advancement of catheter ablation with magnetic navigation caiyi lu, shenghua zhou, lei gao, qiao xue...
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Advancement of Catheter Ablation
With Magnetic Navigation
Caiyi Lu, Shenghua Zhou, Lei Gao, Qiao Xue
PLA General Hospital
Principles of Magnetic Navigation Technology
磁场强度: 0.08~0.10T;范围: 15~20cm
导管特点:含 1.8mm磁体 X3;柔软,可控
磁力线方向和大小 导管受力方向和大小
导丝特点:头端金冒,内含磁体
1. 3 维导航
2. 血管腔内导航
3. “ 牛眼”视图导航
4. “ 钟面”视图导航:
导航方式
导航图像的生成
整合 X 线血管造影机的二维图像,生成三维导航图像
整合 CARTO 图像到磁导航的导航图像中
整合 CT 或 MRI 图像,与造影图像结合,形成导航图像
Courtesy of San Raffaele University Hospital, Milan, Italy
Stereotaxis’ Semi-Automatic Cardiac Chamber Algorithm
自动生成三维导航图像
整合 CARTO图像形成导航图 Main Features
– Real-time Catheter Location on Navigant
– Fully Automated Mapping
– “Click and Go” Navigation on CARTO
– Send Carto Points/Lines to Navigant
– Catheter Contact Indicator
– CT Merge object integrated on Navigant
– Wand can be synchronized to CARTO
Navigation Controls on Carto
Integrated CT Merge object Under US 510(K) review. Not available in the US.
Comparison Between MNS and Mannual Procedure
MNS MANNUAL
Catheter
4mm regular magnetic
8mm regular magnetic
irrigated regular magnetic
Mapping bedside control room
Ablating bedside control room
Journal of the American College of Cardiology Vol. 42, No. 11, 2003
MNS and EPS
特点:定位精准,操作灵活,减少照射时间
Shortages of Manual Procedure
Instability of the ablation catheter Lower reproducibility Longer fluoroscopy time More ineffective energy delivery
Advantages of MNS Reduce fluoroscopic time Reduce RF lesion delivery Improved local contact Minimize fluoroscopic guidance Enhances catheter stability Improve clinical efficacy
MNS and AVNRT
Slow Pathway Was Mapped And Ablated By Magnetic Ablation Catheter
Parameter Comparison Between CMT and MNS
Slow and Fast JR during Energy Delivery
MNS and AVRT
Davis DR, et al. J Interv Card Electrophysiol. 2006, 16(3): 149-51
A case of a concealed parahisian AP Recurrence after 3 conventional ablation Successful ablation during a single RF lesion Total fluoroscopy time 17 min Asymptomatic during follow-up of 12 months
Ablation of Concealed Parahisian Accessory Pathway
1. The first case report of CAP ablation2. Key point is catheter stability during RF3. Minimized the risk of AV block
Cavotricuspid Isthmus Ablation in Pts With Common-Type Atrial Flutter (-)
1. 90 pts randomized to mannual (n45) or RMN (n45)2. Complete bidirectional isthmus block RMN 84%, Conventional 91%, P=0.523. RMN: Shorter fluoroscopy time: 10.6/15.0m,P=0.043 Longer RF application: 17.1/7.5m, P<0.0001 Longer ablation time: 55/17m, P<0.0001 Longer procedure duration: 114±35/ 77±24m,P<0.0001 Lower 6m f/u success: 73%/89%, P=0.063
Vollmann D, et al. Circ Arrhythm Electrophysiol. 2009 Dec;2(6):603-10.
MNS and Atrial Flutter
CON(n=45) RMN(n=45) Difference between means (95% CI)
P
Radiofrequency application duration, min
7.5 (3.6 ~10.9)
17.1 (8.6 ~25.1)
… < 0.0001
No. of radiofrequency applications
9 (6 ~ 16) 22 (10 ~ 30) … < 0.0001
Ablation time, min 17 (7 ~ 31) 55 (28 ~ 76) … < 0.0001
Applied engery, w 54±10 59±11 4 ( 0 ~ 9) 0.047
Temperature ,℃ 51±4 50±4 -1 ( -2 ~ 1) 0.38
Impedance , ohm 93±15 92±12 -2 ( -7- ~ 4) 0.58
Robotic vs Conventional Ablation for Common-type Atrial Flutter
• 50 pts (65.7 +/- 9.3 years) with AFL• Rrandomized to conventional or RNS• Bidirectional cavotricuspid isthmus block without
complications
Steven D, et al. Heart Rhythm. 2008, 5(11):1556-60
Procedural data comparison between both study groups
Conventional group 1
RNS group 2 P
Procedure duration, minutes 58.4 ± 17.7 79.4 ± 30.6 .04
Fluoroscopy time, minutes 8.2 ± 4.6 5.8 ± 3.6 .038
Fluoroscopy exposure time, minutes
8.2 ± 4.6 1.9 ± 1.1 .001
Preparation time, minutes 23.5 ± 9.1 45.4 ± 21.4 .001
RF energy, joules 16,308 ± 6870 8279 ± 5767 .001
RF duration, seconds 496.4 ± 213.9 321.7 ± 214.6 .006
• Safety and feasibility • Increased catheter stability• Increased RF application efficacy
Inferior Isthmus Mapping for Ablation of Typical Atrial Flutter
• 50 pts (58±11 years) with typical atrial flutter • Randomized to receive isthmus ablation
Group I (n24): conventionalGroup II (n26): magnetic
• Complete bidirectional isthmus block: Verified by double potential mappingGroup switch: not achieved by 20 RF or 25 min flu
• Results: Group I to II: 33%Group II to I: 4%Total fluoroscopy: 22.0±6.3 vs 3.9±1.5 m (P<0.0001)Fluo for isthmus mapping: 17.7±6.5 vs 0.2±0.3 min (P<0.0001)
• Conclusions: Significant reduction in exposure to fluoroscopyReduced to levels for diagnostic EPSMaintaining high efficacy
Kottkamp H, et al, Circulation. 2000;102:2082
Clinical Characteristics of Patients
Group I (n=24) Group II (n=26) P
Age, y 58.3±10.7 56.8±11.7 NS
Sex, male/female 19/5 21/5 NS
Structural heart disease, n (%) 16 (66.7) 18 (69.2) NS
Atrial flutter CL, ms 235±45 225±50 NS
Atrial enlargement on echocardiography, n (%)
11 (45.8) 13 (50) NS
MNS
CON
MNS And AT
Mehta R et al. Europace 2008;10:280-283
• 72y, Male
• History of CABG, mitral valvular repair, and prior RF
ablation for typical right AFL
• Daily occurrence of AT
• A single RF (43.8 , 27 W, 91Ω) resulted in prompt ℃
termination of AT
• Safety RF circumferentially surrounding success
site (total lesions 5, 236 s, 41.8 , 28 W, 88Ω)℃
A 12 lead ECG shows AT at ventricular rate of 100 beats/min
Mehta R et al. Europace 2008;10:280-283
Mehta R et al. Europace 2008;10:280-283
Mehta R et al. Europace 2008;10:280-283
Ventricular Arrhythmias Ablation: Comparison Between 4- and 8-mm Catheter Tips
• 65 pts with symptomatic VAs• 4mm to 8mm tip comparison• Succsess rate (4mm vs 8mm):
In CAD, IDC 22% vs 59% p=0.014In normal heart 85% vs 87% p=1.00
• Conclusion Increased success related to catheter tip RVOT origin, 4mm tip provided adequate lesions
Biase LD, et al. Journal of Interventional Cardiac Electrophysiology. 2009 , 26 ( 2 ):133
MNS and Ventricular Arrhythmias
Scar-Related Ventricular Tachycardia
• 27 procedures on 24 consecutive patients• VT related to: myocardial infarction dilated cardiomyopathy arrhythmogenic RV cardiomyopathy hypertrophic cardiomyopathy• Electroanatomic mapping Left ventricule 24 pts Right ventricule 10 pts Epicardial 12 pts• Fluoroscopy time for mapping Endocardial 27±23 s Epicardial 18±18 s• 97% VT were ultimately ablated• F/u: 7±3 m with VT free after 1.2 procedures /pt • Conclusions Safety and feasibility Minimal amount of fluoroscopy exposure
Aryana A,et al. Circulation. 2007;115:1191-1200
Ablation of Atrial Fibrillation
• 40 patients: 20 conventional 20 RMN • End point: PV entrance block• Procedure time: 279±60 vs 209±56 m, p<0.001• Fluoroscopy time: 58.6±21 vs 19.5±9.8 m, p<0.001• Conclusion: RMN is safe and feasible Similar clinical outcomes Decreased fluoroscopy and procedure times
Katsiyiannis WT, et al. The American Journal of Cardiology. 2008, 102(12):1674
MNS and Atrial Fibrillation
First Human Experience With An Irrigated-tip
Magnetic Catheter In Pts with Atrial Fibrillation
• Irrigated-tip magnetic catheter (Biosense Webster)• 29 pts (58.8±11.8 y) with symptomatic refractory AF• Power-control mode with a fixed power of 30 W• Endpoints: patient CPVA remotely catheter feasibility, safety and acute efficacy• Results Safe and success: 27/29 pts Total procedure time: 70.5±7.4 min Total ablation time: 30.7±7.1 min Impedance significantly decreased (p<0.0001) Maximum temperature: 36.4±0.8°C Follow-up: 6±2m with AF free in 27/29 pts • Conclusions 100% PV isolation Safe, feasible and effective Mitral isthmus block was easily achieved
Santinelli V, et al. Circulation.2008;118:984
Human Experience in Pulmonary Vein Ablation (-)
• 45 consecutive pts with AF• Stepwise approach: circumferential PV ablation (CPVA) pulmonary vein antrum isolation (PVAI) if failed, PVAI using conventional approach• End point: electrical disconnection of PVs• target location: 60% VS 100% conventional 8% could be electrically isolated 33% charring on the ablation catheter tip• Conclusions Remote magnetic system is a feasible technique Effective lesions cannot be achieved in most cases
Di Biase L, et al. J Am Coll Cardiol. 2007 Aug 28;50(9):868-74
Ablation Experience of Atrial Fibrillation
• 65 pts with refractory AF (43 paroxysmal, 22 persistent)• Acute complete PVI: 95%• Procedure time: 195±40 min• Operator x-ray time: - 6±4 min (35%)• F/u of 239 days, AF free in pts:
76% for paroxysmal AF
68% for and persistent
73% for any atrial tachyarrhythmia recurrences• Conclusions: PVI can be performed safely and effectively
30% of operator’s fluoroscopy be saved• Questions: whether pt fluoroscopy exposure is reduced
whether RN improves PVI quality
Boris Schmidt, et al. Circulation: Arrhythmia and Electrophysiology. 2009;2:120-128
LV Lead Implantation by 3D Image of CS
• 3D reconstruction of CS by using CardiOp-B system• Accuracy was evaluated by CS angiogram• Aims: Feasibility of deploying the guidewire LV lead into the selected side branch(SB)• Results: 16 pts were included Total fluoroscopy time: 23±14 min Fluoroscopy time to SB: 1.7±1.3 min• Conclusion 3D CS can be made using two angiographic views It allows magnetic navigation of guidewires in CS
Rivero-ayerza M, et al. Europace. 2008 , 10 ( 9 ) 1042-6
MNS and LV Lead Implantation
164
28
100
144
24
83
0
30
60
90
120
150
180
(mi n)操作时间 (mi n)曝光时间 (%)成功率
MNS(n=9) (n=12)对照
Rivero-ayerza M, et al. Europace. 2008 , 10 ( 9 ) 1042-6
总 结总 结
磁导航技术应用于心脏电生理介入治疗:安全、精确、有效 目前主要应用领域包括:
心脏电生理检查 心律失常射频消融 植入心脏起搏电极 心肌内注射治疗
临床应用研究尚处于起步阶段,缺乏大规模临床试验
Thank you for your attention