A Focus on Catheter Ablation of Ventricular Arrhythmias

VT ablation is based on percutaneous catheter insertion under fluoroscopic guidance to selectively destroy (i.e., ablate) myocardial tissue regions responsible for the initiation or propagation of ventricular arrhythmias. Although the last decade has witnessed a rapid evolution of ablation equipment and techniques, the control over catheter movement during manual ablation has remained largely unchanged. Moreover, the procedures are long, and require ergonomically unfavorable positions, which can lead to operator fatigue. In an attempt to overcome these constraints, several technical advancements, including remote magnetic navigation (RMN), have been developed. RMN utilizes a magnetic field to remotely manipulate specially designed soft-tip ablation catheters anywhere in the x, y, or z plane inside the patient's chest. RMN also facilitates titration of the contact force between the catheter and the myocardial tissue, which may reduce the risk of complications while ensuring adequate lesion formation. There are several non-randomized studies showing that RMN has similar efficacy to manual ablation, while complication rates and total radiation exposure appears to be lower. Although these data are promising, larger randomized studies are needed to prove that RMN is superior to manual ablation of VT.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/jce.12938

Remote Magnetic Navigation: A Focus on Catheter Ablation of Ventricular Arrhythmias

Objective
To assess the outcome and associated risks of atrial defragmentation for the treatment of long-standing persistent atrial fibrillation (LSP-AF).

/pdf/clinical-outcome-of-ablation-for-long-standing-persistent-1t6cbyxzf6.pdf

Clinical outcome of ablation for long-standing persistent atrial fibrillation with or without defragmentation.

Remote magnetic navigation has been available as a tool for mapping and ablation for well over a decade. In that period of time, it has shown to be useful in nearly every type of ablation procedure from the most simple to the most complex [1–3]. Some operators prefer the system for atrial fibrillation ablation, others for ventricular tachycardia ablation, and some use it for any ablation. Despite numerous publications showing reductions in fluoroscopic exposure and the obvious benefits of not wearing lead and standing tableside for hours, remote magnetic navigation has not become the standard of care in the world [4]. Most publications appear to show similar success rates, and many show favorable complication rates [5–7]. So what is the limitation to universal acceptance? In addition, many centers have purchased the system, yet it sits unused. Why would a physician give up a more comfortable procedure to perform an ablation wearing lead and being exposed to more radiation? One of the major factors preventing adoption is cost. Not only is the system itself expensive but it also requires shielding, specific X-ray systems, support specifications, a significant space requirement, and cannot be close to an MRI system. Outfitting an existing EP laboratory with a system would likely require significant construction costs. In general, it is much easier to plan for a system in new construction. Once the system is installed, the operator must commit to overcoming the learning curve. Navigation with the system is quite different than manual navigation. Looping the catheter allows access to areas that cannot be reached directly. There is no fixed curve, which allows great versatility but is not always intuitive. Procedures will take longer in the beginning, and learning the advanced techniques takes significant time and patience. In the current world, where we are pushed toward efficiency and increasing volume and throughput, this time is certainly a sacrifice. It is understandable why some would choose not to continue using a system that slows them down under such pressure. Perhaps the most challenging limitation is technological lag. Magnetic navigation systems require partnerships with catheter manufacturing companies and mapping companies to fully enjoy use of the system. These companies have their own financial goals, and since magnetic navigation is only a small portion of catheter sales, the incentive to advance the technology is not present. Since the release of the open-irrigated magnetic ablation catheter almost 10 years ago, catheter technology has significantly changed. New irrigation platforms, contact force sensing, and balloon-based technologies have entered the field, yet the magnetic catheter has remained unchanged in that time. There is ample opportunity to improve the magnetic catheter itself with increased magnetic force, improved handling, and irrigation, but this cannot occur without significant capital or a willing partner. Despite these limitations, magnetic navigation seems to have found a niche in ventricular tachycardia and premature ventricular contraction (PVC) ablation. Magnetic navigation seems well suited to the ventricle. One of the limitations in the atrium is the relatively long stiff segment of the catheter; however, this is not a problem in the larger ventricle. One of the major advantages over manual navigation is the ability to access the entire ventricle with * J. David Burkhardt jdavidburkhardt@hotmail.com

/pdf/remote-magnetic-navigation-for-ventricular-ablation-did-the-4skijxdaxk.pdf

Remote magnetic navigation for ventricular ablation: did the machine win this round?

Background
The purpose of this study was to prospectively evaluate the efficacy and safety of remote magnetic navigation (RMN) in comparison with manual catheter navigation (MCN) in performing ventricular tachycardia ablation.

/pdf/remote-magnetic-navigation-vs-manual-navigation-for-ablation-c1qdefff5y.pdf

Remote magnetic navigation vs. manual navigation for ablation of ventricular tachycardia: a meta-analysis

With an increasing population of patients with end-stage heart failure (HF), orthotopic heart transplantation (OHT) remains an important selective treatment option. Moreover, despite donor pool expansion strategies, the unbalance between organ donors and patients needing OHT led to an increase in waiting-list time; and thus, the rate of left ventricular assist device (LVAD) implantation, as bridge to either transplant or destination therapy, has more than doubled over the last 10 years. In order to prevent arrhythmic death and to improve cardiac performance in those awaiting cardiac transplantation, cardiac implantable electronic devices (CIEDs), including transvenous implantable cardioverter defibrillator (T-ICD) and cardiac resynchronization therapy device, are recommended. Thus, both the population of patients with CIED who will undergo OHT and those with CIEDs/LVAD combination are destined to increase in the future years. Interestingly, a significant portion of patients with CIEDs and advanced HF, ranging from 46% to 77%, does not have a strict pacing indication, including need of resynchronization therapy, as the main aim is primary prevention of sudden cardiac death. The subcutaneous implantable cardioverter defibrillator (S-ICD) was developed as an alternative therapy to T-ICD system, as it is a fully subcutaneous system without any transvenous or epicardial leads. Thus, the S-ICD system has the potential to decrease periprocedural implantation risks, eliminate the problem of difficult venous access, reduce endovascular mechanical stress on leads, and decrease the risk of systemic device-related infection typically observed in patients with a T-ICD, even with the limit of lack of pacing capability as either antitachycardia pacing or sustained pacing for bradycardia. Therefore, S-ICD could play an important clinical role in a significant portion of patients with HF. Furthermore, OHT and LVAD patients with an ICD have some peculiar issues related to the presence of leads inside the cardiac chambers and the venous system, which we are going to address in this paper. Concerning OHT, ICD leads are usually cut when superior vena cava section is performed during surgical operation, and the portion of the leads dwelling in the recipient’s heart is removed from the organ. Then, the proximal portion of the leads is often extracted by manual traction. However, in a non-negligible percentage of patients, ranging from 13% to 42%, this procedure results in a not complete removal of the latter portion, owing to lead–tissue adhesion within the venous system. The most common site for these retained lead fragments is the central venous system (Figure 1A). It has been described elsewhere that the presence of retained ICD lead fragments after OHT would not impact long-term morbidity and mortality. However, raising data reported different potential life-threatening complications, including lead fragment infection, pulmonary embolization, venous obstruction, and electrical interferences with other CIEDs, ranging from 3.4% to 20%. Currently, there are no data in the literature focused on S-ICD patients who received OHT, with only sporadic cases reported in larger series: Pettit et al. reported a series of 206 patients with CIED at time of OHT, in which three (1%) had S-ICD, who did not presented any early or late complication related to device removal. In addition, if needed, an implanted S-ICD can be turned off, left in site at the time of OHT, and subsequently turned on again after testing sensor vectors, with no need to re-implant another device (Figure 1B). GUEST EDITORIAL

Subcutaneous implantable cardioverter defibrillator in patients awaiting cardiac transplantation or left ventricular assist device for refractory heart failure: a feasible alternative to transvenous device?

Percutaneous epicardial mapping and ablation is an emerging method to treat ventricular tachycardias (VT), premature ventricular complexes (PVC), and accessory pathways. The use of a remote magnetic navigation system (MNS) could enhance precision and maintain safety. This multiple case history demonstrates the feasibility and safety of the MNS-guided epicardial approach in mapping and ablation of ischaemic VT, outflow tract PVCs, and a left-sided accessory pathway. All patients had previously undergone endocardial mapping for the same arrhythmia. MNS could present an advantage from more precise navigation for mapping and maintaining catheter stability during energy application.

/pdf/feasibility-of-remote-magnetic-navigation-for-epicardial-2czba6kmkw.pdf

Feasibility of remote magnetic navigation for epicardial ablation

High incidence of unexpected defibrillation coil retention during orthotopic heart transplantation.

Introduction It is well known that after the initial months of implantable cardioverter-defibrillator (ICD) implantation, there is a peak in the incidence of appropriate ICD therapies because of the local irritation effect of the lead on myocardial tissue. Moreover, there is growing evidence of the proarrhythmic effects of pacemaker or ICD leads long after implantation. The pathophysiologic mechanism can be lead fracture, epicardial perforation, local scar formation around the tip, or a change in the activation pattern of the ventricles caused by epicardial or endocardial pacing. Proof of lead-related arrhythmogenesis is based on indirect evidence such as identical pace-map from the lead tip, activation or voltage mapping, or noninducibility of the tachycardia after lead removal. The aim of this report is to present the first direct human pathologic evidence of a probable ICD lead-related scar causing ventricular tachycardia (VT).

First direct human evidence of a probable implantable cardioverter-defibrillator lead-related scar serving as a substrate for ventricular tachycardia

Aims: Delivery of a ventricular extrastimulus shortly after the effective refractory period (ERP) of a sensed (coupled pacing; CP) or a paced (paired pacing; PP) ventricular event can instantly decrease the mechanical pulse rate (MPR) during rapidly conducting atrial fibrillation (AF). We compared the short-term rate-controlling effects of CP and PP during AF with rapid ventricular rates. Methods and results: Sixteen patients with ongoing, spontaneous AF were examined. Mechanical pulse rate was registered via arterial pressure tracings. During CP a coupling interval (CI) of ERP+20 ms was used to reach an optimal haemodynamic effect. Paired pacing was started at a basic cycle length (CL) of 500 ms followed by an extrastimulus with an CI of ERP+20 ms. Drive train was changed at 50 ms increments until the lowest MPR was reached. Proarrhythmic effects were characterized by the number of premature ventricular complexes (PVCs). Mechanical pulse rate significantly decreased in all patients during CP (113 ± 9 vs. 58 ± 4/min). Using CP the controlled rhythm remained irregular (CL range: 896 ± 24-1452 ± 67 ms) while no PVCs were observed. With different drive trains PP resulted in different regular MPRs (range 62 ± 6-80 ± 4/min), but the lowest MPR achieved was significantly higher in the PP group than in the CP. Paired pacing caused premature beats in nine patients (56%) resulting in loss of continuous MPR control. Conclusions: Both CP and PP can reduce the MPR during rapidly conducting AF. Coupled pacing is more applicable, but PP has the advantage to achieve different target heart rates. Paired pacing has more proarrhythmic effects as compared with CP. Published on behalf of the European Society of Cardiology. All rights reserved.

Coupled pacing controls rapid heart rates better than paired pacing during atrial fibrillation.

A pitvarfibrillacio okozta thromboembolias esemenyek megelőzesenek „gold standard”-ja a K-vitamin-antagonistakkal tortenő antikoagulans terapia. A pitvarfibrillalo betegek egy resze a fenti gyogyszerek szedesevel kapcsolatos nehezsegek miatt nem reszesul effektiv veralvadasgatlo kezelesben. Az ineffektiv veralvadasgatlas kovetkezteben kialakult bal pitvari fulcsethrombus, mint a leggyakoribb kardiogen emboliaforras, feloldasa komoly kihivast okozhat a „hagyomanyos” antikoagulans kezelesre nem reagalo, illetve az azt nem toleralo betegek koreben. A szerzők tudomasa szerint első izben szamolnak be egy nem valvularis perzisztens pitvarfibrillalo, magas stroke-kockazatu, a „hagyomanyos” antikoagulans kezelesre intolerans, valtott antikoagulans rezsim mellett is perzisztalo bal pitvari fulcsethrombussal elő nőbeteg direkt trombin inhibitorral valo sikeres fulcsethrombus-feloldasarol, illetve az azt kovető percutan bal pitvari fulcsezarasrol. Orv. Hetil., 2013, 154, 262–265.

Percutaneous left atrial appendage closure after resolution of left atrial appendage thrombi with dabigatran

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