Zero and Minimal Fluoroscopic Approaches During Ablation of Supraventricular Tachycardias : A Systematic Review and Meta-Analysis

Catheter ablations for cardiac arrhythmias are conventionally performed under fluoroscopic guidance. To guide these procedures, zero/minimal fluoroscopy (Z/MF) approaches have become available, using three-dimensional electroanatomical mapping systems. Our aim was to conduct a meta-analysis comparing these two different methods for the treatment of paroxysmal supraventricular tachycardia (SVT).Electronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of conventional, fluoroscopy-guided vs. Z/MF approaches in patients undergoing electrophysiology (EP) procedures for SVTs. The random-effects model was used to derive mean difference (MD) and risk ratios (RRs) with 95% confidence interval (CI).Twenty-four studies involving 9,074 patients met our inclusion criteria. There was no difference between the groups in terms of acute success rate (RR = 1.00, 95% CI, 0.99-1.01; p = 0.97) and long-term success rate (RR: 1.01, 95% CI, 1.00-1.03; p = 0.13). Compared to the conventional method, zero-and-minimal fluoroscopy (Z/MF) ablation significantly reduced fluoroscopic time [MD: -1.58 min (95% CI, -2.21 to -0.96 min; p < 0.01)] and ablation time [MD: -25.23 s (95% CI: -42.04 to -8.43 s; p < 0.01)]. No difference could be detected between the two groups in terms of the procedure time [MD: 3.06 min (95% CI: -0.97 to 7.08; p = 0.14)] and the number of ablation applications [MD: 0.13 (95% CI: -0.86 to 1.11; p = 0.80)]. The complication rate was 1.59% in the entire study population and did not differ among the groups (RR: 0.68, 95% CI: 0.45-1.05; p = 0.08).The Z/MF approach for the catheter ablation of SVTs is a feasible method that reduces radiation exposure and ablation time without compromising the acute and long-term success or complication rates

Vaszkuláris ultrahangvezérelt vena femoralis punkciók szív-elektrofiziológiai beavatkozások során = Vascular ultrasound guided femoral vein puncture in cardiac electrophysiology procedures

Az invazív szív-elektrofiziológia vizsgálatok és katéterablációk leggyakoribb szövődményei a vaszkuláris behatolással kapcsolatosak. Szemben a hagyományos anatómiai alapokon nyugvó, palpáció-irányított technikával, az ultrahangvezérléssel végzett punkciók potenciális előnyöket biztosíthatnak, amelyekkel a vaszkuláris szövődmények aránya csökkenthető. Összefoglaló közleményünk célja az elektrofiziológiai beavatkozások során ultrahangvezérléssel végzett vena femoralis punkciókkal kapcsolatos tudományos adatok áttekintése, saját eredményeink ismertetése, továbbá a saját laboratóriumukban alkalmazott metódus bemutatása

Feasibility and safety of cavotricuspid isthmus ablation using exclusive intracardiac echocardiography guidance: a proof-of-concept, observational trial

IntroductionCatheter ablation is the preferred treatment for typical atrial flutter (AFl), but it can be challenging due to anatomical abnormalities. The use of 3D electroanatomical mapping systems (EAMS) has reduced fluoroscopy exposure during AFl ablation. Intracardiac echocardiography (ICE) has also shown benefits in reducing radiation exposure during AFl ablation. However, there is a lack of evidence on the feasibility of ICE-guided, zero-fluoroscopy AFl ablation without the use of EAMS.MethodsIn this prospective study, we enrolled 80 patients with CTI-dependent AFl. The first 40 patients underwent standard fluoroscopy + ICE-guided ablation (Standard ICE group), while the other 40 patients underwent zero-fluoroscopy ablation using only ICE (Zero ICE group). Procedure outcomes, including acute success, procedure time, fluoroscopy time, radiation dose, and complications, were compared between the groups.ResultsThe acute success rate was 100% in both groups. Out of the 40 cases, the zero-fluoroscopy strategy was successfully implemented in 39 cases (97.5%) in the Zero ICE group. There were no significant differences in procedure time [55.5 (46.5; 66.8) min vs. 51.5 (44.0; 65.5), p = 0.50] and puncture to first ablation time [18 (13.5; 23) min vs. 19 (15; 23.5) min, p = 0.50] between the groups. The Zero ICE group had significantly lower fluoroscopy time [57 (36.3; 90) sec vs. 0 (0; 0) sec, p &lt; 0.001] and dose [3.17 (2.27; 5.63) mGy vs. 0 (0; 0) mGy, p &lt; 0.001] compared to the Standard ICE group. Total ablation time was longer in the Standard ICE group [597 (447; 908) sec vs. 430 (260; 750), p = 0.02], but total ablation energy [22,458 (14,836; 31,116) Ws vs. 17,043 (10,533; 29,302) Ws, p = 0.10] did not differ significantly. First-pass bidirectional conduction block of the CTI and acute reconnection rates were similar between the groups. No complications or recurrences were observed during the follow-up period.ConclusionOur study suggests that zero-fluoroscopy CTI ablation guided solely by ICE for AFl is feasible and safe. Further investigation is warranted for broader validation

Zero fluoroscopy catheter ablation for atrial fibrillation: a systematic review and meta-analysis

IntroductionCatheter ablation for atrial fibrillation (AF) is the most frequently performed cardiac ablation procedure worldwide. The majority of ablations can now be performed safely with minimal radiation exposure or even without the use of fluoroscopy, thanks to advances in 3-dimensional electroanatomical mapping systems and/or intracardiac echocardiography. The aim of this study was to conduct a meta-analysis to compare the effectiveness of zero fluoroscopy (ZF) versus non-zero fluoroscopy (NZF) strategies for AF ablation procedures.MethodsElectronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of ZF vs. NZF approaches in patients undergoing catheter ablation for AF. We used a random-effects model to derive the mean difference (MD) and risk ratios (RR) with a 95% confidence interval (CI).ResultsOur meta-analysis included seven studies comprising 1,593 patients. The ZF approach was found to be feasible in 95.1% of patients. Compared to the NZF approach, the ZF approach significantly reduced procedure time [mean difference (MD): −9.11 min (95% CI: −12.93 to −5.30 min; p &lt; 0.01)], fluoroscopy time [MD: −5.21 min (95% CI: −5.51 to −4.91 min; p &lt; 0.01)], and fluoroscopy dose [MD: −3.96 mGy (95% CI: −4.27 to −3.64; p &lt; 0.01)]. However, there was no significant difference between the two groups in terms of total ablation time [MD: −104.26 s (95% CI: −183.37 to −25.14; p = 0.12)]. Furthermore, there was no significant difference in the acute [risk ratio (RR): 1.01, 95% CI: 1.00–1.02; p = 0.72] and long-term success rates (RR: 0.96, 95% CI: 0.90–1.03; p = 0.56) between the ZF and NZF methods. The complication rate was 2.76% in the entire study population and did not differ between the groups (RR: 0.94, 95% CI: 0.41–2.15; p = 0.89).ConclusionThe ZF approach is a feasible method for AF ablation procedures. It significantly reduces procedure time and radiation exposure without compromising the acute and long-term success rates or complication rates

Diagnosztikus elektrofiziológiai vizsgálatok indikációi az ESC 2022. évi kamrai tachycardiák ellátására és a hirtelen szívhalál megelőzésére vonatkozó irányelvei alapján

A ritmuszavarok katéterablációs procedúrájában betöltött szerepén túl az invazív elektrofiziológiai vizsgálatoknak (EPS) fontos szerepe van a hirtelen szívhalál (SCD) rizikóbecslésében, a malignus kamrai ritmuszavarok kiválthatóságának megítélésében. Jelen összefoglaló célja az EPS fontosságának és szerepének ismertetése az Európai Kardiológusok Társasága (ESC) 2022-ben publikált kamrai tachycardiák és hirtelen szívhalál megelőzéséről szóló irányelvei alapján. A kardiovaszkuláris betegségek számos esetben az SCD emelkedett rizikóját hordozzák magukban, az elektrofiziológiai vizsgálatok jelentős szerepet játszhatnak ezen rizikók identifikálásában ezáltal terápiás döntések meghozatalában. | Beyond the ablation of cardiac arrhythmias, electrophysiologyical studies (EPS) have an important role in risk stratifi- cation of sudden cardiac death and in identification of the inducibility of life-threatening ventricular arrhythmias. This review summarises the role and importance of the EPS according to the 2022 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Numerous cardiovascular diseases carry an increased risk for sudden cardiac death, thus electrophysiological studies may help in the risk stratification and facilitate everyday decision-making

Ultrasound guidance for femoral venous access in electrophysiology procedures : systematic review and meta-analysis

The most common complications of electrophysiology (EP) procedures are related to vascular access. Our study aims to conduct a meta-analysis comparing ultrasound (US)-guided vs. palpation-based technique for femoral venous access in EP procedures.Electronic databases were searched and systematically reviewed for studies comparing femoral vein puncture with/without US in EP procedures. The primary outcome was the rate of major vascular complications; secondary outcomes were minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time. Predefined subgroup analysis was conducted separately for patients undergoing pulmonary vein isolation procedure (PVI). A random-effects model was used to derive risk ratios (RR) with 95% confidence interval (CI).Nine studies involving 8232 patients met our inclusion criteria. Compared with the standard technique, the use of US reduced major vascular complications (from 2.01 to 0.71%, p < 0.0001). The rate of minor vascular complications (RR = 0.30, 95% CI, 0.14-0.62, p = 0.001) and inadvertent artery puncture were lower with US-guided puncture (RR = 0.31, 95% CI, 0.17-0.58, p = 0.0003). Puncture time was shorter (mean difference = - 92.1 s, 95% CI, - 142.12 - - 42.07 s, p = 0.0003) and postprocedural groin pain was less frequent (RR = 0.57, 95% CI, 0.41-0.79, p = 0.0008) in the US group. Subgroup analysis of patients undergoing PVI also showed significant reduction of major vascular complications (RR = 0.27, 95% CI, 0.12-0.64, p = 0.003) and inadvertent artery puncture (RR = 0.35, 95% CI, 0.21-0.59, p < 0.0001).Real-time US-guidance of femoral vein puncture in EP procedures is beneficial: it reduces major and minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time

Bal pitvari fülcsethrombus kimutatása intrakardiális echokardiográfiával

A szerzők az 58 éves csökkent bal kamrai ejekciós frakcióval járó szívelégtelenség (HFrEF) és noniszkémiás dilatatív cardiomyopathia (DCM) miatt gondozott, hipertóniás nőbetegnél EHRA3 fokú panaszokat okozó perzisztens pitvarfibrilláció (PF) miatt pulmonalis vénaizoláció (PVI) elvégzését terveztük. A beteg CHA2DS2-VASc pontszám alapján becsült magas stroke-rizikó miatt 2×5 mg apixabanterápiában részesült a PF diagnózisának felállítása óta, a beavatkozás előtti 4 hétben gyógyszerbevételt nem mulasztott el, a tervezett beavatkozás reggelén esedékes apixaban kihagyásra került. A klinikánkon alkalmazott protokoll szerint a PVI kezdetén aktuálisan is pitvarfibrilláló beteg bal pitvari fülcséjének vizsgálatát intrakardiális echokardiográfia (ICE) segítségével ellenőriztük a transseptalis punkciót megelőzően, amelynek során 2×1,5 cm-es fülcsethrombust igazoltunk, így a PVI elvégzésétől eltekintettünk. Esetbemutatásunk rávilágít arra, hogy aktuálisan is zajló PF mellett végzett PVI előtt megszakítás nélküli, tartós orális antikoagulánst szedő betegek esetén is érdemes kizárni a bal pitvari fülcsethrombus jelenlétét, amelyre a transoesophagialis ultrahang (TEE) és szív-CT-vizsgálatok mellett az ICE is alkalmas lehet. | The authors present the history of 58-year-old woman with heart failure with reduced ejection fraction (HFrEF) non- ischaemic dilated cardiomyopathy (DCM) and hypertension who was scheduled for pulmonary vein isolation (PVI) due to persistent atrial fibrillation. Based on high risk of stroke identified by CHA2DS2-VASc score her on uninterrupted apixaban treatment (5 mg twice daily) before the ablation. According to the protocol used in our centre, the left atrial appendage (LAA) of a patient who was currently in atrial fibrillation at the onset of PVI procedure was checked by in- tracardiac echocardiography (ICE) before transseptal puncture. ICE confirmed a LAA thrombus of 2×1.5 cm, thus PVI was not performed. Our case report highlights that it is worthwhile to exclude the presence of a LAA thrombus before PVI in patients with ongoing oral anticoagulant treatment, which can be done by ICE in addition to transesophageal ultrasound (TEE) or cardiac CT scans

The Influence of Different Multipolar Mapping Catheter Types on Procedural Outcomes in Patients Undergoing Pulmonary Vein Isolation for Atrial Fibrillation

(1) Background: During pulmonary vein isolation (PVI) for atrial fibrillation (AF), multipolar mapping catheters (MMC) are often used. We aimed to compare the procedural outcomes of two MMCs, specifically a circular-shaped and a five-spline-shaped MMC. (2) Methods: We enrolled 70 consecutive patients in our prospective, observational trial undergoing PVI procedures for paroxysmal AF. The initial 35 patients underwent PVI procedures with circular-shaped MMC guidance (Lasso Group), and the procedures for the latter 35 cases were performed using five-spline-shaped MMC (PentaRay Group). (3) Results: No significant differences were identified between the two groups in total procedure time (80.2 ± 17.7 min vs. 75.7 ± 14.8 min, p = 0.13), time from femoral vein puncture to the initiation of the mapping (31.2 ± 7 min vs. 28.9 ± 6.8, p = 0.80), mapping time (8 (6; 13) min vs. 9 (6.5; 10.5) min, p = 0.73), duration between the first and last ablation (32 (30; 36) min vs. 33 (26; 40) min, p = 0.52), validation time (3 (2; 4) min vs. 3 (1; 5) min, p = 0.46), first pass success rates (89% vs. 91%, p = 0.71), left atrial dwelling time (46 (37; 53) min vs. 45 (36.5; 53) min, p = 0.56), fluoroscopy data (time: 150 ± 71 s vs. 143 ± 56 s, p = 0.14; dose: 6.7 ± 4 mGy vs. 7.4 ± 4.4 mGy, p = 0.90), total ablation time (1187 (1063; 1534) s vs. 1150.5 (1053; 1393.5) s, p = 0.49), the number of ablations (78 (73; 93) vs. 83 (71.3; 92.8), p = 0.60), and total ablation energy (52,300 (47,265; 66,804) J vs. 49,666 (46,395; 56,502) J, p = 0.35). (4) Conclusions: This study finds comparable procedural outcomes bet-ween circular-shaped and five-spline-shaped MMCs for PVI in paroxysmal AF, supporting their interchangeability in clinical practice for anatomical mapping