First experience of wave speed guided point-by-point cavo-tricuspid isthmus ablation for typical atrial flutter.
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ABSTRACT:
SUBMITTER: Valles E
PROVIDER: S-EPMC10457232 | biostudies-literature | 2023 Sep
REPOSITORIES: biostudies-literature
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First experience of wave speed guided point-by-point cavo-tricuspid isthmus ablation for typical atrial flutter.
Vallès Ermengol E Jiménez Jesús J González Carlos C Zaraket Fátima F Rodríguez Oriol O Llorca Laia L Anguera Ignasi I di Marco Andrea A Fan Roger R Casteigt Benjamin B
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing 20230321 6
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Project description:Steam pop (SP) refers to audible sound related to the intramyocardial explosion when tissue temperatures reach 100 °C. In this case the SP was recorded using intracardiac echocardiography (ICE), using Sound-star probe and Smart-touch catheter with ablation index (AI) module (Biosense-Webster Inc., Diamond-Bar, CA, USA). Guided by the anatomical reconstruction (EAM) and electrograms, we applied radiofrequencies (RF) in a "point-by-point" along the entire line on cavo-tricuspid-isthmus (CTI) using a target of an AI ≥500. The tip-tissue force recorded was 12-18 g and a power of 35 W. ICE imaging was important so that the anatomical position of the catheter tip can be precisely monitored. During RF, ICE showed a growing, hyperechogenic intramyocardial bubble at the catheter-tissue interface. ICE imaging showed a hyperechogenic intramyocardial formation at the moment of occurrence of the SP. ICE imaging showed that the formation suddenly expanded to a sphere over the course of several seconds. After SP we reduced the RF output energy from 35 W to 30 W. After RF line on CTI the patient had no complications and no recurrence of atrial flutter was recorded. <Learning objective: The use of intracardiac echocardiography during cavo-tricuspid-isthmus ablation permits the detection of the increase of microbubbles before steam pop formation.>.
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Project description:PurposeA novel ablation catheter capable of local impedance (LI) monitoring (IntellaNav MiFi OI, Boston Scientific) has been recently introduced to clinical practice. We aimed to determine the optimal LI drops for an effective radiofrequency ablation during cavo-tricuspid isthmus (CTI) ablation.MethodsThis retrospective observational study enrolled 50 consecutive patients (68 ± 9 years; 34 males) who underwent a CTI ablation using the IntellaNav MiFi OI catheter, guided by Rhythmia. The LI at the start of radiofrequency applications (initial LI) and minimum LI during radiofrequency applications were evaluated. The absolute and percentage LI drops were defined as the difference between the initial and minimum LIs and 100× absolute LI drop/initial LI, respectively.ResultsA total of 518 radiofrequency applications were analyzed. The absolute and percentage LI drops were significantly greater at effective ablation sites than ineffective sites (median, 15 ohms vs 8 ohms, P < .0001; median, 14.7% vs 8.3%, P < .0001). A receiver-operating characteristic analysis demonstrated that at optimal cutoffs of 12 ohms and 11.6% for the absolute and percentage LI drops, the sensitivity and specificity for predicting the effectiveness of the ablation were 66.5% and 88.2%, and 65.1% and 88.2%, respectively. Finally, bidirectional conduction block along the CTI was achieved in all patients.ConclusionsDuring the LI-guided CTI ablation, the effective RF ablation sites exhibited significantly greater absolute and percentage LI drops than the ineffective RF ablation sites. Absolute and percentage LI drops of 12 ohms and 11.6% may be suitable targets for effective ablation.
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| S-EPMC11861939 | biostudies-literature
Project description:Cavotricuspid isthmus (CTI) linear ablation has been established as the treatment for typical atrial flutter. Recently, ablation index (AI) has emerged as a novel marker for estimating ablation lesions. We investigated the relationship between CTI depth and ablation parameters on the procedural results of typical atrial flutter ablation. A total of 107 patients who underwent CTI ablation were retrospectively enrolled in this study. All patients underwent computed tomography before catheter ablation. From the receiver-operating curve, the best cut-off value of CTI depth was < 4.1 mm to predict first-pass success. Although the average AI was not different between deep CTI (DC; CTI depth ≥ 4.1) and shallow CTI (SC; CTI depth < 4.1), DC required a longer ablation time and showed a lower first-pass success rate (p < 0.01). In addition, the catheter inversion technique was more frequently required in the DC (p < 0.01). The lowest AI sites of the first-pass CTI line were determined in both the ventricular (2/3 segment of CTI) and inferior vena cava (IVC, 1/3 segment of CTI) sides. The best cut-off values of the weakest AIs at the ventricular and IVC sides for predicting first-pass success were > 420 and > 386, respectively. Among patients with these cut-off values, the first-pass success rate was 89% in the SC and 50% in the DC (p < 0.01). Although ablation parameters were not significantly different, the first-pass success rate was lower in the DC than in the SC. Further investigation might be required for better outcomes in deep CTIs.
| S-EPMC8599492 | biostudies-literature
Project description:Typical atrial flutter commonly occurs in patients with atrial fibrillation (AF). Limited information exists regarding the effects of concurrent atrial flutter on the long-term outcomes of rhythm control. This study investigated the association between concurrent typical atrial flutter and cavotricuspid isthmus (CTI) ablation and the recurrence of atrial arrhythmia. The data were obtained from a multicenter registry of cryoballoon ablation for AF (n = 2,689). Patients who were screened for typical atrial flutter were included in the analysis (n = 1,907). All the patients with typical atrial flutter underwent CTI ablation. The primary endpoint was the late recurrence of atrial arrhythmia, including AF, atrial flutter, and atrial tachycardia. Among the 1,907 patients, typical atrial flutter was detected in 493 patients (25.9%). Patients with concurrent atrial flutter had a lower incidence of persistent AF and a smaller size of the left atrium. Patients with atrial flutter had a significantly lower recurrence rate of atrial arrhythmia (19.7% vs. 29.9%, p < 0.001). In patients with atrial flutter, the recurrence rate of atrial tachycardia or atrial flutter was more frequent (7.3% vs. 4.7%, p = 0.028), but the recurrence rate of AF was significantly lower (17.0% vs. 29.4%, p < 0.001). Atrial flutter has been identified as an independent predictor of the primary endpoint (adjusted hazard ratio, 0.704; 95% confidence interval, 0.548-0.906; p = 0.006). Typical atrial flutter in patients with AF may serve as a positive marker of the recurrence of atrial arrhythmia, and performing CTI ablation in this population is associated with a reduced likelihood of AF recurrence. Performing routine screening and ablation procedures for coexisting atrial flutter may improve the clinical outcomes of AF.
| S-EPMC10755020 | biostudies-literature
Project description:Atrial flutter (AFL) represents a prevalent variant of supraventricular tachycardia, distinguished by a macro-reentrant pathway encompassing the cavotricuspid isthmus (CTI). Radiofrequency (RF) catheter ablation stands as the favored therapeutic modality for managing recurring CTI-dependent AFL. Intracardiac echocardiography (ICE) has been proposed as a method to reduce radiation exposure during CTI ablation. This study aims to comprehensively compare procedural parameters between ICE-guided CTI ablation and fluoroscopy-only procedures. A total of 370 consecutive patients were enrolled in our single-center retrospective study. In 151 patients, procedures were performed using fluoroscopy guidance only, while 219 patients underwent ICE-guided CTI ablation. ICE guidance significantly reduced fluoroscopy time (73 (36; 175) s vs. 900 (566; 1179) s; p < 0.001), fluoroscopy dose (2.45 (0.6; 5.1) mGy vs. 40.5 (25.7; 62.9) mGy; p < 0.001), and total procedure time (70 (52; 90) min vs. 87.5 (60; 102.5) min; p < 0.001). Total ablation time (657 (412; 981) s vs. 910 (616; 1367) s; p < 0.001) and the time from the first to last ablation (20 (11; 36) min vs. 40 (25; 55) min; p < 0.01) were also significantly shorter in the ICE-guided group. Acute success rate was 100% in both groups, and no major complications occurred in either group. ICE-guided CTI ablation in patients with AFL resulted in shorter procedure times, reduced fluoroscopy exposure, and decreased ablation times, compared to the standard fluoroscopy-only approach.
| S-EPMC10573340 | biostudies-literature
Project description:Background: The advantage of prophylactic cavotricuspid isthmus (CTI) ablation for AF patients without documented atrial flutter is still unclear. The present study aimed to evaluate the role of prophylactic CTI ablation in this population. Methods: A systematic review and meta-analysis study was conducted. The overall effects estimation was conducted using random effects models. The pooled effects were presented as the risk difference and standardised mean difference for dichotomous and continuous outcomes, respectively. Results: A total of 1,476 patients from four studies were included. The risk of atrial tachyarrhythmias following a successful catheter ablation procedure was greater in the pulmonary vein isolation + CTI ablation group than pulmonary vein isolation alone group (34.8% versus 28.2%; risk difference 0.08; 95% CI [0.00-0.17]; p=0.04). Prophylactic CTI ablation was associated with a higher recurrent AF rate (33.8% versus 27.1%; risk difference 0.07; 95% CI [0.01-0.13]; p=0.02). Additional prophylactic CTI ablation to pulmonary vein isolation significantly increased the radio frequency application time (standardised mean difference 0.52; 95% CI [0.04-1.01]; p=0.03). Conclusion: This study suggested that prophylactic CTI ablation was an ineffective and inefficient approach in AF without documented typical atrial flutter patients.
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Project description:Cavo-tricuspid isthmus (CTI) ablation is a cornerstone of atrial flutter ablation. The goal of CTI-dependent flutter ablation is achievement of bidirectional CTI block. Usually bidirectional CTI block is confirmed by atrial activation during septal and lateral atrial pacing or the use of differential pacing maneuvers. According to the pathological findings, the transmural muscle fibers connect the endo- and epicardium. An epicardial-endocardial breakthrough (EEB) sometimes interferes with the confirmation of bidirectional block. Recently, a new ultra-high-resolution 3-dimentional mapping systems (Rhythmia®, Boston Scientific, Marlborough [Cambridge] MA, USA) that allows rapid ultra-high-resolution electroanatomical mapping was introduced. A 64-year-old man with a sustained atrial flutter (AFL) was referred to us. Catheter ablation was performed using an ultra-high-resolution 3-dimensional mapping system. Here, we report the case of a patient with an EEB visualized by ultra-high-resolution 3-dimensional mapping. <Learning objective: The crista terminalis are recognized as the anatomic structure responsible for line of conduction block at the posterior right atrial wall. This block line is mainly functional, and transverse conduction across the posterior wall can be observed. This is the first report to visualize the EEB and examine its influence on the conventional electrophysiological findings.>.
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Project description:BackgroundInterventional cardiac magnetic resonance (iCMR) has been established as a radiation-free alternative compared to standard fluoroscopy-guided catheter ablation for cavotricuspid isthmus (CTI)-dependent atrial flutter to image anatomy, structural alterations, and further catheter guidance.ObjectiveThe purpose of this study was to explore the safety, feasibility, and efficacy of CTI ablations performed completely in the iCMR suite using active catheter imaging.MethodsConsecutive patients underwent iCMR-guided catheter ablation for CTI-dependent atrial flutter. Procedures were performed in a 1.5-T magnetic resonance (MR) imaging unit with MR-conditional ablation catheters. Catheter guidance was achieved using active catheter imaging via integrated MR receive tip coils. Acute success, periprocedural complications, and short-term follow-up were collected for further analysis.ResultsAll patients (N = 15; 73% male; median age 70 years; interquartile range [67-82]) achieved acute procedural success without any complication. Median procedural time was 43 minutes [33-58] with median radiofrequency delivery time of 18 minutes [12-26]. Postprocedural lesion visualization scanning was completed in a median of 32 minutes [10-42]. None of the patients with 6-month follow-up had atrial flutter recurrence.ConclusionIn the iCMR suite, CTI-dependent atrial flutter ablation could be achieved safely using active catheter imaging without any complication. It further allows detailed anatomic visualization of the CTI, intraprocedural lesion visualization, and exclusion of pericardial effusion.
| S-EPMC9626877 | biostudies-literature
Project description:BackgroundMicroFidelity catheter technology may facilitate voltage-guided ablation by high-resolution electroanatomic mapping (HR-EAM) and precisely targeted energy application.ObjectiveTo evaluate the performance of minielectrode (ME) technology for zero-fluoroscopy substrate-guided cavotricuspid isthmus (CTI) ablation.MethodsEighty-two patients underwent near zero-fluoroscopy substrate-guided CTI ablation using a nonirrigated large-tip catheter with 3 MEs. The CTI was subdivided into 15 electroanatomic segments. Bipolar voltage maps were compared with ME signals. The outcome was compared with a historic cohort of 92 patients who underwent linear ablation.ResultsCompared with linear ablation, the substrate-guided approach was associated with an almost halved ablation duration (336 ± 228 vs 649 ± 409 seconds, P < .001), halved radiofrequency energy applied (14.2 ± 10.6 vs 28.6 ± 19.6 kJ, P < .001), and shorter procedure duration (60.8 ± 33.8 vs 76.3 ± 40.9 minutes, P = .008) limiting the extent of energy delivery to 22.7% of the CTI area. HR-EAM visualized 2.03 ± 0.88 conductive pathways with a diameter of 5.35 ± 1.98 mm. A higher number of ME-detected bundles and a larger channel diameter correlated with increased ablation requirements. In 97.6% of the voltage-guided and 88.0% of the linear procedures, fluoroscopy was not used.ConclusionHR-EAM-based substrate-guided CTI ablation may improve procedural outcome compared with the linear approach. Enhanced identification of discrete conductive pathways correlates with ablation efficacy. The electroanatomic subdivision of the CTI into 15 segments was feasible and may improve the understanding and comparability of anatomic variants and ablation results. Independent of the ablation strategy, modern EAM technology enables safe zero-fluoroscopy procedures in the majority of cases.
| S-EPMC8322787 | biostudies-literature