ABSTRACT
Background: Catheter ablation is a cornerstone treatment for symptomatic atrial fibrillation (AF) with major improvements in safety over time. However, rates of adverse events with use of current techniques in a contemporary quality-focused network remain undefined. Objective(s): Across a large, real-world sample, we sought to describe (1) rates of major, adverse events associated with catheter ablation of AF and (2) patient-level factors associated with complications. Method(s): Utilizing the REAL-AF collaboration, a registry of contemporary AF ablation procedures with granular patient, procedural and follow-up data comprised of cases from over 50 operators across academic and non-academic sites, we evaluated all patients undergoing their first ablation procedure from January 2018 - June 2022. Risk-adjusted analyses were conducted to evaluate the relationship between patient factors and complications. Result(s): Among 3144 patients (age 66.1 +/- 11.0 years, 42% female, 67.1% paroxysmal, 32.9% persistent) who underwent AF ablation, procedure-related complications (n =77) were identified in 65 patients (2.1%) with multiple complications occurring in 9 patients (0.2%). Most complications (n=70, 93.5%) occurred in the peri-procedural (within 30 days) period and 6.5% (n=5) after 30 days, the latter of which all represented vascular injuries (Figure). Major complications (18 of 72 peri-procedural complications, 25.0%) are defined, detailed, and associated data reported in the Figure. Unadjusted (16.0% without CHF vs. 33.3% with CHF, p = 0.045) and risk-adjusted (OR 2.8, 95% CI 1.03-7.60, p=0.045) analyses indicated history of CHF was associated with a composite outcome of major complications. Analyses of independent complications showed those who suffered from peri-procedural stroke (n=3) were of significantly greater age (77.3 +/- 5.5 years vs. 66.1 +/- 10.9 years, p=0.035). Risk-adjusted analyses showed history of vascular disease (OR 2.9, 95% CI 1.02-8.20, p=0.045) was associated with vascular injury (n=18). From 0-695 days post-procedure, 31 deaths occurred (unknown cause: 17, COVID-19 related: 4, heart failure: 2, cardiac arrest: 2). Conclusion(s): Major complications represent rare events among those undergoing AF ablation in current practice. Risk-adjusted analyses suggest a history of CHF is associated with major complications. Similarly, older age and a history of vascular disease are associated with stroke and vascular complications, respectively. [Formula presented]Copyright © 2023
ABSTRACT
Background: Covid redefined how the world functions. The electrophysiology (EP) community identified multiple needs that arose due to this paradigm and redefined workflows. The geographic paucity of experienced clinical mapping support was a crucial issue that limited the worldwide adoption of complex ablation procedures. Objective(s): To ascertain the feasibility and safety of utilizing a novel software for remote mapping and remote clinical support for all spectrums of cardiac ablation procedures and to compare the adoption of ablation technology in that geography. Method(s): Ablation procedures performed at Metromed International Cardiac Centre (MICC), India were included in this early feasibility analysis (EFA). All procedures were performed by a single EP operator. Remote Clinical support was provided by an EP physician (primary operator's sibling) in the USA. All mapping was performed by an experienced mapper from a remote location 400 miles away from the primary EP operator in India. The mapping system utilized was Ensite Precision with SJM Connect software. Result(s): 300 contiguous ablation procedures from 2020 to 2022 were included in this EFA. The proprietory SJM Connect software allows remote access to the Ensite console via a secured connection. The software requires the operator to be granted access to the Ensite console via a permission request that must be acknowledged on the Ensite Console. The software will then allow the remote operator to levels of access to the system, view-only access, or complete control of the console to provide full remote support. Communication occurs between the remote user and the console via a chat function and over a voice call. This remote connection can be terminated at any time from either the console or the remote operator. There is no PHI displayed. Results detailing case demographics and acute procedural success and safety will be presented. Results comparing the adoption of ablation technology with the previous 3 years in this geography will be presented. Conclusion(s): This EFA demonstrates the safety and efficacy of using remote clinical support and remote mapping for ablation procedures. This opens a world of possibilities including the expansion of ablation technology to all corridors of the world with experienced clinical and mapping support connecting the EP community on a worldwide platform. Additional studies and strategies are needed to further understand the implication of remote support algorithms in bridging the healthcare gaps in the field of cardiac EP. [Formula presented]Copyright © 2023
ABSTRACT
Background: Ictal-induced cardiac bradyarrhythmia and asystole is a rare phenomenon. The exact mechanism of ictal-induced cardiac bradyarrhythmia and asystole remains unclear. It was postulated that stimulation of central autonomic network during ictal episode may trigger an abrupt burst of hypervagotonia. Prolonged episode of cardiac bradyarrhythmia and asystole may result in syncope or death due to impairment of cerebral perfusion. The role of cardioneuroablation (CNA) in this condition has not been well-described in the literature. Objective(s): To describe a case of successful CNA in a patient with ictal-induced bradyarrhythmia and asystole. Method(s): n/a Results: A 47-year-old female has a 1.5-year history of intractable focal epilepsy and COVID-19 infection. She started having multiple episodes of seizures following a mild COVID-19 infection. Electroencephalogram (EEG) and brain MRI revealed right temporal onset seizures without structural lesions. Due to ongoing uncontrolled seizures with multiple semiologies despite multiple anti-epileptic drugs, she was admitted to Epilepsy Monitoring Unit for seizure classification. Her ictal EEGs (Figure 1) showed onset of ictal rhythm in the right temporal region with episodes of severe sinus bradycardia (15-30 bpm) and sinus pauses (15-16 seconds). Telemetry tracings demonstrated PP interval slowing with PR interval prolongation prior to the pauses consistent with a vagally-mediated mechanism. Cardiac electrophysiology team recommended CNA for treating the episodes of ictal-induced bradyarrhythmia and asystole. 3D anatomic maps of the right atrium (RA) and left atrium (LA) were created using CARTO system (Biosense Webster). Right superior ganglionated plexus (RSGP) was localized with fractionation mapping and intracardiac echocardiography guidance. RSGP was targeted from the RA using an irrigated radiofrequency catheter with power limit of 25 W. Post-ablations of RSGP, her heart rate increased from 60 - 99 bpm. Additional lesions were delivered from the LA site but no additional heart rate increase was not seen. An implantable loop recorder was implanted post-ablation procedure. During follow-up of 8 months, she had recurrent focal epilepsy, but no bradyarrhythmias or asystole was noted on her loop recorder. Resting heart rates at long-term follow up were between 70 - 100 bpm. Conclusion(s): This case highlights the utility of CNA in patient with ictal-induced cardiac bradyarrhythmia and asystole. CNA may be an approach to avoid permanent pacemakers in this population. [Formula presented]Copyright © 2023
ABSTRACT
Ablation includes ethanol injection, radiofrequency ablation (RFA), microwave ablation (MWA), etc. Ablation can be potentially curative, minimally invasive and easily repeatable for recurrence. RFA has been the most widely used ablation technique for liver tumors. The new-generation MWA system incorporating antenna cooling and high-power generation has attracted attention. It can create a more predictable ablation zone and a larger ablation volume in a shorter procedure time. Many high-volume centers have introduced new-generation MWA in Japan. However, many studies failed to show that new-generation MWA is superior to RFA in terms of local control and overall survival. In MWA, clinical data have been insufficient compared with those of RFA. There has been keen competition between surgical resection and ablation for almost 40 years since the era of ethanol injection. In 2021, SURF trial revealed that overall survival and recurrence-free survival were not significantly different between surgical resection and RFA. SURF trial was a multicenter randomized controlled trial in which 49 major centers in Japan enrolled patients with good hepatic function (Child-Pugh scores <= 7) and primary HCC of largest diameter <= 3 cm, and <= 3 nodules during the 6-year period of 2009-2015. The registered patients were followed for at least 5 years. As the result of SURF trial and other comparative studies, the revised Japanese clinical practice guidelines in 2021 treats hepatic resection and ablation equally for patients with <= 3 lesions, <= 3 cm in diameter. Recently, the combination of systemic and locoregional therapies has been attracting much attention. Systemic therapy using molecular targeted agents or immune checkpoint inhibitors is used for advanced HCC which cannot be treated by surgery or ablation. On the other hand, some locoregional therapies, such as hepatectomy and ablation, are potentially curative, but they cannot be indicated for advanced HCC. Combination of both therapies is an approach to improve the prognosis of advanced HCC, which is not indicated for curative treatment. Systemic therapy is used to shrink the tumor, and then locoregional therapies are performed to eradicate it. The combination may build a new strategy for advanced HCC. Ablation is highly operator-dependent. The skills and outcomes are very different from operator to operator. Before the pandemic of COVID-19, we held domestic and international training programs for intermediate and advanced doctors and hands-on seminars for young doctors. These were activities to exchange knowledge and experience and standardize the procedure. During the pandemic, we cannot get together. Since August 2020, we have conducted Japan Ablation Webinar 8 times with a total of 1,566 participants. We have also conducted International Ablation Webinar 4 times with a total of 1,272 participated doctors. Education is important to acquire skills and knowledge for successful ablation. We have established Japan Academy of Tumor Ablation (JATA) this year. There are two triggers. One is that SURF trial revealed that there is no difference between hepatectomy and ablation. The other is that ablation for lung, bone and soft tissue and kidney cancers has become reimbursed with health insurance since this September.
ABSTRACT
Introduction: Autoimmune and inflammatory thyroid diseases have been reported following SARS-CoV-2 infection or vaccination, but thyroid eye disease (TED) post-COVID-19 infection is less common. We describe a case of TED following SAR-CoV-2 infection in a patient with a history of Graves' disease. Case Description: A 59-year-old female with history of Graves' disease status post radioiodine ablation therapy in 2002. She developed post-ablative hypothyroidism which has been stable on levothyroxine 88 mcg daily. In January 2021, the patient's husband and daughter were diagnosed with COVID-19 infection. A few days later, the patient developed an upper respiratory tract infection associated with loss of sense of smell and taste consistent with COVID-19 infection. Three days later, she developed bilateral watery eyes which progressed to eye redness, eyelid fullness, retraction, and pain with eye movement over 1-month duration. Her eye examination was significant for severe periocular soft tissue swelling, lagophthalmos and bilateral exophthalmos. The laboratory workup was consistent with normal TSH 0.388 mIU/L (0.358-3.740 mIU/L) and positive TSI 1.01 (0.0-0.55). The patient was referred to an Ophthalmologist for evaluation of TED. He noted bilateral exophthalmos, no restrictive ocular dysmotility or compressive optic neuropathy (clinical activity score 4/7 points). CT scan of orbit showed findings compatible with thyroid orbitopathy. Based on clinical activity score of 4, treatment with Teprotumumab was recommended pending insurance approval. Discussion(s): Many cases of new-onset Graves' hyperthyroidism have been reported after COVID-19, with only a few associated with TED. Our patient has been in remission for 20 years before she developed COVID-19 infection with occurence of TED.This suggests that COVID-19 infection may have played a role. SARS-CoV-2 may act through several mechanisms, including breakdown of central and peripheral tolerance, molecular mimicry between viral and self-antigens, stimulation of inflammasome with release of type I interferon. In our patient, treatment with Teprotumumab was indicated due to Graves' orbitopathy clinical activity score greater than or equal to 3. In conclusion, it is very uncommon for TED to present after COVID-19 infection. Our case reinforces the speculative hypothesis that SARS-CoV-2 virus could have triggered an autoimmune response against eye antigens. There is a need for increased awareness about the link between COVID-19 and autoimmunity to help better define the management of patients.Copyright © 2023
ABSTRACT
Catheter ablations of cardiac arrhythmias are nowadays frequently guided by electro-anatomic mapping systems. Technical staff with medical training, or medical staff with technical training, is needed to assist the operator. Travel restrictions because of current COVID-19 pandemics have limited the in person availability for technical support staff. These limitations make us to perform the feasibility of remote support with an internet based communication platform. A total cardiac arrhythmias 25 patients (Male: 10 cases, Female: 15 cases) with different arrhythmias such as Atrial fibrillation (1 case), Atrial flutter (5 cases), Atrial tachycardia (2 cases), Right and Left Ventricular Arrhythmias (19 cases), having undergone ablation procedures between 2020 to 2022. Acute procedure success was obtained 25 cases, no complications. Our experience with remote support for electro-anatomic mapping for complex electrophysiological ablation procedures, showed the feasibility and safety of this approach. It increases the availability of technical support for reducing the costs. Remote support for electroanatomic mapping may therefore facilitate continuous care for patients with arrhythmias during the COVID-19 pandemics. As a result of its advantages beyond COVID-19 pandemics related problems, it will likely play a greater role in the future.
ABSTRACT
Background: Complications following atrial fibrillation (AF) ablation have steadily decreased over the past decade. Following the global COVID-19 pandemic, significant pressure was put on electrophysiology labs to reduce their use of hospital beds. We sought to determine the feasibility as well as safety of same-day discharge following AF ablation procedure. Methods and Results: Between April 2020 and April 2022, 134 patients underwent an AF ablation in our institution and were scheduled to be discharged the same day. Among them, 86.6% (116) went home an average of 8.1 hours after the sheaths were pulled. As for the remaining 18 patients, the majority stayed because the procedure finished too late for the monitoring period to be complete and had no complications requiring an overnight stay. Of the remaining 5 patients, 3 stayed for groin bleed, 1 for minor pericardial effusion and 1 for pulmonary edema. All except the pulmonary edema patient went home the next day. As for the 116 patients who went home the same day, 9.5% (11) came back in the following week to the ER with either pericardial pain (7), shortness of breath (1), recurrent arrhythmia (1) or minor groin discomfort (3). All of them were safely discharged from the ER the same day. Conclusion(s): Our data confirms that same-day discharge following AF ablation procedures is both safe and feasible as confirmed by the absence of any major complications in our single center experience. Some patients came back to the emergency room for expected post ablation discomfort, but none required an overnight stay. Copyright © 2022
ABSTRACT
Background: COVID-19 pandemic, limiting the availability of anesthesiologists, has impacted heavily on the organization of invasive cardiac procedures such as transcatheter atrial fibrillation (AF) ablation. Purpose: We compared the safety and efficacy of deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision, against the standard protocol performed with propofol. Methods: We retrospectively included all AF ablation procedures performed in 2020: 23 patients sedated with 1% propofol (2 ml bolus followed by infusion starting at 1 mg/Kg/h), 26 patients with dexmedetomidine (infusion starting at 0.7 mcg/Kg/h). Both groups additionally received 1 mcg/Kg of midazolam as a single bolus and 0.05 mg single boluses of fentanyl prior to ablation on each pair of pulmonary veins (PV). Primary outcomes were oxygen desaturation (< 90%) or need for assisted ventilation/intubation, bradycardia (heart rate < 45 bpm) and persistent hypotension (systolic blood pressure < 90 mmHg). Results: Baseline characteristics and hemodynamic variables did not differ between the two groups (all p > 0.05). In 8/23 (35%) patients propofol infusion velocity reduction was necessary to maintain the hemodynamic values, compared to 7/26 (27%) with dexmedetomidine. Inter-group comparison of hemodynamic variables during the procedure showed no statistically significant difference, despite a trend in favor of dexmedetomidine (3 respiratory depressions and 3 persistent hypotension episodes with propofol vs. 0 with dexmedetomidine;p = 0.057). Conclusion: Deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision is safe and effective for AF transcatheter ablation. A trend towards a lower incidence of hypotension and respiratory depression was noted when compared to propofol.
ABSTRACT
Objectives: Catheter ablation for atrial fibrillation (AF) was a novel treatment in 1998. Today, ablations are commonplace and compete with rate/rhythm drugs as first-line therapies. While some ablations are performed as outpatient procedures, many require an overnight hospital stay. Ablations are expensive because they require substantial human and material resources as well as hospital facilities that are subject to inflationary pressures. The aim of this research is to compare hospital charges for catheter ablations performed in the State of Maryland during three consecutive calendar years prior to Covid. Methods: Retrospective analysis of inpatient and outpatient data from 2017, 2018, and 2019 was performed to determine the stability of hospital charges or the amount of change year to year. Charges account for all resources consumed, medical and surgical, in association with any ablation procedure for any form of AF – paroxysmal, persistent, long-term persistent, or permanent. Results: Median charges for ablations performed during a hospital visit without an overnight stay (outpatient) remained steady from year to year – $31,511 (2017), $31,520 (2018), $32,392 (2019). Median charges for an ablation performed during a hospital visit with at least one overnight stay (inpatient) were $47,793 (2017), $48,673 (2018), and $56,670 (2019), reflecting cost stability between 2017 and 2018 but a 15% increase, 2019 versus 2018. Patients undergoing a second ablation within one year were considered to have a repeat ablation. Repeat ablation rates increased from 7.3% to 9.2% for inpatient procedures and from 8.4% to 9.8% for outpatient procedures between 2017 and 2018. Repeat ablation charges covered by private payers were higher than those covered by Medicare. Conclusions: Inpatient charges for catheter ablations are rising in Maryland and so is the re-ablation rate. Cost-containment measures, improvements in ablation procedures and skills, as well as advances in electrophysiology technologies are needed to improve cost-efficiencies.
ABSTRACT
Introduction, Objectives, and/or Purpose: Incompetent truncal and perforating veins of the legs contribute to a variety of conditions collectively called chronic venous insufficiency (CVI). Symptoms and signs of CVI adversely affect patient's quality-of-life. These can range from tired and heavy legs, through varicose veins, swollen ankles, fasciocutaneous damage all the way to leg ulceration. International guidelines recommend the treatment of venous reflux using endovenous thermal ablation as a first-line, and foam sclerotherapy as a second-line treatment. Both of these ablate the incompetent vein. There has been a push towards less invasive techniques, but most of these still involve endovenous cannulation. High-Intensity Focused Ultrasound (HIFU) is a completely non-invasive ablative technique. The HIFU technique uses to ultrasound systems within one machine. The first, a greyscale ultrasound with a colour flow capability, is used to identify the target vein and to target the focused ultrasound. The second is a conical focused ultrasound beam, that focuses on a point approximately 5 mm high by 3.6 mm circumference. In this focus area, temperatures can rise to 70-90°C. This is sufficient to ablate biological tissue. Objectives: (1) To assess the success of using HIFU for the treatment of incompetent truncal veins (GSV, SSV, AASV). (2) To assess the success of using HIFU for the treatment of incompetent perforator veins. (3) To determine the success of adjuvant foam sclerotherapy with of after HIFU, as a treatment protocol. Methods: A retrospective audit of 55 patients treated with HIFU using the Sonovein device (Theraclion, Paris, France) between May 2019 and September 2020 was performed. Due to the COVID-19 pandemic, and consequent travel restrictions and lockdowns, not all patients could return for follow-up DUS at the planned time intervals (1-2 weeks, 6- 8 weeks, 6 months, 1-year post-treatment). DUS outcome of the treated vein was graded: 1. complete success (complete atrophy of the target vein) 2. partial success (≥ 1 patent section;none giving rise to recurrent varicose veins / subclinical reflux not requiring treatment) 3. partial failure (≥ 1 patent section giving rise to significant recurrent varicose veins) 4. complete failure. Initially, we performed HIFU of incompetent veins and then completed the procedure with ultrasound-guided foam sclerotherapy. Later, the foamsclerotherapy was delayed and only used if required.We analysed the success rate of HIFU alone in those patients who had only HIFU treatment. In those who had additional foam sclerotherapy, we analysed the success rate of HIFU and foam sclerotherapy starting from the date of the foam sclerotherapy, regardless of whether it was performed on the same day as HIFU or subsequently. Results: Fifty patients (female:male 39:11) returned for at least one follow-up scan giving a 90.9% response rate for at least 1 scan. Due to the COVID-19 pandemic, and consequent travel restrictions and lockdowns, not all patients could return for follow-up DUS at planned time intervals (1-2 weeks, 6-8 weeks, 6 months, 1-year post-treatment). There were 78 legs treated, and 41 truncal veins and 146 incompetent perforator veins. Truncal veins: Twenty-nine patients (41 truncal veins in 35 legs) had at least one follow-up scan. Ten patients (15 truncal veins) had concurrent foam sclerotherapy, and nineteen patients (26 truncal veins) did not. Of these nineteen patients, seven patients (10 truncal veins) received foam sclerotherapy within one year of having HIFU treatment. Twelve patients (16 truncal veins) did not receive foam sclerotherapy at all. Those patients having HIFU only showed an 83.3% (15 out of 18) closure at 6- 8 weeks (Figure 1). The results for HIFU and foam sclerotherapy are shown in Figure 2. Despite difficulties in getting patients back for scans, closure rates of 83.3% and 100% were found between 9 and 12 months and over 12 months, respectively. Perforator veins: Forty-three patients (146 perforator veins in 68 legs) attended at least once. Suc essful ablation was seen in 88% at 6 months and 70% at one year in those not having foam sclerotherapy, and 83.3% and 100% in those having HIFU and foam sclerotherapy. Conclusions: High Intensity Focused Ultrasound (HIFU) is a new technique that can treat incompetent truncal and incompetent perforator veins extracorporeally. We have reported the one-year results of patients having either HIFU alone, or HIFU combined with ultrasound guided foam sclerotherapy. Allowances need to be made for the sporadic follow-up due to the COVID-19 pandemic, and also the fact that we changed our protocols of treatment as we got more experienced. Hence, even although we are reporting what is in effect the learning curve for this technique, the outcomes are not dissimilar from the early outcomes from endovenous thermal ablation. Increased speed of treatment with a corresponding reduction in the need of any local anaesthetic is being introduced, and further audits will be performed in the future to ensure the success rates are maintained or improved.
ABSTRACT
The COVID-19 pandemics is a global challenge with a huge impact on medicine, politics, economy, education, travel and many other aspects of human life. The treatment of heart rhythm disorders has also been affected by the disease itself and by restrictions in order to constrain the spread of the virus. Catheter ablations of cardiac arrhythmias are nowadays frequently guided by electro-anatomic mapping systems. Technical staff with medical training, or medical staff with technical training, is needed to assist the operator. Travel restrictions due to current COVID-19 pandemics have limited the in person availability for technical support staff. To overcome these limitations we explored the feasibility of remote support with an internet based communication platform. A total of 9 patients (87,5% male, mean age 66,6 years) with different arrhythmias (atrial fibrillation, left atrial flutter, typical right atrial flutter, left ventricular tachycardia), having undergone ablation procedures between October 2020 and February 2021, were included. Acute procedural success was obtained in 9 out of 9 procedures. No complications occurred. Our experience with remote support for electro-anatomic mapping for complex electrophysiological ablation procedures, show the feasibility and safety of this approach. It increases the availability of technical support at reduced costs and a reduced CO2 footprint. Remote support for electroanatomic mapping may therefore facilitate continuous care for patients with arrhythmias during the COVID-19 pandemics. Due to its advantages beyond COVID-19 pandemics related problems, it will likely play a greater role in the future.
ABSTRACT
The coronavirus disease 2019 (COVID-19) has become a global pandemic since its outbreak in December 2019, which posed a threat to the safety and well-being of people on a global scale. Cancer patients are at high risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and their critical morbidity and case fatality rates are high. The ablation expert committee of the Chinese Society of Clinical Oncology compiled corresponding expert recommendations. These recommendations summarize the preventive measures and management of tumor ablation treatment in medical institutions, including outpatient clinics, oncology wards, ablation operation room, and postablation follow-ups in accordance with the guidelines and protocols imposed by the National Health Commission of the People's Republic of China and the experience in management and prevention according to various hospitals. This consensus aims to reduce and prevent the spread of SARS-CoV-2 and its cross-infection between cancer patients in hospitals and provide regulatory advice and guidelines for medical personnel.