The role of intracardiac echocardiography in reducing radiation exposure during atrial fibrillation ablation

Aims: Intracardiac echocardiography (ICE) is a relatively young technique used during complex electrophysiology proce-dures, such as atrial fibrillation (AF) ablation. The aim of this study was to assess whether the use of ICE modifies the radia-tion exposure at the beginning of the learning curve in AF ablation. Materials and methods: In this retrospective study, 52 patients, in which catheter ablation for paroxysmal or persistent AF was performed, were included. For 26 patients we used ICE guidance together with fluoroscopy, whereas for the remaining 26 patients we used fluoroscopy alone, all supported by electroanatomical mapping. We compared total procedure time and radiation exposure, including fluoroscopy dose and time between the two groups and along the learning curve. Results: Most of the patients included were suffering from paroxysmal AF (40, 76%), pulmonary vein isolation being performed in all patients, without secondary ablation sites. The use of ICE was associated with a lower fluoroscopy dose (11839.60±6100.6 vs. 16260.43±8264.5 mGy, p=0.041) and time (28.00±12.5 vs. 42.93±12.7 minutes, p=0.001), whereas the mean procedure time was similar between the two groups (181.54±50.3 vs 197.31±49.8 minutes, p=0.348). Radiation exposure was lower in the last 9 months compared to the first 9 months of the study (p<0.01), decreasing gradually along the learning curve. Conclusions: The use of ICE lowers radiation exposure in AF catheter ablation from the beginning of the learning curve, without any difference in terms of acute safety or efficacy. Aware-ness towards closest to zero radiation exposure during electrophysiology procedures should increase in order to achieve better protection for both patient and medical staff.

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P338 The road to zero-fluoroscopy catheter ablation in recurrent paroxysmal atrial fibrillation using ICE: training, learning, getting closer

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.191 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

I A Minciuna ◽

M Puiu ◽

G Cismaru ◽

S Istratoaie ◽

G Simu ◽

...

Keyword(s):

Catheter Ablation ◽

Radiation Exposure ◽

Radiofrequency Catheter Ablation ◽

Procedure Time ◽

Total Procedure Time ◽

The Mean ◽

Group 2 ◽

Total Procedure ◽

Zero Fluoroscopy ◽

Group 1

Abstract INTRODUCTION Catheter ablation is the treatment of choice for patients with recurrent paroxysmal atrial fibrillation (AF) in which antiarrhythmic drug therapy has failed to maintain sinus rhythm. Since its first introduction, intracardiac echocardiography (ICE) has proved to increase the efficacy and reduce complications in AF catheter ablation. One of the main advantages of ICE in the electrophysiology laboratory is the reduction of radiation exposure, for both the patient and the physician. Multiple recent studies have shown the feasibility and safety of zero or near-zero fluoroscopy AF ablation, including transseptal puncture, and outlined the importance of using ICE under the support of 3D mapping systems in reducing radiation exposure. PURPOSE The aim of this study was to show whether the use of ICE reduced the radiation exposure and total procedure time in recurrent paroxysmal AF patients undergoing radiofrequency catheter ablation. METHODS Forty patients that undergone radiofrequency catheter ablation for recurrent paroxysmal AF between January 2018 and May 2019 were included. They were divided in two groups: Group 1 – 20 patients in which ICE was performed and Group 2 – 20 patients in which ablation was performed without ICE guidance. We compared the total ablation time and fluoroscopy dose and time between the two groups. The total ablation time was defined as the time from the groin puncture until the withdrawal of all catheters. RESULTS Among the 40 patients included, 28 were men (70%) and the mean age was 57 years old. The mean procedure time was similar between the two groups (175 ± 52.0 for group 1 and 193 ± 49.9 for group 2, p = 0.33). The difference between the two groups was observed in fluoroscopy dose (9914.13 ± 5018.14 vs. 14561.43 ± 7446.1, p = 0.02) and time (26.04 ± 12.5 vs. 40.52 ± 12.6, p = 0.001). We found that in both groups higher fluoroscopy dose was correlated with higher fluoroscopy time (R = 0.74, p = 0.0001 vs. R = 0.57, p = 0.008) and higher total procedure time (R = 0.63, p = 0.002 vs. R = 0.46, p = 0.03). Furthermore, there was also a correlation between higher fluoroscopy dose and time (R = 0.59, p = 0.005 vs. R = 0.58, p = 0.006). No severe procedure-related complications were recorded. CONCLUSIONS This study shows that the use of ICE for recurrent paroxysmal AF catheter ablation reduces radiation exposure by lowering the fluoroscopy dose and the time of exposure. As a result, by increasing the training and learning curve in low-experienced centers it may finally get us closer to the ideal zero or near-zero fluoroscopy ablation. Abstract P338 Figure. ICE-guided transseptal puncture

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The Impact of Advances in Atrial Fibrillation Ablation Devices on the Incidence and Prevention of Complications

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2018.7.3 ◽

2018 ◽

Vol 7 (3) ◽

pp. 169 ◽

Cited By ~ 5

Author(s):

Fehmi Keçe ◽

Katja Zeppenfeld ◽

Serge A Trines ◽

◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Learning Curve ◽

Radiation Exposure ◽

Procedure Time ◽

Reduce Radiation Exposure ◽

Number Of Patients ◽

Technical Advances ◽

The Impact ◽

Procedural Outcome

The number of patients with atrial fibrillation currently referred for catheter ablation is increasing. However, the number of trained operators and the capacity of many electrophysiology labs are limited. Accordingly, a steeper learning curve and technical advances for efficient and safe ablation are desirable. During the last decades several catheter-based ablation devices have been developed and adapted to improve not only lesion durability, but also safety profiles, to shorten procedure time and to reduce radiation exposure. The goal of this review is to summarise the reported incidence of complications, considering device-related specific aspects for point-bypoint, multi-electrode and balloon-based devices for pulmonary vein isolation. Recent technical and procedural developments aimed at reducing procedural risks and complications rates will be reviewed. In addition, the impact of technical advances on procedural outcome, procedural length and radiation exposure will be discussed.

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Protection of the Esophagus During Catheter Ablation of Atrial Fibrillation

10.22541/au.160735888.80832117/v1 ◽

2020 ◽

Author(s):

Mahmoud Houmsse ◽

Emile Daoud

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Potential Risk ◽

High Frequency ◽

Esophageal Injury ◽

Ablation Procedure ◽

High Occurrence ◽

Af Ablation ◽

Important Concern

Esophageal injury still occurs with high frequency during ablation of atrial fibrillation (AF). The purpose of this study is to provide a review of methods to protect the esophagus from injury during AF ablation. Despite advances in imaging and ablation, the potential risk of esophageal injury during AF ablation remains an important concern with a high occurrence of esophageal injury (≈15%). There have been numerous studies evaluating varied techniques for esophageal protection including active cooling and displacement of the esophagus. These techniques are reviewed in this manuscript as well as the role of esophageal protection in managing patients undergoing AF ablation procedure.

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Role of Intracardiac Echocardiography for Catheter Ablation of Atrial Fibrillation

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2019.11.067 ◽

2020 ◽

Vol 75 (10) ◽

pp. 1244-1245 ◽

Cited By ~ 1

Author(s):

Jian-Fang Ren ◽

Shiquan Chen ◽

David J. Callans ◽

Chenyang Jiang ◽

Francis E. Marchlinski

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Intracardiac Echocardiography

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Abstract 17043: Predictors of Length of Stay Following Catheter Ablation of Atrial Fibrillation

Circulation ◽

10.1161/circ.142.suppl_3.17043 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Sahitya Allam ◽

Evan Harmon ◽

James M Mangrum ◽

David Haines ◽

Nishaki K Mehta

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Linear Regression ◽

Length Of Stay ◽

Multivariate Linear Regression ◽

Procedure Time ◽

Same Day Discharge ◽

Group A ◽

The Mean ◽

Group B

Background: Catheter ablation (CA) of atrial fibrillation (AF) is a safe and effective management strategy for symptomatic AF. Traditionally, patients are observed overnight following CA, but recent data has suggested same day discharge may be feasible with low risk of complications. However, little data is available to predict length-of-stay (LOS) in AF patients undergoing CA. Methods: We conducted a single-center retrospective analysis of 200 consecutive patients undergoing CA at a tertiary care academic center from July 2017 through June 2018. Baseline demographic data, echocardiographic data, procedural characteristics and postprocedural outcomes were collected through chart review. Multivariate linear regression modeling was used to identify factors associated with increased LOS (LOS > 1 day). Results: Among 200 patients, 11.5% (23) of patients had LOS > 1 day (Group B) while the rest were discharged after overnight stay (Group A). The mean ages were similar in Groups A and B (64.8 years and 64.9 years respectively, p = 0.98). The mean LOS was 1.44 ± 1.83 days. Higher proportions of hypertension (p = 0.02), diabetes (p = 0.1), baseline loop diuretic use (p < 0.001), EF < 50% (p < 0.001), increased LA diameter (p = 0.01), longer procedure time (p = 0.03), and recurrent AF following CA (p < 0.001) were noted in Group B patients (Table 1). A multivariate linear regression model demonstrated that procedure time (p = 0.02) and LA diameter (p = 0.04) were positively associated with increased LOS. Conclusion: Identifying risk factors for increased LOS in patients undergoing CA of AF may guide appropriate patient selection for same day discharge. Table 1. Comparison of patients with overnight observation (Group A) and LOS > 1 day (Group B) following AF ablation.

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Abstract 5663: Intracardiac Echocardiography From Within the Left Atrium Improves the Accuracy of Image Integration During Catheter Ablation of Atrial Fibrillation

Circulation ◽

10.1161/circ.118.suppl_18.s_980 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Sheldon M Singh ◽

E. Kevin Heist ◽

David M Donaldson ◽

Theofanie Mela ◽

Jeremy N Ruskin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Left Atrium ◽

Intracardiac Echocardiography ◽

Surface Registration ◽

List Type ◽

Image Integration ◽

Ablation Procedure ◽

Af Ablation ◽

Integration Error

Background: Intracardiac echocardiography (ICE) can be integrated with pre-procedural CT or MR imaging to direct catheter ablation of atrial fibrillation (AF). Prior work has described ICE imaging of the left atrium (LA) with the ICE probe in the RA, but it is feasible to image the LA from an ICE probe placed directly into the LA via a trans-septal puncture performed for the mapping/ablation procedure. The purpose of this study was to determine whether direct LA imaging with ICE results in improved image integration during AF ablation compared with LA imaging indirectly from the RA. Methods: Twenty-five consecutive patients undergoing an AF ablation procedure with the CARTO-Sound system were studied. A 10 French phased array catheter with an embedded CARTO navigation sensor was employed to provide 2D echocardiogram images of the LA - 13 patients underwent imaging from the RA alone and 12 patients from the LA. The accuracy of the image integration was assessed by the average integration error after surface registration and the requirement to take supplementary electroanatomic mapping points to obtain acceptable image integration. Results: Twenty-five patients (56% paroxysmal AF, average LA size = 42±8 mm, average EF = 63±10 %) were examined. There was no difference in the time or number of ultrasound contours required to create a LA anatomic map with ICE imaging from the RA versus the LA (24±17min vs. 24±25min, P=1.0, 24±16 contours vs. 29±18 contours, P=0.5). The average integration error for all patients was 2.19±0.59mm. Direct LA imaging was associated with improved integration error compared to indirect LA imaging from the RA (1.85±0.33mm versus 2.51±0.62mm, P=0.004). Image integration using RA acquired LA images had a tendency to be less accurate resulting in the primary operator acquiring additional registration points to supplement the registration process (patients requiring additional registration points for registration: 3/12 for LA imaging versus 9/13 for RA imaging of the LA, P=0.05). Conclusion: Direct ICE imaging from within the LA is feasible and associated with improved accuracy of image integration during AF ablation.

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The Role of Atrial Fibrosis Detected by Delayed - Enhancement MRI in Atrial Fibrillation Ablation

Current Medical Imaging Formerly Current Medical Imaging Reviews ◽

10.2174/1573405614666180806130327 ◽

2020 ◽

Vol 16 (2) ◽

pp. 135-144 ◽

Cited By ~ 1

Author(s):

Zsuzsanna Kis ◽

Astrid Amanda Hendriks ◽

Taulant Muka ◽

Wichor M. Bramer ◽

Istvan Kovacs ◽

...

Keyword(s):

Atrial Fibrillation ◽

Imaging Modality ◽

Final Analysis ◽

Atrial Fibrosis ◽

Atrial Wall ◽

Af Ablation ◽

Left Atrial Wall ◽

Cmr Imaging

Introduction: Atrial Fibrillation (AF) is associated with remodeling of the atrial tissue, which leads to fibrosis that can contribute to the initiation and maintenance of AF. Delayed- Enhanced Cardiac Magnetic Resonance (DE-CMR) imaging for atrial wall fibrosis detection was used in several studies to guide AF ablation. The aim of present study was to systematically review the literature on the role of atrial fibrosis detected by DE-CMR imaging on AF ablation outcome. Methods: Eight bibliographic electronic databases were searched to identify all published relevant studies until 21st of March, 2016. Search of the scientific literature was performed for studies describing DE-CMR imaging on atrial fibrosis in AF patients underwent Pulmonary Vein Isolation (PVI). Results: Of the 763 citations reviewed for eligibility, 5 articles (enrolling a total of 1040 patients) were included into the final analysis. The overall recurrence of AF ranged from 24.4 - 40.9% with median follow-up of 324 to 540 days after PVI. With less than 5-10% fibrosis in the atrial wall there was a maximum of 10% recurrence of AF after ablation. With more than 35% fibrosis in the atrial wall there was 86% recurrence of AF after ablation. Conclusion: Our analysis suggests that more extensive left atrial wall fibrosis prior ablation predicts the higher arrhythmia recurrence rate after PVI. The DE-CMR imaging modality seems to be a useful method for identifying the ideal candidate for catheter ablation. Our findings encourage wider usage of DE-CMR in distinct AF patients in a pre-ablation setting.

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Posterior circulation stroke: an easily overlooked complication of catheter ablation of atrial fibrillation

BMJ Case Reports ◽

10.1136/bcr-2020-234661 ◽

2020 ◽

Vol 13 (8) ◽

pp. e234661

Author(s):

Tahir Nazir ◽

Mohiuddin Sharief ◽

James Farthing ◽

Irfan M Ahmed

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Treatment Options ◽

Posterior Circulation ◽

Diagnosis And Treatment ◽

Neurological Deficits ◽

Cerebellar Infarction ◽

Af Ablation ◽

Posterior Circulation Stroke ◽

Ventricular Response

Catheter ablation of atrial fibrillation (AF) has established itself as a safe and proven rhythm control strategy for selected patients with AF over the past decade. Thromboembolic complications of catheter ablation are becoming rare in anticoagulated patients with a risk of stroke reported as 0.3%. A particular challenge is posed by clinical presentation due to ischaemic stroke involving the posterior circulation following catheter ablation because of its substantial differences from the carotid territory stroke, making the timely diagnosis and treatment very difficult. It is crucial to keep an index of clinical suspicion in patients presenting with neurological deficits related to vertebrobasilar circulation following ablation. We describe the case of a man who presented with dizziness and palpitations after radiofrequency catheter ablation of AF. He was found to be in AF with a rapid ventricular response. His dizziness was initially attributed to the cardiac dysrhythmia. As his symptoms continued despite heart rate control, he underwent further investigations and was eventually diagnosed with a posterior circulation stroke resulting in left cerebellar infarction. He was treated with antiplatelet therapy and improved significantly over the following few days. We review and present an up-to-date brief literature review on the complications of catheter ablation of AF and describe pathophysiology, clinical features, diagnosis and treatment options for posterior circulation stroke after AF ablation. This case aims to raise awareness among clinicians about posterior circulation stroke after AF ablation.

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B-PO05-104 UTILITY OF ISOPROTERENOL INFUSION DURING CATHETER ABLATION OF ATRIAL FIBRILLATION: INSIGHTS FROM THE UC SAN DIEGO AF ABLATION REGISTRY

Heart Rhythm ◽

10.1016/j.hrthm.2021.06.1023 ◽

2021 ◽

Vol 18 (8) ◽

pp. S414

Author(s):

Omar Mahmoud Aldaas ◽

Douglas Darden ◽

Praneet S. Mylavarapu ◽

Frederick T. Han ◽

Kurt S. Hoffmayer ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

San Diego ◽

Af Ablation ◽

Isoproterenol Infusion

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Randomized comparison between dexmedetomidine–remifentanil and midazolam–fentanyl for deep sedation during catheter ablation of atrial fibrillation

International Journal of Arrhythmia ◽

10.1186/s42444-019-0002-3 ◽

2019 ◽

Vol 20 (1) ◽

Author(s):

Young Choi ◽

Sung-Hwan Kim ◽

Ju Youn Kim ◽

Youmi Hwang ◽

Tae-Seok Kim ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Primary Outcome ◽

Secondary Outcome ◽

Positive Pressure ◽

Efficacy And Safety ◽

Af Ablation ◽

Hemodynamic Compromise ◽

3D Mapping System ◽

Sedative Agents

Abstract Background and objectives The efficacy of dexmedetomidine for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) has not been well established. We evaluated the efficacy and safety of sedation using dexmedetomidine with remifentanil compared to conventional sedative agents during RFCA for AF. Subjects and methods A total of 240 patients undergoing RFCA for AF were randomized to either the dexmedetomidine (DEX) group (continuous infusion of dexmedetomidine and remifentanil) or the midazolam (MID) group (intermittent injections of midazolam and fentanyl) according to sedative agents. Non-invasive positive pressure ventilation was applied to all patients during the procedure. The primary outcome was patient movement during the procedure resulting in a 3D mapping system discordance, and the secondary outcome was adverse events including respiratory or hemodynamic compromise. Results During AF ablation, the incidence of the primary outcome was significantly reduced for the DEX group (18.2% vs. 39.5% in the DEX and the MID groups, respectively, p < 0.001). The frequency of a desaturation event (oxygen saturation < 90%) did not significantly differ between the two groups (6.6% vs. 1.7%, p = 0.056). However, the incidences of hypotension not owing to cardiac tamponade (systolic blood pressure < 80 mmHg, 19.8% vs. 8.4%, p = 0.011) and bradycardia (HR < 50 beats/min: 39.7% vs. 21.8%, p = 0.003) were higher in the DEX group. All efficacy and safety results were consistent within the predefined subgroups. Conclusion The combined use of dexmedetomidine and remifentanil provides higher stability sedation during AF ablation, but can lead to more frequent hemodynamic compromise compared to midazolam and fentanyl.

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