Unexpected effects of new covid-19 infection in arrhythmia surgery

The article presents two clinical cases of patients with a fatal outcome after a coronavirus infection. The first patient had sepsis and purulonecrotic phlegmon complication after radiofrequency ablation of the cavatricuspid isthmus. The second one had a complication in the form of the esophageal rupture in the middle third after transesophageal echocardiography.Copyright © 2021, NJSC Institute of Cardiological Technology (INCART). All rights reserved.

Ablation for hepatocellular carcinoma (HCC)

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.

Management of Metastatic CA (Cancer) Pancreas Pain in Post Chemotherapy, Radiotherapy Patient With Combination of Neural Interventions (Oral Neuromodulators, Peripheral Nerve Blocks) and Muscular Intervention USGDN (Ultrasonography Guided Dry Needling): A Case Report

Aims: To describe combined neural and muscular interventions in post covid exacerbations of cancer pain with disabilities.To present a new perspective of neuromyopathy to explain Intractable CA pancreas pain. Introduction: Additional challenges in cancer pain management are due to cancer treatment complications (chemotherapy, radiotherapy). CA Pancreas pains routinely addressed with oral neuromodulators, opioids neurolytic coeliac plexus block (NCPB) or splanchnic nerve radiofrequency ablation (SRF). 75 years male, CA pancreas with spine, pelvic bone metastasis, post chemotherapy radiotherapy. 6 months bedridden with post covid exacerbations in pain (vas 10/10) received prior painkillers. Started oral pregabalin 75mg od, ultracet bd, myospaz bd. Result(s): With 15 days medications vas 6/10, patient could sit on wheelchair. Given sciatico-femoral block, pain reduced vas 2/10 but recurred in 7 day vas 5/10. Started USGDN of tight back and lower limb muscles with 32G solid needles.post3 sessions vas 2/10, able to walk with support after 4 weeks. Discussion(s): Viscerosomatic convergence at the dorsal horn neurons produces visceral pain referred to back and abdominal muscles led to muscle spasm with generation of myofascial trigger points(MTrPs)and pain. USGDN addresses MTrPs. Needle insertion produces local twitch reflex (LTR) followed by muscle relaxation with pain relief. Neural interventions addresses only visceral nociceptive afferents from celiac plexus which forms 10% of total spinal cord afferent input which sensitizes peripheral and central motor nociceptive pathway processing neuromyopathy. Conclusion(s): Viscerosomatic convergence with muscles involvement (neuromyopathy) proved to be effectively managed by using combined approaches, neuromoduation and USGDN in Ca pancreas pain with disabilities.Copyright © 2023

Ultrasound-Guided Percutaneous Thermal Ablation of Renal Cancers-In Search for the Ideal Tumour.

Over the recent years, the progress in imaging techniques has led to an increased detection of kidney tumours, including small renal masses. While surgery is still the standard of care, there is a growing interest in minimally invasive methods. Ultrasound (US)-guided percutaneous ablation is particularly attractive because it is a safe and relatively simple procedure. In this study, we investigated the success of percutaneous radiofrequency ablation (RFA) in relation to kidney tumour diameter and location. Between August 2016 and September 2021, 253 patients with 259 renal tumours underwent US-guided RFA as a primary treatment in our institution. A total of 67 patients were excluded from this study. Abdominal computed tomography (CT) and tumour biopsy were performed before the procedure. Patients were followed with contrast-enhanced CT, the average follow-up time was 28 months. The studied group was composed of 186 patients with 191 renal tumours-only biopsy-confirmed renal cancers were included. During the follow-up, 46 cases of residual disease and 4 cases of local progression were found. There was a significant correlation between tumour size and the ablation success rate. The success rate was 73.5% and 87.6% for lesions ≤25 mm, 94.6% for lesions ≤25 mm and exophytic, 79.1% for lesions 26-30 mm and 84.4% for lesions 26-30 mm and exophytic, respectively. Four Clavien-Dindo grade ≥2 complications were observed. US-guided percutaneous RFA of T1a renal cancers is safe and well-tolerated. Its effectiveness depends on tumour size, with best results for exophytic lesions smaller than 3 cm. Most of the recurrent or residual tumours can be successfully re-treated with US-guided percutaneous RFA.

Left atrial thrombus exclusion before atrial fibrillation ablation: Reconsidering the role of cardiac computed tomography

Objectives: Considering the risk of aerosolization during the COVID-19 pandemic associated with transesophageal echocardiography (TEE), we evaluated the diagnostic performance of cardiac computed tomography (CCT) before pulmonary vein isolation (PVI) in comparison to semi-invasive TEE in excluding left atrial (LA)/LA appendage (LAA) thrombus, limiting the need for TEE to only patients with possible thrombus on CCT. Material(s) and Method(s): We included a total of 145 consecutive patients with atrial fibrillation (AF) (age 52.4 +/- 10.3 years;63% males;89 paroxysmal AF) referred for radiofrequency ablation in National Cardiovascular Center Harapan Kita, Jakarta, Indonesia. All patients underwent preprocedural single-phase 128-slice multidetector CT and subsequent TEE as the reference standard with a mean time interval of 6.5 +/- 5.3 days between the two procedures. Result(s): CCT identified 30 patients (20.7%) with a filling defect in the LA/LAA, 8 of which were confirmed by TEE as thrombi (22 false positives and 8 true positives), whereas 9 true thrombi (6.2%) were detected by TEE (1 false negative by CCT). The sensitivity and specificity of CCT were 88.9% and 83.8%, respectively, with a positive predictive value of 26.8% and a negative predictive value of 99.1%. The overall accuracy was 84.1%. Conclusion(s): Apart from being a planned preparation modality before PVI, CCT is sufficient and could be used as an initial step to exclude the presence of LA/LAA thrombus, limiting the invasive TEE only for confirmation of the thrombus if detected by CCT.

Radiofrequency ablation of incessant atrial tachycardia after COVID-19 infection

Objectives: We present a case of a 38-year-old male with no known comorbidities who presented with incessant focal atrial tachycardia complicated by tachycardia-mediated cardiomyopathy and COVID-19 infection. He successfully underwent 3D Cardiac Mapping + radiofrequency ablation of the right superior pulmonary vein. Material(s) and Method(s): Results: A 38-year-old male presented with persistent palpitations and tachycardia associated with heart failure symptoms. On work up, 12 L-ECG showed sustained focal atrial tachycardia with heart rate (HR) ranges 170-190 bpm with positive p-wave axis in lead I, II, III, AVF and upright in lead V1. He was initially started on HR-lowering medications and given electrical synchronized cardioversion which were both unsuccessful. A week later, patient developed COVID-19 pneumonia and subsequently completed isolation as per local government protocol. During the course of admission, a POCUS echocardiogram was done which showed a newly depressed left ventricular ejection fraction (EF) of 22% compared to a previous 44% two weeks earlier. Hence, patient eventually underwent successful 3D-mapping and radiofrequency ablation of the right super pulmonary vein via transseptal approach. He was then successfully discharged with Metoprolol 200 mg twice daily alongside with other heart failure medications. Conclusion(s): Development of COVID-19 infection can run the risk of worsening and clinical decompensation among patients with incessant tachyarrhythmia and there are still no established data regarding the safety of doing radiofrequency ablation post-COVID-19 infection. This case report illustrates doing a successful radiofrequency frequency ablation post-COVID-19 infection in a patient who developed incessant atrial tachycardia.

ENDOSCOPIC FINDINGS AND CLINICAL OUTCOMES IN PATIENTS WITH ABNORMAL CYTOSPONGE RESULTS

Background Published outcomes from Cytosponge sampling of oesophageal mucosa are so far limited to trial setting data or single centres. This project aimed to describe endoscopic sample histopathology in the Scottish 'real life' setting when endoscopy was indicated by abnormal Cytosponge results. Methods In light of the COVID-19 pandemic and pre-existing pressures on endoscopy services, the Scottish government agreed to fund the national roll-out of the Cytosponge programme for patients previously undergoing endoscopic surveillance for Barrett's oesophagus or presenting with reflux-predominant symptoms. All patients undergoing Cytosponge for Barrett's oesophagus surveillance with an abnormal Cytosponge result indicating 'atypia' from three Scottish health boards between September 2020 and January 2022 were included in this study. Patients' electronic records were interrogated to ascertain if they had undergone endoscopy following abnormal Cytosponge result. Histopathology results and clinical outcomes were extracted from patient notes. Results In the three Scottish health boards included in this study, 1863 Cytosponge procedures were performed and formally reported, of which 1350 (72.5%) were performed for Barrett's oesophagus surveillance. 95 samples (7.0%) indicated the presence of atypia. 65 patients had endoscopy and pathology results available and were included in the analysis. In our cohort, 26/65 (40.0%) patients had endoscopic biopsies suggestive of dysplasia: 8/26 (30.8%) were indefinite for dysplasia;6/26 (23.1%) showed low grade dysplasia;5/26 (19.2%) showed high grade dysplasia. Malignant disease was identified in 7 patients: 4/26 (15.4%) confirmed intramucosal adenocarcinoma;3/26 (11.5%) confirmed invasive adenocarcinoma. 10/26 (38.5%) patients with confirmed dysplasia were awaiting or had undergone endoscopic mucosal resection (EMR) or radiofrequency ablation (RFA). All 3 patients with confirmed invasive adenocarcinoma had undergone neoadjuvant chemotherapy and surgical resection at the time of analysis. 21/26 (80.8%) of samples confirming dysplasia on formal biopsy were also positive for p53 staining at initial Cytosponge. Conclusion Cytosponge is a valuable tool in the allocation of sparse endoscopy resources during the COVID-19 pandemic, with high rates of pathological findings in the cohort where immediate endoscopy has been recommended based on abnormal Cytosponge result.

Analyzing the adoption of radiofrequency ablation of thyroid nodules using the diffusion of innovations theory: understanding where we are in the United States?

Thyroid nodules are very common and found in up to 68% of the general U.S. population on ultrasound. Although thyroidectomy has long been the mainstay of treatment for malignant and symptomatic benign thyroid nodules, various interventional ablative techniques have emerged in the last couple of decades as alternative non-surgical treatment options. Globally, the most widely adopted technique has been ultrasound-guided radiofrequency ablation (RFA). RFA of thyroid nodules was first performed in 2002, and there has been an expanding body of evidence since 2006 showing that RFA and other interventional ablative techniques are effective treatments for benign solid thyroid nodules, toxic adenomas, and thyroid cysts. More recently, evidence has emerged that these techniques may be effective treatment for low-risk thyroid cancer and recurrent disease. Despite these findings, the United States has been slow to adopt these techniques, with only a single publication on RFA more than a decade after the first series was published. EM Rogers' Diffusion of Innovation Theory provides us the appropriate lens to carefully analyze the process of adoption of RFA for thyroid nodules-to understand where we are currently, as well as, the important next steps that must be accomplished in order for RFA and other ablative techniques to be successfully adopted into the management algorithm of thyroid nodules in the United States.

Radiofrequency ablation for management of thyroid nodules in quarantine zone of COVID-19 pandemic setting in Indonesia.

Surgery using minimally invasive procedures has been continuously developing in the medical field including in the treatment and resection of thyroid tumors. In addition to open thyroid surgery, several types of procedures are well developed and adopted in our center including the endoscopic thyroid and radiofrequency ablation (RFA). The COVID-19 pandemic has substantially changed the healthcare system in Indonesia. Lack of oxygen and hospital wards, unaffordable screening tests, and limited health workers affect the perpetuation of non-emergency healthcare service including in the management of thyroid nodules. To preserve the resources needed during the pandemic, PFA for the thyroid procedure provides a better option in terms of hospital bed availability, healthcare cost, and patients' emotional distress. We safely conducted RFA procedures during the period of quarantine levels of 1-3 (low to high) by implementing COVID-19 protocols without any significant postoperative complications.

Is endovascular treatment of the great saphenous vein (with immediate foam sclerotherapy of superficial tributary veins) in an outpatient clinic really safe and profitable?

BACKGROUND: This preliminary study aimed to evaluate the safety of radiofrequency (RF) thermoablation of the great saphenous vein (GSV) with immediate foam sclerotherapy of superficial tributary veins performed in the outpatient clinic (Hospital Department). Further, we also evaluated the cost reduction compared to the same procedure performed in the operating room. METHODS: Thirty patients were evaluated for RF thermoablation of the GSV. Foam sclerotherapy was performed with 1-3%sodium-tetra-decyl-sulphatefoam (Tessari’s method). We evaluated the possible risks of the procedure and methods to resolve them. We compared the costs of both procedures performed in the operating room and in the outpatient clinic. RESULTS: We had complete occlusion of the GSV in 28/30 patients (93.3%). Periodic check-up revealed a reflux through an anterior lateral saphenous vein in one patient and a long saphenous stump in another patient. There were no severe intraoperative complications. In two cases, it was necessary to convert the radiofrequency procedure into foam sclerotherapy (using the hollow probe as a long catheter in one case and using needle injection in the second case). In another case, it was necessary to perform surgical cannulation of the GSV. There were no severe postoperative complications. Moreover, the cost of the operating room procedure was € 1226.50, while that of the outpatient clinic procedure was € 1082.65 (cost reduction, 12.5%). CONCLUSIONS: This procedure is safe and sufficiently cost-effective to perform in an outpatient clinic and the operating room can hence be reserved for patients with more serious pathologies. These results should be validated in further studies with larger sample size.

Atrial Tachycardia Masquerading As Inappropriate Sinus Tachycardia (IST) After COVID-19 Infection: A Matter of Concern?

COVID-19 Infection has wrecked havoc all over the world; the spectrum of this disease ranges from asymptomatic mild cases to severe cases such as acute respiratory distress syndrome (ARDS). Not only the acute infection but post COVID sequelae are also a cause of concern. Post-COVID states or Long COVID are the sequences of complications following the active infection. As post COVID sequelae are unpredictable it is absolutely the need of the hour to educate physicians and make them aware of all possibilities. We report one such case of a post COVID recovered young lady, who presented with drug-refractory recurrent palpitations. She was initially suspected to have inappropriate sinus tachycardia. But electrophysiological study confirmed the diagnosis of atrial tachycardia which was successfully ablated. The patient now has completed six months of follow-up and is off any medication.

New next-generation microwave thermosphere ablation for small hepatocellular carcinoma.

BACKGROUND/AIMS: In July 2017, the Emprint™ next-generation microwave ablation system using thermosphere technology (Covidien, Boulder, CO, USA) was approved for use in Japan. This system can produce a predictable spherical ablation zone at higher temperatures than radiofrequency ablation (RFA). The aim of the present study was to elucidate whether this new microwave thermosphere ablation (MTA) could safely improve outcome compared to RFA, which is the standard of care for small hepatocellular carcinoma (HCC). METHODS: This retrospective study analyzed 513 patients with 630 HCCs (≤3 cm) who were performed by percutaneous RFA (174 patients, 214 HCCs) or MTA (339 patients, 416 HCCs) between January 2016 and March 2020. RESULTS: Median ablation time was significantly shorter for MTA (240 seconds) than for RFA (721 seconds; P<0.001). A significant difference in 3-year local tumor progression rate was evident between the RFA group (22%) and MTA group (8%; P<0.001). Multivariable analysis revealed ablation procedure and tumor diameter as independent factors contributing to local tumor progression (MTA; P<0.001; hazard ratio, 0.565; 95% confidence interval, 0.437-0.731). In patients with primary HCC, a significant difference in overall survival was evident (RFA vs. MTA, 3-year, 77% vs. 95%, P=0.029). Ablation procedure and Child-Pugh score were independent factors contributing to survival. The total complication rate was significantly lower for MTA (8%) than for RFA (14%, P<0.05), particularly for bile duct injury (3% vs. 9%, respectively; P<0.05). CONCLUSION: Next-generation MTA for small HCC could provide safer, more curative treatment in a shorter ablation time than RFA.

One-Year Recording of Cardiac Arrhythmias in a Non-Infected Population with Cardiac Implantable Devices During the COVID-19 Pandemic.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) was associated with a higher risk of arrhythmia in infected patients. However, there are no reports about the effect of the ongoing pandemic on arrhythmias in the non-infected population. We measured the arrhythmia burden in a non-infected population with cardiac implantable devices. METHODS: The arrhythmia burden during the COVID-19 pandemic was compared to a 6-month interval in the pre-COVID-19 period. The COVID-19 pandemic was divided into high-risk (17 January 2020 to 16 March 2020) and low-risk periods (17 March 2020 to 17 July 2020) according to whether there were locally infected patients. Arrhythmia burdens were compared among the pre-COVID-19, high-risk, and low-risk periods. RESULTS: A total of 219 patients with 1859 episodes were included. We observed a larger proportion of patients with atrial fibrillation (AF) during the COVID-19 pandemic (38.36% vs 26.03%, p = 0.006). There was not significantly more ventricular arrhythmia during the COVID period than the pre-COVID-19 period (p > 0.05). During the high-risk period, daily frequency of non-sustained ventricular tachycardia (NSVT) (0.0172, 0.0475 vs 0.0109, 0.0164, p < 0.05), atrial tachycardia (AT) (0.0345, 0.0518 vs 0.0164, 0.0219 p < 0.05) and AF (0.0345, 0.0432 vs 0.0164, 0.0186, p < 0.05) and daily duration of NSVT (0.1982, 0.2845 vs 0.0538, 0.1640 p < 0.05) were higher and longer than those in the pre-COVID-19 period. Regression modeling showed that the impact of COVID-19 pandemic lead to an increased onset of AF (odds ratio 2.465; p < 0.01). Patients with paroxysmal AF who had undergone a previous radiofrequency ablation had a lower burden of AF (incidence 21.43% vs 55.00%, P = 0.049, daily frequency 0.0000, 0.0027 vs 0.0000, 241.7978, P = 0.020) during the pandemic. CONCLUSION: The COVID-19 pandemic contributed to a higher burden of arrhythmias in non-infected patients. Patients would experience a lower burden of AF following radiofrequency ablation treatment, and this effect persisted during the pandemic.

Clinical outcomes of radiofrequency ablation for patients with varicose veins of the lower extremities combined with grade II iliac vein compression.

BACKGROUND: Iliac vein compression (IVC) is a common condition in patients with varicose veins (VVs) of the legs. IVC has been classified into three grades in previous studies. Grade II IVC is defined by >50% stenosis without the development of collateral circulation. The purpose of the present study was to investigate the outcomes of radiofrequency ablation (RFA) for patients with VVs combined with grade II IVC. METHODS: A retrospective analysis was conducted of 339 patients who had undergone RFA for VVs of the left leg from March 2017 to January 2019. Duplex ultrasonography, computed tomography venography, and venography were performed to evaluate for grade II IVC. All the patients were divided into two groups. Group 1 included patients with VVs only, and group 2, patients with VVs combined with grade II IVC. Propensity score matching was used to ensure an even distribution of confounding factors between groups. The venous clinical severity score (VCSS) and chronic venous insufficiency questionnaire (CIVIQ) score were recorded during the 12-month follow-up. Occlusion of the truncal veins was evaluated using duplex ultrasound scans. RESULTS: Using 1:1 propensity score matching, 50 pairs of patients were enrolled in the present analysis. The average age of groups 1 and 2 was 58.7 ± 13.1 and 60.1 ± 7.1 years, respectively. The VCSS had decreased significantly from baseline to 12 months postoperatively (group 1, from 5 to 1; group 2, from 4 to 1; P < .01). A significant increase in the CIVIQ score was found between the baseline and 12-month evaluations for both groups (group 1, from 62.5 to 69; group 2, from 63 to 70; P < .01). The truncal occlusion rate was 98% in both groups at 12 months. No significant differences were found between the two groups in the VCSS, CIVIQ score, procedure complications, or occlusion rate during the 12-month follow-up. CONCLUSIONS: RFA is effective for patients with VVs combined with grade II IVC.

Thermal ablation alone vs thermal ablation combined with transarterial chemoembolization for patients with small (<3 cm) hepatocellular carcinoma.

PURPOSE: Thermal ablation (TA) and transarterial chemoembolization (TACE) may be used alone or in combination (TACE+TA) for the treatment of hepatocellular carcinoma (HCC). The aim of our study was to compare the time to tumor progression (TTP) and overall survival (OS) for patients who received TA alone or TACE+TA for HCC tumors under 3 cm. MATERIALS AND METHODS: This HIPAA-compliant IRB-approved retrospective analysis included 85 therapy-naïve patients from 2010 to 2018 (63 males, 22 females, mean age 62.4 ± 8.5 years) who underwent either TA alone (n = 64) or TA in combination with drug-eluting beads (DEB)-TACE (n = 18) or Lipiodol-TACE (n = 3) for locoregional therapy of early stage HCC with maximum tumor diameter under 3 cm. Kaplan-Meier analysis was performed using the log-rank test to assess TTP and OS. RESULTS: All TA and TACE+TA treatments included were technically successful. TTP was 23.0 months in the TA group and 22.0 months in the TACE+TA group. There was no statistically significant difference in TTP (p = 0.64). Median OS was 69.7 months in the TA group and 64.6 months in the TACE+TA group. There was no statistically significant difference in OS (p = 0.14). The treatment cohorts had differences in AFP levels (p = 0.03) and BCLC stage (p = 0.047). Complication rates between patient groups were similar (p = 0.61). CONCLUSION: For patients with HCC under 3 cm, TA alone and TACE+TA have similar outcomes in terms of TTP and OS, suggesting that TACE+TA may not be needed for these tumors unless warranted by tumor location or other technical consideration.

Multimodal Percutaneous Thermal Ablation of Small Hepatocellular Carcinoma: Predictive Factors of Recurrence and Survival in Western Patients.

BACKGROUND: To identify the predictive factors of recurrence and survival in an unselected population of Western patients who underwent multimodal percutaneous thermal ablation (PTA) for small Hepatocellular Carcinomas (HCCs). METHODS: January 2015-June 2019: data on multimodal PTA for <3 cm HCC were extracted from a prospective database. Local tumor progression (LTP), intrahepatic distant recurrence (IDR), time-to-LTP, time-to-IDR, recurrence-free (RFS) and overall (OS) survival were evaluated. RESULTS: 238 patients underwent 317 PTA sessions to treat 412 HCCs. During follow-up (median: 27.1 months), 47.1% patients had IDR and 18.5% died. LTP occurred after 13.3% of PTA. Tumor size (OR = 1.108, p < 0.001; hazard ratio (HR) = 1.075, p = 0.002) and ultrasound guidance (OR = 0.294, p = 0.017; HR = 0.429, p = 0.009) independently predicted LTP and time-to-LTP, respectively. Alpha fetoprotein (AFP) > 100 ng/mL (OR = 3.027, p = 0.037) and tumor size (OR = 1.06, p = 0.001) independently predicted IDR. Multinodular HCC (HR = 2.67, p < 0.001), treatment-naïve patient (HR = 0.507, p = 0.002) and AFP > 100 ng/mL (HR = 2.767, p = 0.014) independently predicted time-to-IDR. RFS was independently predicted by multinodular HCC (HR = 2.144, p = 0.001), treatment naivety (HR = 0.546, p = 0.004) and AFP > 100 ng/mL (HR = 2.437, p = 0.013). The American Society of Anesthesiologists (ASA) score > 2 (HR = 4.273, p = 0.011), AFP (HR = 1.002, p < 0.001), multinodular HCC (HR = 3.939, p = 0.003) and steatotic HCC (HR = 1.81 × 10-16, p < 0.001) independently predicted OS. CONCLUSIONS: IDR was associated with tumor aggressiveness, suggesting a metastatic mechanism. Besides AFP association with LTP, IDR, RFS and OS, treatment-naïve patients had longer RFS, and multi-nodularity was associated with shorter RFS and OS. Steatotic HCC, identified on pre-treatment MRI, independently predicted longer OS, and needs to be further explored.

Editor's Choice - Role of Compression After Radiofrequency Ablation of Varicose Veins: A Randomised Controlled Trial☆.

OBJECTIVE: Post-procedure limb compression, hitherto routine following open varicose vein surgery, has been extended to endovenous procedures. However, no robust evidence exists to support this practice. Most of the previous studies have focused on the ideal duration of compression. This study evaluates the clinical and patient reported outcomes with and without post-procedure leg compression following radiofrequency ablation (RFA). METHODS: This single centre, prospective, non-inferiority randomised controlled trial recruited adult patients, into two groups (A: RFA with compression stocking for two weeks, B: RFA alone). The primary outcome was ultrasound determined target vein obliteration at 12 weeks. Secondary outcome measures included a Quality of Life (QoL) score [Aberdeen Varicose Vein Severity Score (AVSS) and Revised Venous Clinical Severity Score (RVCSS)], patient satisfaction, pain score, and complications. RESULTS: In total, 100 consecutive patients were recruited (A: 51; B: 49) classified as clinical class C2-C6 of the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification. At 12 weeks the occlusion rate of the target vein was similar in both groups at 98% (n = 47) and 98% (n = 45), respectively (p = 1.0). There was no statistically significant difference in mean AVSS 6 vs. 5.0 (mean difference -1, 95% CI -2 - 3, p = .57) and mean RVCSS 3 vs. 4 (mean difference 1, 95% CI -1 - 2, p = .46) scores at 12 weeks. Comparable patient satisfaction scores were observed (p = .72) and pain score 2.0 vs. 2.0 (p = .92) were achieved in both groups. Two patients in each group developed deep vein thrombosis at two weeks follow up (p = 1.0 for above the knee and p = 1.0 for below the knee). CONCLUSION: The clinical and patient reported outcomes following RFA without compression are no worse than with compression. This trial supports the conclusion that the widely practised use of compression after RFA adds no clinical benefit for the patients. However, a much larger study, preferably a multicentre trial, may be required to confirm this conclusion.

Radiofrequency Ablation vs Electrocautery Blinded Randomized Trial: Impact on Clinically Meaningful Outcomes.

OBJECTIVE: To analyze patients' return to normal activity, pain scores, narcotic use, and adverse events after undergoing tonsillectomy or adenotonsillectomy with monopolar electrocautery or radiofrequency ablation. STUDY DESIGN: Randomized double-blinded clinical trial based on prospective parallel design. SETTING: Academic medical center and tertiary children's hospital between March 2018 and July 2019. METHODS: Inclusion criteria included patients aged ≥3 years with surgical indication of recurrent tonsillitis or airway obstruction/sleep-disordered breathing. Patients were randomly assigned to monopolar electrocautery or radiofrequency ablation. Patients were blinded to treatment assignment. Survey questions answered via text or email were collected daily until postoperative day 15. The primary outcome was the patient's return to normal activity. Secondary outcomes included daily pain score, total amount of postoperative narcotic use, and adverse events. RESULTS: Of the 236 patients who met inclusion criteria and were randomly assigned to radiofrequency ablation or monopolar electrocautery, 230 completed the study (radiofrequency ablation, n = 112; monopolar electrocautery, n = 118). There was no statistically significant difference between the groups in the number of days for return to normal activity (P = .89), daily pain scores over 15 postoperative days (P = .46), postoperative narcotic use (P = .61), or return to hospital for any reason (P = .60), including bleeding as an adverse event (P = .13). CONCLUSIONS: As one of the largest randomized controlled trials examining instrumentation in tonsillectomy, our data do not show a difference between monopolar electrocautery and radiofrequency ablation with regard to return to normal activity, daily pain scores, total postoperative narcotic use, or adverse events.

Rebooting atrial fibrillation ablation in the COVID-19 pandemic.

PURPOSE: Catheter ablation procedures for atrial fibrillation (AF) were significantly curtailed during the peak of coronavirus disease 2019 (COVID-19) pandemic to conserve healthcare resources and limit exposure. There is little data regarding peri-procedural outcomes of medical procedures during the COVID-19 pandemic. We enacted protocols to safely reboot AF ablation while limiting healthcare resource utilization. We aimed to evaluate acute and subacute outcomes of protocols instituted for reboot of AF ablation during the COVID-19 pandemic. METHODS: Perioperative healthcare utilization and acute procedural outcomes were analyzed for consecutive patients undergoing AF ablation under COVID-19 protocols (2020 cohort; n=111) and compared to those of patients who underwent AF ablation during the same time period in 2019 (2019 cohort; n=200). Newly implemented practices included preoperative COVID-19 testing, selective transesophageal echocardiography (TEE), utilization of venous closure, and same-day discharge when clinically appropriate. RESULTS: Pre-ablation COVID-19 testing was positive in 1 of 111 patients. There were 0 cases ablation-related COVID-19 transmission and 0 major complications in either cohort. Pre-procedure TEE was performed in significantly fewer 2020 cohort patients compared to the 2019 cohort patients (68.4% vs. 97.5%, p <0.001, respectively) despite greater prevalence of persistent arrhythmia in the 2020 cohort. Same-day discharge was achieved in 68% of patients in the 2020 cohort, compared to 0% of patients in the 2019 cohort. CONCLUSIONS: Our findings demonstrate the feasibility of safe resumption of complex electrophysiology procedures during the COVID-19 pandemic, reducing healthcare utilization and maintaining quality of care. Protocols instituted may be generalizable to other types of procedures and settings.