Advancing Surgical Arrhythmia Ablation: Novel Insights on 3D Printing Applications and Two Biocompatible Materials.

To date, studies assessing the safety profile of 3D printing materials for application in cardiac ablation are sparse. Our aim is to evaluate the safety and feasibility of two biocompatible 3D printing materials, investigating their potential use for intra-procedural guides to navigate surgical cardiac arrhythmia ablation. Herein, we 3D printed various prototypes in varying thicknesses (0.8 mm-3 mm) using a resin (MED625FLX) and a thermoplastic polyurethane elastomer (TPU95A). Geometrical testing was performed to assess the material properties pre- and post-sterilization. Furthermore, we investigated the thermal propagation behavior beneath the 3D printing materials during cryo-energy and radiofrequency ablation using an in vitro wet-lab setup. Moreover, electron microscopy and Raman spectroscopy were performed on biological tissue that had been exposed to the 3D printing materials to assess microparticle release. Post-sterilization assessments revealed that MED625FLX at thicknesses of 1 mm, 2.5 mm, and 3 mm, along with TPU95A at 1 mm and 2.5 mm, maintained geometrical integrity. Thermal analysis revealed that material type, energy source, and their factorial combination with distance from the energy source significantly influenced the temperatures beneath the 3D-printed material. Electron microscopy revealed traces of nitrogen and sulfur underneath the MED625FLX prints (1 mm, 2.5 mm) after cryo-ablation exposure. The other samples were uncontaminated. While Raman spectroscopy did not detect material release, further research is warranted to better understand these findings for application in clinical settings.

Pericarditis prophylactic therapy after sinus node-sparing hybrid ablation for inappropriate sinus tachycardia/postural orthostatic sinus tachycardia.

Background: Pericarditis is the most common complication following hybrid sinus node-sparing ablation for inappropriate sinus tachycardia (IST)/postural orthostatic tachycardia syndrome (POTS). Objective: The study sought to evaluate the association of prophylaxis therapy on the risk of symptomatic pericarditis following hybrid IST/POTS ablation. Methods: All consecutive patients undergoing to hybrid ablation of symptomatic IST/POTS refractory or intolerant to drugs were retrospectively analyzed. Pharmacological prophylaxis therapy was based on acetylsalicylic acid and colchicine started on the day of the ablation and continued for at least 3 months. The primary endpoint was occurrence of symptomatic pericarditis. The secondary endpoint was occurrence of pericarditis-related complications, including the following: duration of pericarditis >3 months, hospitalization for pericarditis, postpericardiectomy pleuro-pericarditis, and pericardiectomy. Results: A total of 220 patients undergone to hybrid IST/POTS ablation were included and 44 (20%) underwent prophylaxis therapy. Pericarditis occurred in 101 (45.9%) patients, with 97 (96%) in the first 5 days. At survival analysis, prophylaxis was associated with higher rate of freedom from pericarditis (81.9% vs 47.2%, log-rank P < .001). Pericarditis-related complications were low, occurring in 7 (3.2%) patients. There was no difference in pericarditis-related complications between the patients who underwent prophylaxis therapy and patients who did not. At Cox multivariate analysis, predictors of pericarditis were IST (vs POTS) (hazard ratio 0.61, 95% confidence interval0.39-0.99, P = .04) and prophylaxis therapy (hazard ratio 0.27, 95% confidence interval 0.13-0.55, P < .001). Conclusion: In a large cohort of patients undergoing hybrid ablation for IST/POTS, a prophylaxis therapy with acetylsalicylic acid and colchicine was associated with a lower rate of symptomatic pericarditis.

Coronary artery disease in atrial fibrillation ablation: impact on arrhythmic outcomes.

AIMS: Catheter ablation (CA) is an established treatment for atrial fibrillation (AF). A computed tomography (CT) may be performed before ablation to evaluate the anatomy of pulmonary veins. The aim of this study is to investigate the prevalence of patients with coronary artery disease (CAD) detected by cardiac CT scan pre-ablation and to evaluate the impact of CAD and revascularization on outcomes after AF ablation. METHODS AND RESULTS: All consecutive patients with AF diagnosis, hospitalized at Universitair Ziekenhuis Brussel, Belgium, between 2015 and 2019, were prospectively screened for enrolment in the study. Inclusion criteria were (i) AF diagnosis, (ii) first procedure of AF ablation with cryoballoon CA, and (iii) contrast CT scan performed pre-ablation. A total of 576 consecutive patients were prospectively included and analysed in this study. At CT scan, 122 patients (21.2%) were diagnosed with CAD, of whom 41 patients (7.1%) with critical CAD. At survival analysis, critical CAD at CT scan was a predictor of atrial tachyarrhythmia (AT) recurrence during the follow-up, only in Cox univariate analysis [hazard ratio (HR) = 1.79] but was not an independent predictor in Cox multivariate analysis. At Cox multivariate analysis, independent predictors of AT recurrence were as follows: persistent AF (HR = 2.93) and left atrium volume index (HR = 1.04). CONCLUSION: In patients undergoing CT scan before AF ablation, critical CAD was diagnosed in 7.1% of patients. Coronary artery disease and revascularization were not independent predictors of recurrence; thus, in this patient population, AF ablation should not be denied and can be performed together with CAD treatment.

Redo procedures after sinus node sparing hybrid ablation for inappropriate sinus tachycardia/postural orthostatic sinus tachycardia.

AIMS: A novel sinus node (SN) sparing hybrid ablation for inappropriate sinus node tachycardia (IST)/postural orthostatic tachycardia syndrome (POTS) has been demonstrated to be an effective and safe therapeutic option in patients with symptomatic drug-resistant IST/POTS. The aim of this study was to evaluate the long-term rate of redo procedures after hybrid IST ablation and procedural strategy, outcomes and safety of redo procedures. METHODS AND RESULTS: All consecutive patients from 2015 to 2023 were prospectively enrolled in the UZ Brussel monocentric IST/POTS registry. They were analysed if the following inclusion criteria were fulfilled: 1) diagnosis of IST or POTS, 2) symptomatic IST/POTS refractory or intolerant to drugs, and 3) hybrid SN sparing ablation performed. The primary endpoint was redo procedure. The primary safety endpoint was pacemaker (PM) implantation. A total of 220 patients undergone to hybrid IST ablation were included, 185 patients (84.1%) were treated for IST and 61 patients (27.7%) for POTS.After a follow-up of 73.3 ± 16.2 months, 34 patients (15.4%) underwent a redo. A total of 23 patients (67.6%) had a redo for IST recurrence and 11 patients (32.4%) for other arrhythmias. Pacemaker implantation was performed in 21 patients (9.5%). Nine patients (4.1%) had no redo procedure and experienced sick sinus syndrome requiring a PM. Twelve patients (5.4%) received a PM as a shared therapeutic choice combined with SN ablation procedure. CONCLUSION: In a large cohort of patients the long-term free survival from redo procedure after hybrid IST ablation was 84.6% with a low PM implantation rate.

3D mapping challenges in hybrid video-assisted thoracoscopic surgical ablation of Brugada syndrome.

OBJECTIVES: Brugada syndrome is a life-threatening disease with an arrhythmogenic substrate located in the epicardium of right ventricle outflow tract. Therefore, the correct region identification is crucial for a successful ablation procedure. Various mapping techniques can be adopted to elaborate this issue, but they were all initially developed for endovascular use. METHODS: In this study, we analysed 21 consecutive hybrid video-assisted thoracoscopic ablation of Brugada syndrome, performed using different mapping systems to identify the ablation target and confirm the elimination of arrhythmogenic substrate; 35 maps have been analysed. RESULTS: Acute success of epicardial right ventricle outflow tract ablation has been achieved in 100% of procedures, no periprocedural complications have been observed; HD Grid catheter showed higher area identification speed and faster fractionated potentials visualization; Rhythmia system has demonstrated the best map density; Carto 3 system showed a significant advantage in patient preparation time, but mapping speed was reduced due to focal catheter use only. CONCLUSIONS: All tested electro anatomical mapping systems can be used for hybrid video-assisted thoracoscopic ablation with same clinical success; however, accuracy and efficacy of mapping systems are heterogenous and highly dependent on proper patient preparation, mapping system and physician skills.

Excision of Atrial Myxoma Through a Totally Thoracoscopic Approach on the Fibrillating Heart.

Cardiac myxomas are the most common form of primary cardiac neoplasms. Although benign, they can be deleterious by causing embolic events and intracardiac obstruction. After complete surgical resection, the prognosis is excellent. Although isolated case reports performing video-assisted thoracotomy on the arrested heart have been published, median sternotomy with central cannulation remains the standard approach. We herein describe the case of a morbidly obese patient undergoing successful total resection of a left atrial myxoma using a completely thoracoscopic approach on the fibrillating heart.

Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience.

AIMS: Hybrid atrial fibrillation (AF) ablation is a promising approach in non-paroxysmal AF. The aim of this study is to assess the long-term outcomes of hybrid ablation in a large cohort of patients after both an initial and as a redo procedure. METHODS AND RESULTS: All consecutive patients undergoing hybrid AF ablation at UZ Brussel from 2010 to 2020 were retrospectively evaluated. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation. Additional lesions were performed based on clinical indication and physician judgement. Primary endpoint was freedom from atrial tachyarrhythmias (ATas). A total of 120 consecutive patients were included, 85 patients (70.8%) underwent hybrid AF ablation as first procedure (non-paroxysmal AF 100%), 20 patients (16.7%) as second procedure (non-paroxysmal AF 30%), and 15 patients (12.5%) as third procedure (non-paroxysmal AF 33.3%). After a mean follow-up of 62.3 months ± 20.3, a total of 63 patients (52.5%) experienced ATas recurrence. Complications occurred in 12.5% of patients. There was no difference in ATas between patients undergoing hybrid as first vs. redo procedure (P = 0.53). Left atrial volume index and recurrence during blanking period were independent predictors of ATas recurrence. CONCLUSION: In a large cohort of patients undergoing hybrid AF ablation, the survival from ATas recurrence was 47.5% at ≈5 years follow-up. There was no difference in clinical outcomes between patients undergoing hybrid AF ablation as first procedure or as a redo.

Stiff left atrial syndrome with pulmonary veins occlusion after percutaneous radiofrequency ablation: a life-long complication that can lead to heart transplantation.

BACKGROUND: Stiff left atrial syndrome (SLAS) and pulmonary vein (PV) occlusion are rare yet potentially major life-long complications after radiofrequency ablation for atrial fibrillation. While mostly controlled by medical management, SLAS can progress to refractory congestive heart failure. Treatment of PV stenosis and occlusion remains a challenging problem with ongoing risk for recurrence regardless of techniques employed. Herein we present the case of a now 51-year-old male with acquired PV occlusion and SLAS who, over the course of eleven years, despite multiple interventions, ultimately required heart transplantation. CASE PRESENTATION: After undergoing three radiofrequency catheter procedures for paroxysmal atrial fibrillation (AF), a hybrid ablation was planned due to reappearance of symptomatic AF. Preoperative echocardiography and chest computed tomography (CT) revealed an occlusion of both left PVs. Furthermore, left atrial dysfunction, high pulmonary artery and pulmonary wedge pressures were diagnosed as well as an important reduction of the left atrial volume. The diagnosis of stiff left atrial syndrome was made. Primary surgical repair of the left-sided PVs was performed using a pericardial patch as a tubular neo-vein, combined with cryoablation in the left and right atrium to treat the patient's arrhythmia. Initial results were favorable, however, after two years the patient experienced progressive restenosis with hemoptysis. Therefore, stenting of the common left PV was performed. Over the years, progressive right heart failure with severe tricuspid regurgitation developed, despite maximal medical therapy, which led to the need for heart transplantation. CONCLUSION: The impact of PV occlusion and SLAS after percutaneous radiofrequency ablation can be lifelong and devastating for the clinical course of the patient. Since the presence of a small left atrium could be an important predictor for SLAS in case of redo ablation, preprocedural imaging should guide the operator to an algorithm of a decision-making containing lesion set, energy source, and safety of re-ablation.

Epicardial open chest ventricular tachycardia ablation in no entry left ventricle.

A 57-year-old patient with a history of aortic and mitral mechanical valve replacement was admitted with recurrent implantable cardioverter device shocks and antitachycardia pacing therapies. On electrocardiogram, the clinical ventricular tachycardia (VT) was compatible with an antero-lateral peri-mitral basal exit. Because of the inability to access the left ventricle through a percutaneous approach, epicardial VT ablation was performed. The VT and a second VT, consistently induced and coming from the left ventricular apex, were successfully treated with epicardial cryoablation via median sternotomy under cardiopulmonary bypass.

Esophageal Protection and Temperature Monitoring Using the Circa S-Cath™ Temperature Probe during Epicardial Radiofrequency Ablation of the Pulmonary Veins and Posterior Left Atrium.

Although epicardial bipolar radiofrequency ablation should diminish the risk of esophageal thermal injury in comparison to an endocardial ablation, cases of lethal atrio-esophageal fistula have been reported. To better understand this risk and to reduce the possibility of a thermal injury, we monitored the esophageal temperature with the Circa S-Cath™ temperature probe during and immediately after the ablation while implementing three procedural safety measures. Twenty patients (15 males; 63 ± 10 years) were prospectively enrolled (November 2019-February 2021). All patients underwent an epicardial ablation procedure, including an antral left and right pulmonary vein isolation with bidirectional bipolar clamping, and a roof and inferior line using unidirectional bipolar radiofrequency. Three procedural preventive mitigations were implemented: (1) transesophageal echocardiographic visualization of the atrio-esophageal interface, with probe retraction before the energy delivery; (2) lifting the ablated tissue away from the esophagus during an energy application; and (3) a 30 s cool-off and irrigation period after the energy delivery. The esophageal temperature was recorded using an insulated multisensory intraluminal esophageal temperature probe (Circa S-Cath™). Of the 20 patients enrolled, 7 patients had paroxysmal atrial fibrillation (AF), 8 persistent AF and 5 longstanding persistent AF. The average maximum luminal esophageal temperature observed was 36.2 ± 0.7 °C (34.8-38.2 °C). In our clinical experience, no abrupt increase in the luminal esophageal temperature above the baseline was observed. Since no measurements exceeded the threshold of 39 °C, no prompt interruption of energy delivery was required. Intraluminal esophageal temperature monitoring is feasible and can be helpful in confirming correct catheter position and safe energy application in bipolar epicardial left atrial ablation. Intra-procedural preventive mitigations should be implemented to reduce the risk of esophageal temperature rises.

A novel hybrid technique for the repair of an atrioesophageal fistula post-atrial radiofrequency ablation.

An atrioesophageal fistula is an uncommon complication of atrial ablation with a mortality rate of 40-100%. Uniform treatment guidelines have yet to be established. Herein, we illustrate the successful surgical management of an atrioesophageal fistula, avoiding the need for an oesophageal surgical intervention by sealing and clipping of the oesophagus. This novel single-step hybrid approach combining cardiac surgical and gastroenterological techniques provides a less aggressive strategy with potentially a more favourable prognosis.

Esophageal Findings in the Setting of a Novel Preventive Strategy to Avoid Thermal Lesions during Hybrid Thoracoscopic Radiofrequency Ablation for Atrial Fibrillation.

Purpose The development of an atrio-esophageal fistula, a rare yet potentially lethal complication of ablation for atrial fibrillation, could be related to direct tissue heat transfer during and immediately after the ablation. We therefore studied the postoperative esophageal findings by esophagogastroduodenoscopy in patients that underwent a hybrid ablation procedure using a novel preventive strategy to avoid thermal lesions. Methods Thirty-four patients (28 males; 65 years ± 9 years) were retrospectively included. All underwent a hybrid ablation in our center between April 2015 and November 2019 and agreed to an esophagogastroduodenoscopy within 0-14 days (mean: 5 days) following the ablation. To reduce the incidence of thermal lesions three procedural preventive strategies were introduced: (i) videoscopic intrathoracic transesophageal echocardiographic probe visualization to understand the relationship between posterior left atrial wall and esophagus, with probe retraction before ablation; (ii) lifting the cardiac tissue away from the esophagus during energy application; and (iii) a 30-s cool-off period after energy delivery with irrigation of the device, the ablated tissue, and the surrounding tissues. Results No esophageal thermal lesions were observed. One third of patients were diagnosed with incidental esophageal findings unrelated to the ablation procedure (11; 32.4%). Conclusion Novel preventive strategies by visualization and by avoiding contact between the ablation catheter or ablated tissue and the pericardium, seems to eliminate the potential risk of esophageal thermal lesions in the setting of hybrid ablation. Since one third of patients had preexisting esophageal disease, a more comprehensive pre-operative screening could be important to reduce the risk.