Snaring of the right ventricular lead during cavotricuspid isthmus ablation.
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ABSTRACT:
SUBMITTER: Darrat YH
PROVIDER: S-EPMC5331259 | biostudies-literature | 2017 Mar
REPOSITORIES: biostudies-literature
Publications
Snaring of the right ventricular lead during cavotricuspid isthmus ablation.
Darrat Yousef H YH X Gustavo Morales M Waespe Cristen Kelly CK Gurley John C JC Elayi Claude S CS
Clinical case reports 20170205 3
The presence of a right ventricular (RV) lead may interfere with cavotricuspid isthmus (CTI) ablation. We present a new option of lifting the RV lead from the CTI allowing a successful ablation of a CTI-dependent flutter without compromising lead integrity and functionality. ...[more]
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Project description:BackgroundA subeustachian pouch (SEP) often hinders the completion of a cavotricuspid isthmus (CTI) ablation of typical atrial flutter (AFL) and sometimes causes steam-pops during a power-controlled ablation. We hypothesized that real-time bull's-eye monitoring of the catheter surface temperature might be useful to locate the SEP where the temperature can rise rapidly, and a temperature-controlled ablation might avoid steam pops. This study aimed to demonstrate this hypothesis.MethodsA temperature-controlled CTI ablation with a QDOT MICRO™ catheter (n = 10) and a conventional power-controlled CTI ablation (n = 10) were performed with an output power of 35 W. During the RF application, the bull's eye monitor for monitoring the catheter surface temperatures was assessed. A "red-bull sign" was defined as an entire red-colored bull's-eye monitor, indicating that the catheter-tip temperature of all 6 thermocouples rose rapidly over 47°C.ResultsIn a total of 115 lesions (12 ± 3 per patient), a "red-bull sign" was observed in 39 (33.9%) lesions where the RF output was reduced to 26 ± 8 W. All 39 "red-bull sign" lesions corresponded to the location of the SEP as delineated by ICE before the ablation. The red-bull sign accurately indicated the presence of a SEP with a sensitivity of 84.7% and specificity of 100%. Bidirectional block of the CTI was completed in all patients in either catheter group without any steam-pops.ConclusionReal-time surface temperature monitoring and a red-bull sign might be useful to detect the SEP. A temperature-controlled CTI ablation with the QDOT MICRO catheter might be safe for avoiding steam pops.
| S-EPMC9745479 | biostudies-literature
Project description:Complete block creation by radiofrequency (RF) ablation at the cavotricuspid isthmus (CTI) is a highly successful procedure for the treatment of typical atrial flutter (AFL). Occasionally, a rare type of AFL, such as lower or upper loop reentry, or partial isthmus-dependent flutter, can coexist with typical right AFL. A 73-year-old man underwent CTI ablation for a clockwise CTI-dependent typical atrial flutter. During the ablation procedure, the morphology of the flutter wave changed in the surface electrocardiogram and endocardial atrial activation sequence, suggesting that the typical AFL had converted to another AFL (AFL2). High-density mapping using the HD grid catheter could not reveal the reentrant circuit of AFL2 but detected a critical conduction gap at the boundary between the inferior vena cava and CTI. There was also an impulse collision in the remaining CTI. The RF application at the gap terminated the AFL2 and completed the block line of the CTI. Based on these findings, AFL2 was comparable with partial isthmus-dependent flutter. The present case demonstrates the utility of high-density mapping with a HD grid for the identification of small amplitude high-frequency electrograms at critical sites of the arrhythmia.Learning objectiveA rare type of atrial flutter (AFL) can coexist with typical AFL. In such cases, a high-density mapping is useful to identify the critical portion of the reentrant circuit. The Advisor HD grid multipolar catheter (Abbott, St Paul, MN, USA) is unique in that it allows bipolar recording perpendicular and parallel to the splines via 16 electrodes. In this case report, high density mapping using HD grid catheter identified small amplitude high-frequency electrograms at critical sites of the arrhythmia.
| S-EPMC9508577 | biostudies-literature
Project description:Pulmonary vein isolation (PVI) with cavotricuspid isthmus (CTI) ablation is feasible in patients with situs inversus totalis. Orientation challenges are improved with the use of electroanatomical mapping prior to transseptal puncture. Care must be taken to note the opposing anatomic locations of important structures such as the left atrial appendage, descending aorta, and phrenic nerve.
| S-EPMC4736523 | biostudies-other
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:Background and objectivesCavotricuspid isthmus (CTI) block is easily achieved, and prophylactic ablation can be performed during atrial fibrillation (AF) ablation. However, the previous study was too small and short-term to clarify the efficacy of this block.MethodsPatients who underwent catheter ablation for paroxysmal AF were enrolled, and patients who had previous or induced atrial flutter (AFL) were excluded. We randomly assigned 366 patients to pulmonary vein isolation (PVI) only and prophylactic CTI ablation (PVI vs. PVI+CTI).ResultsThere was no significant difference in procedure time between the two groups because most CTI blocks were performed during the waiting time after the PVI (176.8±72.6 minutes in PVI vs. 174.2±76.5 minutes in PVI+CTI, p=0.75). All patients were followed up for at least 18 months, and the median follow-up was 3.4 years. The recurrence rate of AF or AFL was not different in the 2 groups (25.7% in PVI vs. 25.7% in PVI+CTI, p=0.92). The recurrence rate of any AFL was not significantly different in the 2 groups (3.3% in PVI vs. 1.6% in PVI+CTI, p=0.31). The recurrence rate of typical AFL also was not different (0.5% in PVI vs. 0.5% in PVI+CTI, p=0.99).ConclusionsIn this large and long-term follow-up study, prophylactic CTI ablation had no benefit in patients with paroxysmal AF without typical AFL.Trial registrationClinicalTrials.gov Identifier: NCT02031705.
| S-EPMC7779821 | biostudies-literature
Project description:IntroductionCryoablation has evolved as a safe alternative to radiofrequency ablation in the treatment of several supraventricular arrhythmias and has potential advantages, yet is limited by the properties of the cryogen used. We investigated a novel ultralow temperature cryoablation (ULTC) system using nitrogen near its liquid-vapor critical point as a freezing source, achieving temperatures as low as -196 degrees Celsius in a long linear catheter with a continuous energy release. Initial safety, procedural and efficacy outcomes of ULTC are described in patients undergoing cavotricuspid isthmus (CTI) ablation.Methods and resultsThe Cryocure studies (NCT02355106, NCT02839304) are prospective, single-arm, multi-center, first-in-human clinical studies in 17 patients with atrial flutter (AFL) and 13 patients with atrial fibrillation (AF). A total of 30 patients, mean age 65 ± 8 years old and 67% male, were enrolled and underwent ablation of the CTI. Acute success, defined as the confirmation of stable bidirectional conduction block across the CTI, was achieved in all 30 patients. After 12 months of follow-up, 14 out of 17 AFL patients remained free from any AFL. One (3.3%) procedure-related but not device-related serious adverse event was reported, involving transient inferolateral ST-elevation associated with temporary AV conduction block.ConclusionIn this first-in-human clinical study the safety and performance results demonstrate the capabilities of ultralow temperature near-critical nitrogen as an effective energy source for CTI ablation. Ongoing, larger, studies should confirm our findings and evaluate the capabilities to create linear and focal transmural lesions in other arrhythmias.
| S-EPMC8457224 | biostudies-literature
Project description:AimsWe aimed to prospectively investigate the effectiveness of a standardized follow-up for AF-detection after common atrial flutter (cAFL) ablation.MethodsA total of 309 patients after cAFL ablation without known AF, from 5 centers, and at least one completed, standardized follow-up at 3, 6 and 12 months, including a 24 h Holter-electrocardiogram (ECG), were included. The primary outcome was incident atrial fibrillation (AF), or atrial tachycardia (AT). Predictors were investigated by Cox proportional-hazards models.ResultsThe mean age was 67.9 years; 15.2% were female and the mean CHA2DS2-VASc (Congestive heart failure, Hypertension, Age, Diabetes, Stroke, Vascular disease, Sex category) score was 2.4 points. The great majority of patients (90.3%) were anticoagulated. Over a mean follow-up of 12.2 months with a standardized approach, AF/AT was detected in 73 patients, corresponding to 11.7% at 3 months, 18.4% at 6 months and 28.2% at 12 months of follow-up. AF was found in 64 patients, AT in 9 and both in 2 patients. Occurrence of AF was recorded in 40 (60.6%) patients by Holter-ECG and in the remaining 26 (39.4%) by clinical follow-up only. There was no difference in male versus female (p = 0.08), or in younger versus older patients (p = 0.96) for AF/AT detection. Only coronary artery disease (hazard ratio [95% confidence intervals] 1.03 [1.01-1.05], p = 0.01) was associated with the primary outcome.ConclusionsAF or AT was detected in a large proportion of cAFL patients after cavotricuspid-isthmus (CTI) ablation, using a standardized follow-up over 1 year. This standardized screening can be easily implemented with high patient acceptance. The high proportion of post-ablation AF needs to be taken into consideration when deciding on long-term oral anticoagulation.
| S-EPMC8509798 | biostudies-literature
Project description:To detect detouring gap conduction, as demonstrated in this case, 3-D mapping is useful in addition to conventional methods.
| S-EPMC7250971 | 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.
| S-EPMC9277616 | biostudies-literature