Comparison of fluoroscopy time in short and long cephalomedullary nailing for 31A2 intertrochanteric hip fractures

There is no study that has compared the radiation exposure during short (Short PFN) and long proximal femoral nailing (Long PFN) for 31A2 intertrochanteric hip fractures. The objective of the present study was to compare the radiation exposure time in short and long proximal femoral nail during the treatment of 31A2 intertrochanteric hip fractures. This prospective cohort study was carried out in a University teaching hospital. Sixty one consecutive patients with 31A2 intertrochanteric femur fracture treated with pro- ximal femoral nail were included in the study. The distal locking in the short PFN was performed using the locking zig and distal locking in the long PFN was performed using the free hand perfect circle technique. The same mobile image intensifier (Multimobil 5E, Siemens, Erlangen, Germany) was used in the entire study. The outcome measure was the fluoroscopy exposure time (seconds) which was measured directly from the image intensifier. Thirty patients underwent fixation with short PFN and 31 patients underwent fixation using long PFN. The mean fluoroscopy exposure time in short PFN cohort was 189.5 seconds ± 26 (range : 150-250 seconds) and the mean fluoroscopy exposure time in long PFN cohort was 283.4 seconds ± 43.8 (range : 200-400 seconds). The mean fluoroscopy exposure time was 93.9 seconds shorter in the short PFN cohort and this difference was statistically significant (p < 0.0001 ; 95% CI : 75.4 to 112.3). The radiation exposure to the operating team is significantly less during treatment with short PFN in 31A2 intertrochanteric fractures.

Validation of a Virtual Reality Simulator for Percutaneous Pedicle Screw Insertion

Introduction: Working-hour restrictions, rota gaps and an increasing drive for theatre efficiency have resulted in challenges to surgical training. As a result, Virtual Reality (VR) has emerged as a popular tool to augment this training. Our aim was to evaluate the validity of a VR simulator for performing percutaneous pedicle screw guidewire insertion. Materials and Methods: Twenty-four participants were divided into three equal groups depending on prior surgical experience: a novice group (<10 procedures), an intermediate group (10-50 procedures) and an expert group (>50 procedures). All subjects performed four guidewire insertions on a TraumaVision® simulator (Swemac Innovation AB, Linköping, Sweden) in a set order. Six outcome measures were recorded; total score, time, fluoroscopy exposure, wire depth, zone of placement and wall violations. Results: There were statistically significant differences between the groups for time taken (p<0.001) and fluoroscopy exposure (p<0.001). The novice group performed the worst, and the expert group outperformed both intermediates and novices in both categories. Other outcome results were good and less variable. There was an observed learning effect in the novice and intermediate groups between each of the attempts for both time taken and fluoroscopy exposure. Conclusions: The study contributes constructive evidence to support the validity of the TraumaVision® simulator as a training tool for pedicle screw guidewire insertion. The simulator is less suitable as an assessment tool. The learning effect was evident in the less experienced groups, suggesting that VR may offer a greater benefit in the early stages of training. Further work is required to assess transferability to the clinical setting.

Robot-Assisted Versus Fluoroscopy-Assisted Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fracture: A Retrospective Study

Study design: A retrospective study. Objectives: To compare the clinical and radiological outcomes of robot assisted (RA) and fluoroscopy assisted (FA) percutaneous kyphoplasty (PKP) in treating single/double segment osteoporotic vertebral compression fracture (OVCF). Methods: Patients with single/double segment OVCF receiving either RA or FA PKP were evaluated retrospectively at our spine center from April 2018 to October 2019. The operation time, fluoroscopy frequency, fluoroscopy exposure time, total radiation dose, visual analogue scale (VAS), local kyphosis angle (LKA), height of fractured vertebra (HFV) and complications were compared between the single/double RA group and the FA group. Results: A total of 96 cases were included in this study, with 59 cases of single segment OVCF and 37 cases of double segment OVCF. For single/double segment OVCF, both RA and FA PKP could relieve pain and reduce fracture. The RA group showed lower fluoroscopy frequency, shorter fluoroscopy exposure time during operation for surgeons, better correction in LKA and HFV, lower rate of cement leakage, but more fluoroscopy frequency, fluoroscopy exposure time and radiation dose for patients compared with the FA group (P < 0.05), while the single RA group showed longer operation time compared with the FA group (P < 0.05). Conclusions: For single/double segment OVCF, RA has more advantages in correcting vertebra fracture, reducing intraoperative radiation exposure for surgeons, and reducing the cement leakage rate, but it increases intraoperative radiation for patients compared with FA PKP. And FA has shorter operation time in treating single segment OVCF than RA PKP.

Left atrial appendage closure with zero fluoroscopic exposure via intracardiac echocardiographic guidance

Background Percutaneous left atrial appendage closure (LAAC) is currently guided by fluoroscopy and transesophageal echocardiography (TEE). Objective We report an LAAC technique using intracardiac echocardiography (ICE) and electroanatomic mapping system (EAMS) under local anesthesia without fluoroscopy exposure. Methods Seven non-valvular atrial fibrillation (NVAF) patients with high risk of stroke and bleeding (male 5/7, aged 71.7±8.8 years, mean CHA2DS2-VASc score 5.1±2.1; mean HAS-BLED score 3.0±1.2) were enrolled. ICE probe was advanced into left atrium (LA) navigated by the EAMS. LAA sizing and LAmbreTM device implantation were guided by ICE following the orthogonal tri-axial algorithm (Axis-X: from left pulmonary veins [LPVs] to LAA; Axis-Y: from right PV ostium to LAA; Axis-Z: from lower LA to LAA). Results There were two cauliflower-like, two chicken-wing-like and three cactus-like LAAs. The mean diameters of ostia and landing zone were 21.4±3.9mm and 20.4±4.2mm, respectively. LAmbre devices with a mean umbrella diameter of 23.7±4.2mm and cover disc diameter of 29.4±3.6mm were successfully implanted and acute complete LAA sealing without peri-device leak (PDL) were achieved in all cases. The mean procedural duration was 73.0±21.4min. No fluoroscopy exposure nor contrast consumption were recorded. No procedure-related complications were documented. The PDL at 45-day follow-up was 1.7±0.8mm. No stroke or thromboembolic events were documented. Conclusions The fluoroscopic exposure could be minimized, even to zero, in the ICE-guided LAAC procedures feasibly and safely using LAmbre devices. The orthogonal tri-axial assessment is considered efficacious and safe for the procedures. Orthogonal tri-axial algorithm Funding Acknowledgement Type of funding source: None

P1453Feasibility and safety of a minimal fluoroscopy approach, aiming to ALARA strategy, compared to conventional approach in a population of adult patients with high risk accessory pathways

Funding Acknowledgements None Introduction Catheter ablation is the treatment of choice for accessory pathways (AP) in high risk patients.Traditionally fluoroscopy has been the primary tool for visualizing catheter position and stability, however it has been shown that 3D electro-anatomic mapping systems (3D EAMS) can significantly reduce and even eliminate fluoroscopy exposure during catheter ablation, thus reducing the stochastic risk of malignancies. Purpose aim of our study is to assess that an ablation strategy using 3D EAMS with limited or no fluoroscopy, rigorous set-up of the X-ray equipment and intracardiac or transesofageal (TEE)echo to guide the transeptal puncture has the same degree of safety and effectiveness in ablating APs as the conventional fluoroscopic approach (CFA), and can be adopted for both right and left sided APs in the adult population,reducing the effective doses. Methods our retrospective analysis included 60 consecutive-prospective enrolled adult patients with high-risk APs treated either with a CFA in IRCCS Policlinico San Matteo (Pavia) or with a 3 EAMS guided minimally fluoroscopic approach (MFA) in Klinikum Fuerth (Fuerth) between 01/2016 and 09/2019. Results the 2 groups were homogeneous and comparable for age,sex and numbers of right/left-sided SP. In the MFA group we demonstrated the safety and feasibility of a principally 3D EAMS guided ablation approach, having the same rate of acute ablation success,while obtaining a statistically different fluoroscopy exposure time (P &lt;0.000), dosis-area product (P&lt; 0.000) and effective dosis (P &lt; 0.000) compared to the CFA group. (Table) Conclusions the radiation exposure risk is cumulative and lifelong. We demonstrated that to adopt a MFA increasing the use of 3D EAMS, fluoro optminization and of TEE guided transeptal is feasible and safe forAPs ablation in adults, which will benefit of a lower or even absent fluoroscopic exposure while having the same degree of safety and efficacy of a CFA. Results Conventional Fluoroscopic Approach Minimal fluoroscopic approach P Patient (N) 31 29 n.s. Right AP 10 6 n.s. Left AP 21 23 n.s. Acute Efficacy 27 (87%) 28 (96.6%) n.s. Complication 1 (3%) 0 n.s. Fluoroscopy Time (min) 43+/-32 1.8+/-3.8 0.000 DAP (microGray*m2) 15252+/-11132 56.8+/-135.6 0.000 Effective Dosis (mSv) 30.35+/-27.7 0.09+/-0.28 0.000 AP, accessory pathway; min, minutes.

2398Efficacy of remote controlled catheter ablation for atrial arrhythmias in patients with atrial switch

Introduction Since arterial switch procedure replaced the Mustard and Senning (M/S) operations for D-transposition of great arteries (TGA) in 1980s, there are many M/S survivors who are now over 30 yrs old. Atrial arrhythmias are common in these patients and catheter ablation is a valid alternative to medical treatment. Purpose Assess the efficacy of atrial arrhythmia ablation using remote magnetic navigation (RMN) in M/S patients. Methods All ablations performed on patients with M/S by a single operator in a tertiary center over a 10 year period (2008–2019) were reviewed and analyzed. All documented sustained recurrences were recorded. Results Twenty-eight patients (57% M, age 41 [33–44] yrs, 2 Senning), underwent 41 procedures, 40 of which consisted of ablation for atrial tachycardia (AT, 36, 91%: 81% in PVA, 8% SVA, 11% in PVA+SVA), atrio-ventricular nodal re-entry tachycardia (1, 1%) or atrial fibrillation (AF 3, 8%). All procedures were carried out using remote navigation, electroanatomical mapping and 3D image integration. Pre-procedure echo showed at least moderately impaired systemic ventricle in 68% and moderate or severe tricuspid regurgitation in 58% of patients. Access to pulmonary venous atrium (PVA) was gained retrogradely in all cases while to access systemic venous atrium (SVA) either via femoral, subclavian or jugular veins. All except one procedure (98%) were acutely successful. At 1 and 3 years, 82% and 74% of patients were free from recurrent arrhythmia. Multiple procedures were required to control arrhythmias in 10 (36%) patients ablated for AT (60% in PVA, 30% in PVA+SVA). After the 2nd ablation 60% of these patients were in sinus rhythm at 3 years. On multivariate Cox analysis, Senning repair was associated with a higher recurrence risk after ablation compared to patients undergone a Mustard procedure (HR 1.47, p=0.01). Overall median procedural duration was 210 [155–265] min with a median fluoroscopy time of 0.9 [0.4–1.5] min and fluoroscopy exposure of 60 [43–120] μGy·m2. Conclusions Remote magnetic navigation represents a valid treatment for atrial arrhythmias in patients post M/S operation, with good short and longer-term results. Moreover, it allows the retrograde approach sparing the transbaffle puncture and enables a low fluoroscopy exposure.

Catheter ablation of left posterior fascicular ventricular tachycardia in children with limited fluoroscopy exposure

Introduction:Catheter ablation of left posterior fascicular ventricular tachycardia in the pediatric population remains challenging, and most studies about this topic have been conducted on adult patients. This study aimed to assess the clinical presentation features and outcomes of catheter ablations performed using limited fluoroscopy with three-dimensional electroanatomic mapping system guidance in a pediatric left posterior fascicular ventricular tachycardia patient group.Methods:A total of 20 consecutive patients undergoing left posterior fascicular ventricular tachycardia ablation at a single tertiary centre were enrolled. All children with left posterior fascicular ventricular tachycardia underwent electrophysiological studies using the EnSite NavX system guidance. Ablations were performed during the sinus rhythm based on the Purkinje potentials in all patients.Results:The mean patient age was 12.7 years (range 2–16), and the mean patient weight was 51 kg (range 11–84). The mean procedure and median fluoroscopy times were 143.1 minutes and 3.4 minutes, respectively. No fluoroscopy was used in three patients. Acute success was achieved in 19 patients (95%). During a mean follow-up of 38.6 ± 19.35 months, left posterior fascicular ventricular tachycardia recurred in four patients (20%). Repeat ablations were performed successfully in those patients who developed recurrences. No complications were seen.Conclusions:Catheter ablation of left posterior fascicular ventricular tachycardia in children can be performed safely and effectively with low fluoroscopy exposure using a three-dimensional electroanatomic mapping system.