练）。在这两种方法镇静，不要使用代理麻痹，使膈神经监测可以消融过程中被使用。 </li><li>在AF消融过程，使用ICE指导的穿刺导管与穆林斯型护套。使用ICE指导隔垫来定位穿刺针，避免穿刺主动脉，并以防止意外LA侧壁针头穿刺（通过检查期间间隔穿刺针"隆起"的距离）12。 注:在传统FO位置，穿刺接入点是在最薄室间隔组织深度邻近其由"隆起"下，ICE成像的穿刺针的隔膜（ 图1）评估了隔膜的中心。 </li><li>对于IL穿刺位置，输入低于传统FO大约1厘米坐e和在一个前间隔位置（ 图1;图A和B）。白细胞介素位置是通过ICE和透视的评估发现，一旦FO网站成立。 <ol><li>用冰面上成像来定义IL位置的入口点。扫ICE图像前向二尖瓣值的平面定义站点的前位置。 </li><li>下位置将依赖于IL，其为三角形的横截面。将穿刺针穿刺在该三角区的中心。 </li></ol></li><li>通过进一步弯曲穿刺针约半英寸，从这个远端尖端促进IL穿刺。弯针定制对LAO视图下腔静脉入右心房的接近角。使用更多的针的弯曲时的接近角是垂直的而不是水平的患者的身体轴线。 <ol><li>或者，使用射频穿刺业务承包商E要促进IL位置技术;然而，唯一的标准穿刺针被用于该研究。 </li></ol></li><li>立即间隔穿刺后，用病人体重为基础的协议管理肝素推注，然后给补充剂量肝素的整个维持350和400秒之间的活性凝血时间的目标的过程。 </li><li>建立穿刺访问路线与穿刺针与导丝交换。 </li></ol> 2. Cryoballoon消融<ol><li>使用导丝引入cryoballoon护套。然后部署cryoballoon导管和专用内腔圆形映射导管送入洛杉矶通过cryoballoon护套。 </li><li>在每个cryoballoon消融，膨胀cryoballoon和提前过来内腔圆形标测导管这是有线向PV口。 </li><li>注入5〜10毫升的不透射线造影剂（isovue 300）通过量小时cryoballoon导管内腔。 </li><li>通过使用造影剂的滞留注射在气囊的远端尖端后确认cryoballoon到光伏闭塞。 <ol><li>另外（或者可选地），使用缺乏围绕球囊前表面流动作为闭塞的指标的确认下彩色血流多普勒cryoballoon到光伏闭塞ICE成像。 </li></ol></li><li>启动cryoballoon冷冻一旦闭塞通过按cryoconsole的"开始"按钮确立。这一行动将推动cryorefrigerant到cryoballoon导管并启动冷冻。 </li><li>在右路的PV，使用诊断导管在右心房/上腔静脉连接处并将其定位踱步正确的膈神经。 </li><li>踱步膈神经在20mA振幅和2.0毫秒脉冲宽度，并监视由人工检测膈收缩的膈神经功能。立即终止，如果膈NE任何消融RVE功能减退，延迟或丢失。 </li><li>提供至少两冻结，每次持续120至180秒，而使用的内腔圆形映射导管监测通过入口和出口块检测的实时和后消融PVI。 </li><li>一旦出入口块建立在每一个PV，撤销cryoballoon，护套和内腔圆形标测导管。 </li><li>使用标准的医疗保健停在血管入口点出血，并通过医院的协议，其中可能包括抗心律失常药物抗凝药物治疗和指导患者出院。 </li></ol>

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利益冲突:迈克尔·瑞奇 - 无;安德鲁曾雅妮 - 无;海美敦力Lim-有限公司的员工;保罗王 - 无;威尔伯苏 - 研究和酬金;美敦力公司，AtriCure，圣犹达医疗。

此研究中观察到，使用的前下方穿刺部位方法导致的93％的患者不要求额外的焦点消融的辅助局灶性消融导管来实现急性程序PVI。通过比较，停止AF试验报告的83％的速度急性程序PVI当只有cryoballoon导管用4。当在STOP AF 4被用来辅助焦点消融导管获得了97.6％的急性程序PVI的速度递增，并停止自动对焦研究过程中一个典型的穿刺针穿刺被设在FO位置。然而，最近，急性PVI的更高的速率已经使用第二代cryoballoon导管，其不需要完美cryoballoon到光伏轴向对准以实现PVI 6-11时报告。 观察（即使用将IL站点间隔穿刺的导致cryoballoon和PV之间的更小的角度）可解释成功的高度自穿刺部位是更可能是在相同的水平下的PV。的cryoballoon导管和外鞘偏转结果为cryoballoon到光伏口的定位这有利于缓解闭塞的更直接的路径这个小的角度。与此相反，cryoballoon和PV之间更大的角度典型地使得光伏更难以实现的闭塞，因此导致降低PVI。因此，以前的研究（与第一代cryoballoon导管）已经描述了利用cryoballoon的"曲棍"的方式配置的时，穿刺部位是以上下的PV 13,14的水平。这个程序运动（曲棍球棒）是没有必要与第二代cryoballoon当IL穿刺部位采用。 在虚拟心脏内重建（ 图4），所述cryoballoon导管取尖锐TURn至到达从FO穿刺位置右路的PV。与传统的FO穿刺部位，以达到完全闭塞所需的cryoballoon到光伏角度是131°，32°，206°，329°，右上PV（RSPV），左上PV（LSPV），右下PV（RIPV）和左下PV（LIPV），分别。相比之下，下部的IL穿刺场地允许cryoballoon到光伏闭塞角度达到完全阻塞，在121°，45°，182°，和349°。当比较实现cryoballoon闭塞所需的角度，前部和下穿刺部位的机械优点变得很明显。 此外，通过直接比较，这项研究表明，IL位置有统计学比FO穿刺部位在预防急性IASD通过多普勒血流对ICE为更好地监测。急性左到右分流中的给定一个FO transsepta 100％的患者中检测到升穿刺，而这是研究与IL穿刺部位时，患者减少到33％的税率。一个看似显而易见的解释是，更厚，更肌隔，在前壁，下的做法，允许夯实组织破坏和极小化。由比较薄壁FO不具有足够的组织通过组织接触，一旦15星期五室间隔门户已经建立建立闭合。但是，进一步的随访检查是必要的，以确定穿刺进入诱导IASDs的长期持续性。通过系统地检查穿刺接入位置，本研究能够证明使用前下方的方式接近的IL的优点。 目前的研究只能通过多普勒血流显像ICE检查IASD急性实例。长期和持续左到右心房分流是更相关的病人的整体健康。它是可能的（并且很可能），其大部分（如果不是人L）的患​​者表现出较长期的随访护理没有不利心脏症候。另外，虽然IL间隔穿刺确实有某些有利的在这项研究中，重要的是澄清，许多其他使用cryoballoon医师有利用FO穿刺位置成功消融过程是很重要的，并且穿刺入口的最终点应该在医生的选择医疗决定。这项研究是从一个单一的中心回顾检查的临床结果，因此该技术的重复性和效用可以在很大程度上依赖于医生的用户体验。 当选择使用IL位置，ICE成像是必需的建议。越前和IL间隔穿刺的劣位置可能会使患者心房穿孔和/或主动脉穿刺的风险较高。 ICE的成像是至关重要的间隔穿刺和重要的过程中保持安全，它可以为used的确定是好后方的主动脉根部的位置。在向前方向，ICE成像将确保间隔穿刺不是太前壁而不是靠近科克三角形解剖学，这将避免任何潜在的房室结损伤。而在使用本研究报告的所有373 ICE程序，没有以间隔穿刺相关的并发症，并且有房间隔解剖和左心房血肿形成已射频焦尖消融导管在使用过程中被前面所提到的任何实例15。 通过定位穿刺进入点到低于FO的典型水平大约1厘米，有一个cryoballoon导管房颤消融的操作期间被引入几个优点。的间隔穿刺部位和四个肺静脉之间的改进的角导致cryobal之间的更好的对准和一机械优点卢恩和PV口。作为一个直接的结果是，"气球只是"PVI率为强劲。此外，下部穿刺部位（在较厚的隔膜）减少急性IASDs，其可具有在长期护理病人进一步影响的发生率。 最后，这项研究的医生在这个定性检查发现，这是比较容易通过IL位置推15套神父相比，FO位置。 （通过一个更核心的刚性心脏结构推）机械优势促进大鞘通道入口时，更控制运动过程中推。相比之下，FO立场是容易出现"悬"，因为在15套神父的"步升"项更薄（合规）隔。

Haïssaguerre 等人最初描述的肌肉袖子环绕肺静脉（PVS）是心律失常和发起房颤（AF）的症状1的维护。由于最初的描述中，肺静脉隔离（PVI）已成为AF 2的治疗的导管消融策略的基石。随后，导管消融装置，已建成以方便PVI与各种能源3，并且这些专用PVI导管已有时称为"单次"消融导管。目前，cryoballoon是唯一被FDA批准单次导管，其被批准用于药物治疗无效的，复发性，并对症阵发性AF 4的治疗。与众不同的是，cryoballoon系统允许一个简单的方法来PVI有良好的安全性。在关键的STOP AF IDE试验中，受试者69.9％，无房颤的一年期&lt;SUP&gt; 4。 交付cryoballoon导管到的PV需要穿刺插管用15法国（FR）外径可控护套。典型的间隔穿刺设置在卵圆窝（FO），这是该隔膜的最薄的部分执行，并且对FO可以是一个简单的访问点到室间隔的左心房（LA），因为稀疏的（或减少）组织深度。该cryoballoon系统采用膨胀的气球导管导丝的交付，和导丝可以是传统的J-尖端设计或提出建（多极圆形内部气囊腔）标测导管的cryoballoon导管系统。然而，从焦点消融导管不同，则cryoballoon导管使用前的气球表面推压周围光伏口其导致同时递送低温热能向接触心房组织并最终病变的形成心房组织。因此，一个cryoballoon导管接近角是更前和下（近下缘（IL））可促进机械的优势就消融下肺静脉时，力矢量推特别。此外，IL穿刺位置可能潜在地减少医源性房间隔缺损（IASD）后cryoballoon程序5的出现。 在这项研究中，主要假设是，经中隔穿刺的位置可能影响急性IASD的同时利用腔内超声（ICE）检查被检测立即消融后经由穿刺多普勒频率。另外，第二个目的是评估急性速率PVI，同时使用前下方穿刺接近角（IL位置）实现了与cryoballoon系统。通过检查两个备用间隔穿刺位置（FO与IL），这项研究试图确定哪种方法是最有益的用c时ryoballoon系统AF通过PVI治疗。 案例分析从2012年8月至2013年8月，这个研究回顾了200例谁在一个单一的专门心脏护理中心被称为一个cryoballoon房颤消融手术。上述所有的患者给予一个cryoballoon AF消融，其中该间隔穿刺位置是靠近的IL。通过回顾性调查，这些患者的图表是检查，以确定急性PVI的速度，这是可以实现通过cryoballoon消融导管的奇异不使用辅助的AF消融导管的使用。此图审查考试是一个单臂，单中心，数据收集。此外，在同一时期收集，173例患者进行了检查前瞻性调查相比间隔穿刺通过多普勒血流动力学的急性后程序ICE成像网站（FO与IL）。这种比较分析是一个双一RM，3:1集合（IL到FO穿刺部位，分别地），单中心前瞻性检查。在这两种评价，所有患者症状和药物难​​治性房颤病史。 患者选择在这两种评价，入选标准为所有患者有症状房颤，一种药物治疗难治性房颤的一个等级的记载病史I或III类抗心律失常药物，以及AF消融治疗策略，其中包括一个cryoballoon导管PVI作为主PV消融方法。排除标准是18岁以下的患者，超过90岁的患者，谁曾以前LA消融患者，谁曾以前间隔穿刺进入，谁需要房颤消融双穿刺方法的患者，或患者永久性房颤。所有的cryoballoon消融手术是在一个单一的有经验的心脏护理中心，以及超过600进行的呐喊oballoon程序完成在这家医院，所有患者均采用第二代cryoballoon导管治疗。

<table><tbody><tr><td>Arctic Front Advance Cardiac CryoAblation Catheter</td><td>Medtronic, Inc.</td><td>2AF284</td><td>28 mm Cryoballoon catheter</td></tr></tbody></table>

reduction of iatrogenic atrial septal defects with an anterior and inferior transseptal puncture site when operating the cryoballoon ablation catheter

该cryoballoon导管消融房颤（AF）触发了左心房（LA），并通过穿刺进入肺静脉（PVS）。典型的房间隔穿刺部位是卵圆窝（FO） - 房间隔上最薄的部分。一个潜在的有利穿刺部位，对于cryoballoon，是近下缘（IL）。本研究探讨替代穿刺部位附近的IL，这可能会降低医源性急性房间隔缺损（IASD）的频率。此外，该研究评估利用IL位置急性肺静脉隔离（PVI）的成功率。 200例患者经回顾性急性PVI的成功率与IL穿刺部位进行评估。一个额外的128 IL穿刺的患者进行了比较，45 FO穿刺患者通过执行多普勒腔内超声（ICE）消融后去除外皮掌握房间隔后，以评估穿刺流。后拔除鞘管和多普勒成像ICE，42 128（33％），IL穿刺患者表现出急性穿刺流，而45 45（100％），FO间隔穿刺患者有急性穿刺流。在FO和IL站点之间的尖锐穿刺流量检测差异有统计学显著（P &lt;0.0001）。此外，186的200例（与IL间隔穿刺）并不需要额外的消融（多个），并通过一个"cryoballoon只有"技术来实现的一种急性PVI。伊尔间隔穿刺网站cryoballoon AF消融是调解PVI在所有四个肺静脉的有效位置。此外，相对于对FO将IL穿刺位置可以降低急性穿刺流多普勒ICE的发生率。潜在的IL穿刺部位以后可能会减少并发症IASD后cryoballoon程序。

200例患者接受了回顾性分析都领到了附近的IL位置的间隔穿刺。检查的设备清单和消融记录用于患者建立了实现PVI与cryoballoon导管的奇异使用的比例。 173例的附加组进行了评估，并测试的穿刺进入位置的差分的使用。数据被收集在3:1的方式，由此128患者进行检查以将IL穿刺位置，并相对于45例谁一个FO穿刺部位。急性IASD率FO与IL穿刺位置由多普勒成像ICE评估，后来由Fisher精确统计检验进行比较。在这项研究中，统计显着性设定为P &lt;0.05。 在本组200例患者接受了IL网站间隔穿刺，186例（93％），不需要额外的焦点用法射频消融导管。各期间cryoballoon消融四个肺静脉的代表性透视图像中示出了图2A-D。检查图2的说明，在cryoballoon导管和可操纵鞘使用全导管和外鞘偏转实现PVI在低劣的PV均不是必需的。此外，通过在所有328例IL间隔穿刺劣质光伏冷冻过程中分析了导管和外鞘偏转角显示，全cryoballoon导管鞘偏转从来没有要实现一个cryoballoon到PV闭塞。 去除皮消融后的剧烈ICE多普勒血流分析表明，所有45例谁了FO穿刺部位有房间隔流的证据与小房间隔缺损一致的左到右心房流体运动（QP-Q报告比大于1）。与此相反，128例42（32.8％）与IL穿刺部位证明除去穿刺鞘（ 图3）后的急性多普勒ICE流动。在IL和FO间隔穿刺部位之间的急性多普勒血流检测，差异有统计学显著费舍尔的精确检测（P &lt;0.0001）。 最后，373例患者在整个检查过程中，没有患者出现心包积液或心包填塞。此外，既没有隔夹层也不血肿地层，观察或者FO或IL穿刺技术。 ICE和透视成像过程中的所有程序的结合定性证明了IL位置往往有充足的距离从附近组织穿刺较低的入口位置。在IL位置时，穿刺针将指向二尖瓣而非左心耳或左心房屋顶。两个后两者左心房横结构的需要多个成像注意当utilizi纳克FO穿刺的方法。 图1显示了FO的"隆起"可以帮助确定在附近的IL劣质和前穿刺位置。这个前下方穿刺位置可以允许以最小的导管和/或鞘偏转所使用的cryoballoon导管。具体地，在较低的PV消融，该IL穿刺位置允许cryoballoon导管和每个PV的管状部之间的"更直接的"对准。这表现在图2中，PV和cryoballoon导管之间的这种对准允许闭塞力的最直接传递是必要确保一个完整和周缘损伤时创建围绕cryoballoon消融过程期间每个PV。当有所述cryoballoon和PV接触之间的间隙被创建不全cryoballoon病变套，的whICH导致冷气球和组织之间的转移减少。 图3示出一个cryoballoon消融过程期间使用的IL位置的另一个急性优点。当对FO位置被使用时，cryoballoon和护套的立即撤销往往会离开左到右血液分流在间隔穿刺位置，它可以与彩色血流多普勒成像观察急性。可替代地，白细胞介素位置经中隔穿刺通常在隔膜的较厚部分。因此，当cryoballoon和鞘被从洛杉矶除去，有较少的左到右的血液分流，并在某些情况下，有由彩色血流多普勒成像观察时没有检测到血液分流。 <img alt="图1" src="/files/ftp_upload/52811/52811fig1highres.jpg" width="700" /> 图1:FO和IL间隔穿刺ICE图像。 </str翁&gt;（A）在荧光透视观察时在卵圆窝穿刺条目的传统安置将展示隔垫组织的"隆起"由于组织的稀疏性。 （B）在劣缘的劣质和前穿刺方法将使用cryoballoon导管时提供一个机械优势。黄色箭头指示的间隔穿刺位置。 <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/52811/52811fig1highres.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/52811/52811fig2highres.jpg" width="700" /> 图2:冷冻消融的肺静脉 Cryoballoon安置在四个肺静脉（PV）在每个静脉作为鉴于透视窦气球定位的位置。所有光伏被认为在老挝的定位与劣质和前transseptal入口位置（IL位置）。 （A）中的左上PV为一个从穿刺条目几乎直上的方法，并且它通常是因为便于导线的方法的该被烧蚀的第一PV。 （ 二）左下PV将使用护套偏转来达到合适的PV到球囊阻断。 （C和D）膈神经起搏将用于在右路消融监测神经功能。两者的PV将用鞘偏转，以及右下的PV（RIPV）将典型使用最高偏转度。但是，请注意与劣质和前办法，RIPV消融并不要求是在cryoballoon系统提供的最大变形能力。黄括号内为cryoballoon和蓝色括号内为导向鞘。 <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/52811/52811fig2highres.jpg" target="_blank">请点击此处查看该图的放大版本。</a><img alt="图3" src="/files/ftp_upload/52811/52811fig3highres.jpg" width="700" /> 图3:ICE成像彩色血流多普勒从心腔内超声多普勒图像。注意多普勒血流的比较卵圆窝穿刺位置（A）相比，下缘位置（B）时也就是导管去除在所述隔膜后的存在量。黄色箭头指示的间隔穿刺位置。 <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/52811/52811fig3highres.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <img alt="图4" src="/files/ftp_upload/52811/52811fig4highres.jpg" width="500" /> 图4:cryoballoon方式进入肺静脉角 FO的IL与穿刺locatio虚拟重建。纳秒。该FO穿刺部位达到完全闭塞下面偏转角:131°，32°，206°，329°。通过比较，该IL穿刺部位实现闭塞具有以下的偏转角:121°，45°，182°，和349°。需要注意的是少导管偏转中需要的低劣的PV为IL位置。绿线代表的是从FO网站的cryoballoon导管的方向，和红色线表示从IL网站的cryoballoon方向。 <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/52811/52811fig4highres.jpg" target="_blank">请点击此处查看该图的放大版本。</a>

Watch this Scientific Journal Video about Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter at JoVE

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

这项研究的目的是房颤的治疗cryoballoon导管消融手术过程中表现出间隔穿刺的优先位置。

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 ...

reduction-iatrogenic-atrial-septal-defects-with-an-anterior-inferior

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

13.8K 次观看.  Banner-University Medical Center. 这项研究的目的是房颤的治疗cryoballoon导管消融手术过程中表现出间隔穿刺的优先位置。 

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

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 ...

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

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 ...

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 ...

Three-Dimensional Echocardiographic Method for the Visualization and Assessment of Specific Parameters of the Pulmonary Veins

The dimensions of the pulmonary veins are important parameters when planning pulmonary vein isolation (PVI), especially with the cryoballoon ablation technique. Acknowledging the dimensions and anatomical variations of the pulmonary veins (PVs) may improve the outcome of the intervention. Conventional 2D transoesophageal echocardiography can only provide limited data about the dimensions of the PVs; however, 3D echocardiography can further evaluate relevant diameters and areas of the PVs, as well as their spatial relationship to surrounding structures. In previous literature data, parameters influencing the success rate of PVI have already been identified. These are the left lateral ridge, the intervenous ridge, the ostial area of the PVs and the ovality index of the ostium. Proper imaging of the PVs by 3D echocardiography is a technically challenging method. One crucial step is the collection of images. Three individual transducer positions are necessary to visualize the important structures; these are the left lateral ridge, the ostium of the PVs and the intervenous ridge of the left and right PVs. Next, 3D images are acquired and saved as digital loops. These datasets are cropped, which result in the en face views displaying spatial relationships. This step can also be employed to determine the anatomical variations of the PVs. Finally, multiplanar reconstructions are created to measure each individual parameter of the PVs.
Optimal quality and orientation of the acquired images are paramount for the appropriate assessment of PV anatomy. In the present work, we examined the 3D visibility of the PVs and the suitability of the above method in 80 patients. The aim was to provide a detailed outline of the essential steps and potential pitfalls of PV visualization and assessment with 3D echocardiography.

The dimensions of the pulmonary veins (PV) are important parameters when planning pulmonary vein isolation. 2D transoesophageal echocardiography can only provide limited data about the PVs; however, 3D echocardiography can evaluate relevant diameters and areas of the PVs, as well as their spatial relationship to surrounding structures.

用于肺静脉特定参数可视化和评估的三维超声心动图方法

The dimensions of the pulmonary veins are important parameters when planning pulmonary vein isolation (PVI), especially with the cryoballoon ablation ...

生物工程

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 ...

Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale (PFO) detection, for patient selection for transcatheter ASD/PFO closure,&#160;for intraoperative guidance and for long-term follow-up. The size, shape, location and the number of the atrial communications schould be determined. The accuracy of PFO detection can be improved by using agitated saline together with maneuvers to transiently increase the right atrial (RA) pressure. The appearance of microbubbles in the left atrium (LA) within 3 cardiac cycles after opacification of the RA is considered positive for the presence of an intracardiac shunt. Three dimensional TEE identifies further septal fenestrations and describes the dynamic morphology of ASD/PFO and atrial septal aneurysm. Follow-up evaluations with TTE is recommended at 1, 6, and 12 months after the procedure, with a subsequent evaluation every year. Previous studies showed an increased incidence of atrial arrhythmias early after device closure. Speckle tracking analysis may help to understand functional left atrial remodeling following percutaneous closure and its impact on atrial arrhythmias.

Transthoracic (TTE) and transesophageal (TEE) echocardiography represent the basic imaging tools for interatrial septum examination. Three dimensional (3D) TEE provides incremental information in the assessment of the interatrial septum. Further advanced echocardiography techniques using speckle tracking echocardiography are applied for sensitive volumetric and functional assessment of the heart chambers.&#160;

经导管闭合前心房通路的超声心动图评估

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale ...

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the left ventricle by draining blood from the left atrium (LA) and returning it to the systemic arterial circulation via the femoral artery. It can provide flows ranging from 2.5-5 L/min depending on the size of the cannula. Here, we discuss the mechanism of action of LAFAB, available clinical data, indications for its use in cardiogenic shock, steps of implantation, post-procedural care, and complications associated with the use of this device and their management.
We also provide a brief video of the procedural component of device therapy, including the pre-placement preparation, percutaneous placement of the device via transseptal puncture under echocardiographic guidance and the post-operative management of device parameters.

The following article describes the stepwise procedure for placement of a device (e.g., Tandemheart) in cardiogenic shock (CS) that is a percutaneous left ventricular assist device (pLVAD) and a left atrial to femoral artery bypass (LAFAB) system that bypasses and supports the left ventricle (LV) in CS.

使用经皮心室辅助装置/左心房至股动脉旁路系统治疗心源性休克

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the ...

Cox-Maze IV Procedure Concomitant with Valvular Surgery In Situs Inversus Dextrocardia: A Single-Center Experience in China

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The use of ablation technologies made the Cox-Maze IV procedure (CMP-IV) technically easier, faster, becoming the gold standard for the surgical treatment of AF. However, the efficacy and safety of CMP-IV in situs inversus dextrocardia are largely unknown. This paper summarizes the CMP-IV procedure performed concomitantly with valvular surgery in patients with situs inversus dextrocardia at this institution.
From February 2016 to September 2020, three dextrocardia patients with persistent AF and valvular diseases were referred to this institution for valvular and CMP-IV surgery. CMP-IV was performed using either cryoablation with a nitrous oxide (N2O)-based cryoprobe or a bipolar radiofrequency clamp and bipolar radiofrequency pen. Mechanical valve replacement or mitral vavuloplasty was performed in another patient in addition to tricuspid annuloplasty. Transmurality of the ablated atrial tissues was evaluated by electron microscopy. Heart function was assessed by transthoracic echocardiography. Cardiac rhythm was monitored by 24 h Holter at 3, 6, 12, 18, 24, and 48 months follow-up. 
All the AF was successfully eliminated in the ablation procedure without recurrence or other complications during hospitalization. The mean bypass and crossclamp times were similar in all the patients. The postoperative ventilator support time, the duration of stay in the ICU, and postoperative residence time were also not significantly different among the patients. Transmural atrial necrosis was detected in the ablated atrial tissues. Sinus rhythm maintenance was achieved at 3, 6, 12, 18, 24, and 48 months follow-up in all the patients. All valve protheses switched freely; no tricuspid regurgitation was observed. The results of the present study demonstrate that the CMP-IV is safe and effective in eliminating AF in dextrocardia patients concomitant with valvular surgery.

We summarize the Cox-Maze IV procedure concomitant with valvular surgery performed in patients with situs inversus dextrocardia at this institution.

Cox-Maze IV手术与瓣膜手术在位内与右旋心动过速中同时进行:中国的单中心经验

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The use of ablation technologies made the Cox-Maze IV procedure (CMP-IV) technically ...