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Romero J, Patel K, Briceno D, Alviz I, Tarantino N, Della Rocca DG, Natale V, Zhang XD, Di Biase L. Fluoroless Atrial Fibrillation Catheter Ablation: Technique and Clinical Outcomes. Card Electrophysiol Clin 2020; 12:233-245. [PMID: 32451107 DOI: 10.1016/j.ccep.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Fluoroscopy continues to be considered an indispensable part of atrial fibrillation (AF) ablation worldwide. Deleterious effects of radiation exposure to patients, physicians, and catheter laboratory personnel are gaining increased consideration. Safety and efficacy of a fluoroless approach for AF ablation is comparable with outcomes achieved with fluoroscopy use. This article focuses on AF ablation with zero fluoroscopy use as well as current evidence on efficacy and safety of this technique. In contrast, minimal fluoroscopy is an alternative. Relying on intracardiac echocardiography for transseptal access and electroanatomic mapping for catheter manipulation can help implement this approach on a wider scale.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Kavisha Patel
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - David Briceno
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Nicola Tarantino
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | | | - Veronica Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Xiao-Dong Zhang
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
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Goya M, Frame D, Gache L, Ichishima Y, Tayar DO, Goldstein L, Lee SHY. The use of intracardiac echocardiography catheters in endocardial ablation of cardiac arrhythmia: Meta-analysis of efficiency, effectiveness, and safety outcomes. J Cardiovasc Electrophysiol 2020; 31:664-673. [PMID: 31976603 PMCID: PMC7078927 DOI: 10.1111/jce.14367] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/10/2020] [Accepted: 01/20/2020] [Indexed: 02/02/2023]
Abstract
Aims The optimal use of intracardiac echocardiography (ICE) may reduce fluoroscopy time and procedural complications during endocardial ablation of cardiac arrhythmias. Due to limited evidence in this area, we conducted the first systematic literature review and meta‐analysis to evaluate outcomes associated with the use of ICE. Methods and Results Studies reporting the use of ICE during ablation procedures vs without ICE were searched using PubMed/MEDLINE. A meta‐analysis was performed on the 19 studies (2186 patients) meeting inclusion criteria, collectively representing a broad range of arrhythmia mechanisms. Use of ICE was associated with significant reductions in fluoroscopy time (Hedges' g −1.06; 95% confidence interval [CI] −1.81 to −0.32; P < .01), fluoroscopy dose (Hedges' g −1.27; 95% CI −1.91 to −0.62; P < .01), and procedure time (Hedges' g −0.35; 95% CI −0.64 to −0.05; P = .02) vs ablation without ICE. A 6.95 minute reduction in fluoroscopy time and a 15.2 minute reduction in procedure time was observed between the ICE vs non‐ICE groups. These efficiency gains were not associated with any decreased effectiveness or safety. Sensitivity analyses limiting studies to an atrial fibrillation (AF) only population yielded similar results to the main analysis. Conclusion The use of ICE in the ablation of cardiac arrhythmias is associated with significantly lower fluoroscopy time, fluoroscopy dose, and shorter procedure time vs ablation without ICE. These efficiency improvements did not compromise the clinical effectiveness or safety of the procedure.
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Affiliation(s)
- Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Diana Frame
- Real World Evidence, CTI Clinical Trial & Consulting, Covington, Kentucky
| | - Larry Gache
- Real World Evidence, CTI Clinical Trial & Consulting, Covington, Kentucky
| | | | | | - Laura Goldstein
- Health Economics & Market Access, Johnson & Johnson Medical Devices, Irvine, California
| | - Stephanie Hsiao Yu Lee
- Health Economics & Market Access, Johnson & Johnson Medical Asia Pacific, Singapore, Singapore
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Osorio J, Bubien RS, Ruff JD, Brenyo AJ, Rajendra A, Gidney BA, Zei P, Morales GX. Single Day Observational Experience at High Volume Ablation Programs: What is the Impact to Practicing Electrophysiologists? J Atr Fibrillation 2019; 11:2059. [PMID: 31139281 DOI: 10.4022/jafib.2059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/19/2017] [Accepted: 09/14/2018] [Indexed: 12/28/2022]
Abstract
Introduction Significant improvements in catheter technology, electro-anatomic (EA) mapping and techniques to reduce fluoroscopy during radiofrequency ablation (RFA) of atrial fibrillation (AF) are on-going.However, few educational opportunities are available post fellowship for Electrophysiologists (EPs) to understand and integrate them into their practice, preventing wide spread adoption. The impact of observational learning for adoption of new technologies and techniques in the field of cardiac electrophysiology has not been studied. We sought to report the impact of a visit to a high-volume center with experience in new technologies and fluoroscopy reductionto the clinical practice of EPs. Methods Between 8/2014 and 10/2017 a total of 150 EPs visited 3 hospitals that perform a high volume of AF RFAs. EPs observed a minimum of 4 RFAs, primarily AF. AF RFAs were performed without fluoroscopy, using Carto 3 Version 4 (Biosense Webster) and intracardiac Echocardiography. There was ample interaction and discussion between hosting and visiting EP. Results 73 EPs (48.6% of visitors) completed an electronic survey after the visit. The majority reported a significant reduction in fluoroscopy (>50%) and procedure (>20%).68% adopted a rigorous workflow and reported an increase in their confidence level with intracardiac echo (79%), continuous mapping (52%) and the Visitag module (61%). Conclusions Observational experience can have an immense impact on the clinical practice of EPs. Further effort should be devoted to such programs and to study in a more systematic way their ultimate impact on patient care.
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Affiliation(s)
| | | | | | | | | | | | - Paul Zei
- Brigham and Women's Hospital, Boston, MA
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Radiation-Induced Sarcoma following Prolonged Coronary Stent Placement. Case Rep Surg 2018; 2018:2903801. [PMID: 30174980 PMCID: PMC6098899 DOI: 10.1155/2018/2903801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 07/19/2018] [Indexed: 11/17/2022] Open
Abstract
Radiation exposure for the average coronary stent placement varies based on a number of factors but typically amounts to 6-11 mSv per patient (compared to 3 mSv background). As with all procedures which utilize radiation, there is an inherent risk of genetic mutation and the possible development of malignancy. Here, we present the case of a 75-year-old male who presented with an exophytic mass on his back following prolonged coronary catheterization with a radiation burn seven years prior. Biopsy of the lesion revealed the mass was consistent with an undifferentiated pleomorphic sarcoma emanating from the site of the radiation burn. After staging studies demonstrated no evidence of metastatic disease, radical excision with negative margins was performed. This case demonstrates that despite the rarity of radiation injury, each incidence necessitates strict monitoring of radiation exposure and continual follow-up due to the risk of malignancy.
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Fujita S, Fujii E, Kagawa Y, Inoue K, Yamada T, Ito M. The seamless integration of three-dimensional rotational angiography images into electroanatomical mapping systems to guide catheter ablation of atrial fibrillation. Heart Vessels 2018; 33:1373-1380. [PMID: 29736557 DOI: 10.1007/s00380-018-1180-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/27/2018] [Indexed: 12/19/2022]
Abstract
It is important to visually confirm radiofrequency ablation lesions during atrial fibrillation (AF) ablation for procedural efficiency, which requires the integration of a three-dimensional (3D) left atrial image reconstructed from computed tomography (CT) or a magnetic resonance imaging. However, an EP Navigator allows seamless integration of 3D anatomy obtained through 3D rotational angiography (3D-ATG) into an electroanatomical mapping system. We hypothesized that 3D-ATG can be used during AF ablation while significantly reducing the effective dose (ED) and without compromising image morphology compared to a 3D-CT image. Organ dose was measured at 37 points with a radiophotoluminescence glass dosimeter inserted in an anthropomorphic Rando Phantom. The ED was calculated by multiplying the organ dose by the tissue weighting factor. The dose-area product (DAP)-to-ED conversion factor was calculated by measuring the DAP during radiation exposure. The ED for the CT examination was estimated from the dose-length product with a conversion factor of 0.014. ED was calculated from DAP measurements in 114 patients undergoing AF ablation using 3D-ATG. The DAP-to-ED conversion factor for 3D-ATG was 2.4 × 10-4 mSv/mGy cm2 in our hospital. The mean DAP for all patients was 7777 ± 1488 mGy cm2 for the 3D-ATG of the left atrium. The corresponding ED for 3D-ATG was 1.9 ± 0.4 mSv. The ED for CT examinations was 13.6 ± 4.2 mSv (P < 0.001). 3D-ATG can be used during AF ablation while significantly reducing the ED and without compromising image morphology.
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Affiliation(s)
- Satoshi Fujita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Eitaro Fujii
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yoshihiko Kagawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Katsuhiro Inoue
- Department of Radiological Technology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tsuyoshi Yamada
- Department of Radiological Technology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Yamagata K, Aldhoon B, Kautzner J. Reduction of Fluoroscopy Time and Radiation Dosage During Catheter Ablation for Atrial Fibrillation. Arrhythm Electrophysiol Rev 2016; 5:144-9. [PMID: 27617094 DOI: 10.15420/aer.2016.16.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Radiofrequency catheter ablation has become the treatment of choice for atrial fibrillation (AF) that does not respond to antiarrhythmic drug therapy. During the procedure, fluoroscopy imaging is still considered essential to visualise catheters in real-time. However, radiation is often ignored by physicians since it is invisible and the long-term risks are underestimated. In this respect, it must be emphasised that radiation exposure has various potentially harmful effects, such as acute skin injury, malignancies and genetic disease, both to patients and physicians. For this reason, every electrophysiologist should be aware of the problem and should learn how to decrease radiation exposure by both changing the setting of the system and using complementary imaging technologies. In this review, we aim to discuss the basics of X-ray exposure and suggest practical instructions for how to reduce radiation dosage during AF ablation procedures.
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Affiliation(s)
- Kenichiro Yamagata
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Bashar Aldhoon
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
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Marinello E, Causin F, Brumana MB, Alaibac M. Radiodermatitis after spinal arteriovenous fistula embolisation. BMJ Case Rep 2016; 2016:bcr-2016-214384. [PMID: 27166008 DOI: 10.1136/bcr-2016-214384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report acute radiation dermatitis on a patient's back and left arm, which developed 4 weeks after endovascular embolisation of a spinal arteriovenous malformation. Vesciculation and erosions were followed by a gradual re-epithelisation of the skin resulting in rectangular hyperpigmented patches that resolved almost completely within 1 month. Fluoroscopic radiodermatitis has been reported with more frequency over the past decades because of the rise in duration and number of procedures performed under fluoroscopic guidance. Articles concerning this issue are mostly limited to case reports after coronary interventions, renal artery catheterisations, transjugular intrahepatic portosystemic shunt procedures and embolisations of intracranial arteriovenous malformation. To the best of our knowledge, only two cases of radiation dermatitis after spinal arteriovenous malformation embolisation have been reported to date.
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Affiliation(s)
| | | | | | - Mauro Alaibac
- Unit of Dermatology, University of Padua, Padova, Italy
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Ma Y, Qiu J, Yang Y, Tang A. Catheter Ablation of Right-Sided Accessory Pathways in Adults Using the Three-Dimensional Mapping System: A Randomized Comparison to the Conventional Approach. PLoS One 2015; 10:e0128760. [PMID: 26083408 PMCID: PMC4471277 DOI: 10.1371/journal.pone.0128760] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/28/2015] [Indexed: 11/19/2022] Open
Abstract
Three-dimensional (3D) mapping and navigation systems have been widely used for the ablation of atrial fibrillation and ventricular tachycardia, but the applicability of these systems for the ablation of supraventricular tachycardia (SVT) due to right-sided accessory pathways (RAPs) remains unknown. The goal of this prospective randomized study was to compare the safety, efficiency, and efficacy of nonfluoroscopic and conventional fluoroscopic mapping techniques in guiding catheter ablation of SVT due to RAPs. Of the 393 consecutive patients with SVT who were randomized to receive either conventional fluoroscopic or Ensite NavX mapping-guided ablation, 64 patients with RAPs were included for analysis. Endpoints for ablation were no evidence of RAP conduction and no inducible atrioventricular reentrant tachycardia (AVRT). The 3D group showed fewer ablation pulses and a shorter total ablation time compared to the conventional group, although the acute procedural success did not differ significantly between the two groups. Total procedure time, electrophysiological study time, total fluoroscopy time, and cumulative radiation doses were also significantly reduced in the 3D group. Patients in the conventional group with a right atrium diameter (RAD) ≥ 47 mm required a longer fluoroscopy time. There was no significant difference in the recurrence rates between the two groups over a follow-up period of 3 to 29 months. There were no permanent complications. The 3D mapping system may be a preferred alternative for patients with AVRT due to RAPs, especially for patients with a large RAD (≥ 47 mm).
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Affiliation(s)
- Yuedong Ma
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jia Qiu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yang Yang
- Department of Pathology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Anli Tang
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- * E-mail:
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Akbulak RÖ, Schäffer B, Jularic M, Moser J, Schreiber D, Salzbrunn T, Meyer C, Eickholt C, Kuklik P, Hoffmann BA, Willems S. Reduction of Radiation Exposure in Atrial Fibrillation Ablation Using a New Image Integration Module: A Prospective Randomized Trial in Patients Undergoing Pulmonary Vein Isolation. J Cardiovasc Electrophysiol 2015; 26:747-53. [PMID: 25807878 DOI: 10.1111/jce.12673] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 02/23/2015] [Accepted: 03/17/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Recently, a new image integration module (IIM, CartoUnivu™ Module) has been introduced to combine and merge fluoroscopy images with 3-dimensional-(3D)-electroanatomical maps (Carto® 3 System) into an accurate 3D view. The aim of the study was to investigate the influence of IIM on the fluoroscopy exposure during pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) in a prospective randomized trial. METHODS AND RESULTS Between June and November 2014, a total of 60 patients with PAF (73.3% male, 64.0 ± 9.2 years), who underwent PVI with the endpoint of unexcitability of the ablation line, were randomized to either a conventional 3D mapping system (Carto® 3 System) or to an additional IIM on the basis of an assumed reduction of fluoroscopy exposure by the use of IIM. There were no significant differences in baseline characteristics. The median ablation procedure time was identical in both groups (140.7 ± 27.8 minutes vs. 140.8 ± 39.5 minutes; P = 0.851). A significant decrease of mean fluoroscopy time from 11.9 ± 2.1 to 7.4 ± 2.6 minutes (P < 0.0006) and median fluoroscopy dose from 882.9 to 476.5 cGycm(2) (P < 0.001) was achieved. The main reduction of radiation could be realized during creation of the 3D-map. No major complications occurred during the procedures. After a median follow-up of 125.7 ± 45.6 days 80% of the patients were free from any atrial arrhythmias. CONCLUSION CartoUnivu™ module easily integrates into the workflow of PVI with the endpoint of unexcitability of the ablation line without prolonging the procedure time. It is associated with a marked reduction in fluoroscopic dose when compared to a conventional 3D mapping system.
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Affiliation(s)
- Ruken Özge Akbulak
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Schäffer
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Mario Jularic
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Moser
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Doreen Schreiber
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Salzbrunn
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Meyer
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Eickholt
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pawel Kuklik
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Boris A Hoffmann
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stephan Willems
- Department of Cardiology - Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Bourke T, Moriarty J, Boyle NG, Shivkumar K. Atrial Fibrillation Ablation: Do We Really Need Preprocedural Imaging? Card Electrophysiol Clin 2012; 4:305-315. [PMID: 26939950 DOI: 10.1016/j.ccep.2012.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Atrial fibrillation is the most common human arrhythmia, causing significant mortality and morbidity. Because of the potential for complications, it is important that procedures be made as safe and effective as possible by combining safe procedural planning with effective therapy delivery. To change the current approach, large randomized studies are needed to guide the selection of patients who may safely undergo ablation without transesophageal echocardiography to exclude thrombus. For institutions routinely using computed tomography and magnetic resonance imaging to assess pulmonary vein anatomy before procedures, the possibility of excluding intracardiac thrombi using these imaging modalities should be considered.
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Affiliation(s)
- Tara Bourke
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, UCLA Health System, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA; Department of Cardiology, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - John Moriarty
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, UCLA Health System, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Noel G Boyle
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, UCLA Health System, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, UCLA Health System, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
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2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol 2012; 33:171-257. [PMID: 22382715 DOI: 10.1007/s10840-012-9672-7] [Citation(s) in RCA: 256] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.
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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJG, Damiano RJ, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012; 14:528-606. [PMID: 22389422 DOI: 10.1093/europace/eus027] [Citation(s) in RCA: 1144] [Impact Index Per Article: 95.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJG, Damiano RJ, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm 2012; 9:632-696.e21. [PMID: 22386883 DOI: 10.1016/j.hrthm.2011.12.016] [Citation(s) in RCA: 1299] [Impact Index Per Article: 108.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Indexed: 12/20/2022]
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The effect of NavX on fluoroscopy times in pediatric catheter ablation. J Interv Card Electrophysiol 2011; 33:123-6. [DOI: 10.1007/s10840-011-9604-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 07/05/2011] [Indexed: 10/16/2022]
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Stabile G, Scaglione M, del Greco M, De Ponti R, Bongiorni MG, Zoppo F, Soldati E, Marazzi R, Marini M, Gaita F, Iuliano A, Bertaglia E. Reduced fluoroscopy exposure during ablation of atrial fibrillation using a novel electroanatomical navigation system: a multicentre experience. Europace 2011; 14:60-5. [PMID: 21893511 DOI: 10.1093/europace/eur271] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
AIMS Catheter ablation of atrial fibrillation (AF) focuses on pulmonary vein (PV) ablation with or without additional atrial substrate modification. These procedures require significant fluoroscopy exposure. A new 3D non-fluoroscopic navigation system (CARTO(®) 3 System, Biosense Webster, CA, USA) that allows precise location visualization of diagnostic and ablation catheters was evaluated for its impact on fluoroscopic exposure during AF ablation procedures. METHODS AND RESULTS Two groups of patients were treated by our centres for drug refractory AF. One group was treated using the new CARTO(®) 3 system to guide catheter ablation (Group A, 117 patients). The other group was treated using the CARTO(®) XP system (Biosense Webster) 3 months previously (Group B, 123 patients). For both groups, circumferential PV ostia ablation was performed; PV isolation was validated using a circular catheter placed at each ostium. There was no difference in any clinical characteristics (age, sex, AF type, left atrium diameter and volume, and heart disease) among the two study groups. The mean number of PVs identified and isolated per patient was similar in both groups, as were the mean procedural duration and radiofrequency time. However, mean fluoroscopic time was significantly reduced in Group A (15.9±12.3 min) as compared with Group B (26±15.1 min) (P < 0.001). CONCLUSION This multicentre observational study demonstrates a significant reduction of fluoroscopy exposure using a new 3D non-fluoroscopic mapping system to guide AF catheter ablation.
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Reddy VY, Morales G, Ahmed H, Neuzil P, Dukkipati S, Kim S, Clemens J, D'Avila A. Catheter ablation of atrial fibrillation without the use of fluoroscopy. Heart Rhythm 2010; 7:1644-53. [PMID: 20637313 DOI: 10.1016/j.hrthm.2010.07.011] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 07/11/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND In performing catheter ablation of paroxysmal atrial fibrillation (PAF), the advent of electroanatomical mapping (EAM) has significantly reduced fluoroscopy time. Recent advances in the ability of EAM systems to simultaneously visualize multiple catheters have allowed some operators to perform certain procedures, such as catheter ablation of supraventricular tachycardias, with zero fluoroscopy use. OBJECTIVE The purpose of this study was to evaluate the feasibility and safety of pulmonary vein (PV) isolation with zero fluoroscopy use, using a combination of three-dimensional EAM and intracardiac echocardiography (ICE). METHODS Using the NavX EAM system, the right atrial (RA) and coronary sinus (CS) geometries were created without fluoroscopy. Fluoroless transseptal puncture was performed under ICE guidance. Using a deflectable sheath and a multipolar catheter, the left atrial (LA) and PV anatomies were rendered and, in select cases, integrated with a three-dimensional computed tomography (CT) image. Irrigated radiofrequency ablation was performed to encircle each pair of ipsilateral PVs. RESULTS This series included 20 consecutive PAF patients. RA/CS mapping required 5.5 ± 2.6 minutes. In all patients, single (n = 18) or dual (n = 2) transseptal access was successfully achieved. The LA-PV anatomy was rendered using either a circular (14 patients) or penta-array (six patients) catheter in 22 ± 10 minutes; CT image integration was used in 11 patients. Using 49 ± 18 ablation lesions/patient, electrical isolation was achieved in 38/39 ipsilateral PV isolating lesion sets (97%). The procedure time was 244 ± 75 minutes. There were no complications. CONCLUSION Completely fluoroless catheter ablation of paroxysmal AF is safely feasible using a combination of ICE and EAM.
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Affiliation(s)
- Vivek Y Reddy
- Cardiac Arrhythmia Service, Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Lakkireddy D, Nadzam G, Verma A, Prasad S, Ryschon K, Di Biase L, Khan M, Burkhardt D, Schweikert R, Natale A. Impact of a comprehensive safety program on radiation exposure during catheter ablation of atrial fibrillation: a prospective study. J Interv Card Electrophysiol 2008; 24:105-12. [DOI: 10.1007/s10840-008-9316-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 09/08/2008] [Indexed: 11/29/2022]
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18
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Atrial fibrillation ablation complications. J Interv Card Electrophysiol 2008; 22:167-72. [DOI: 10.1007/s10840-007-9200-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Accepted: 12/21/2007] [Indexed: 10/22/2022]
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19
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Natale A, Raviele A, Arentz T, Calkins H, Chen SA, Haïssaguerre M, Hindricks G, Ho Y, Kuck KH, Marchlinski F, Napolitano C, Packer D, Pappone C, Prystowsky EN, Schilling R, Shah D, Themistoclakis S, Verma A. Venice Chart international consensus document on atrial fibrillation ablation. J Cardiovasc Electrophysiol 2007; 18:560-80. [PMID: 17456138 DOI: 10.1111/j.1540-8167.2007.00816.x] [Citation(s) in RCA: 291] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andrea Natale
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, USA
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20
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Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJG, Damiano RJ, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007; 4:816-61. [PMID: 17556213 DOI: 10.1016/j.hrthm.2007.04.005] [Citation(s) in RCA: 966] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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21
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Lickfett L, Mahesh M, Vasamreddy C, Bradley D, Jayam V, Eldadah Z, Dickfeld T, Kearney D, Dalal D, Lüderitz B, Berger R, Calkins H. Radiation Exposure During Catheter Ablation of Atrial Fibrillation. Circulation 2004; 110:3003-10. [PMID: 15505084 DOI: 10.1161/01.cir.0000146952.49223.11] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The purpose of this study was to determine the radiation exposure during catheter ablation of atrial fibrillation (AF) using the pulmonary vein (PV) approach.
Methods and Results—
The study included 15 patients with AF and 5 patients each with atrial flutter and atrioventricular nodal reentrant tachycardia (AVNRT) who underwent fluoroscopically guided procedures on a biplane x-ray system operated at a low-frame pulsed fluoroscopy (7.5 frames per second). Radiation exposure was measured directly with 50 to 60 thermoluminescent dosimeters (TLDs). Peak skin doses (PSDs), effective radiation doses, and risk of fatal malignancies were all computed. Mean fluoroscopy durations for AF procedures were 67.8±21 minutes in the right anterior oblique (RAO) and 61.9±16.6 minutes in the left anterior oblique (LAO) projection, significantly different from that required for atrial flutter and AVNRT. The mean PSDs measured with the TLDs were 1.0±0.5 Gy in the RAO and 1.5±0.4 Gy in the LAO projection. The lifetime risk of excess fatal malignancies normalized to 60 minutes of fluoroscopy was 0.07% for women and 0.1% for men.
Conclusions—
The relatively small amounts of the patient’s radiation exposure in this study, despite the prolonged fluoroscopy durations, can be attributed to the use of very-low-frame pulsed fluoroscopy, the avoidance of magnification, and optimal adjustments of the fluoroscopy exposure rates. The resulting lifetime risk of fatal malignancy is within the range previously reported for standard supraventricular arrhythmias.
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Affiliation(s)
- Lars Lickfett
- Division of Cardiology, The Johns Hopkins Hospital, Baltimore, Md, USA
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22
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Rodríguez Nevado IM, Argila Fernández-Durán DD, Farré IR, Fuentes Cañamero ME. Radiodermitis crónica secundaria a cateterismo cardíaco. ACTAS DERMO-SIFILIOGRAFICAS 2001. [DOI: 10.1016/s0001-7310(01)76487-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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23
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Alaei P, Gerbi BJ, Geise RA. Generation and use of photon energy deposition kernels for diagnostic quality x rays. Med Phys 1999; 26:1687-97. [PMID: 10501068 DOI: 10.1118/1.598674] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Accurately determining the dose from low energy x rays is becoming increasingly important. This is especially so because of high doses in interventional radiology procedures and also because of the desire to model accurately the dose around low energy brachytherapy sources. Various methods to estimate the dose from specific procedures are available but they only give a general idea of the true dose to various organs. The use of sophisticated three-dimensional (3D) dose deposition algorithms designed originally for radiation therapy treatment planning can be extended to lower photon energy regions. The majority of modern 3D treatment planning systems use a variation of the convolution algorithm to calculate dose distributions. This could be extended into the diagnostic energy range with the availability of lower energy deposition kernels ( < 100 keV). We have used version four of the Electron Gamma Shower (EGS4) system of Monte Carlo codes to generate photon energy deposition kernels in the energy range of 20-110 keV and have implemented them in a commercial 3D treatment planning system (Pinnacle, ADAC Laboratories, Milpitas, CA). The kernels were generated using the "SCASPH" EGS4 user code by selecting the appropriate transport parameters suitable for the relative low energy of the incident photons. The planning system was subsequently used to model diagnostic quality beams and to calculate depth dose and cross profile curves. Comparisons of the calculated curves have been made with measurements performed in a homogeneous water phantom.
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Affiliation(s)
- P Alaei
- Department of Diagnostic Radiology, University of Minnesota, Minneapolis 55455, USA.
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Rosenthal LS, Mahesh M, Beck TJ, Saul JP, Miller JM, Kay N, Klein LS, Huang S, Gillette P, Prystowsky E, Carlson M, Berger RD, Lawrence JH, Yong P, Calkins H. Predictors of fluoroscopy time and estimated radiation exposure during radiofrequency catheter ablation procedures. Am J Cardiol 1998; 82:451-8. [PMID: 9723632 DOI: 10.1016/s0002-9149(98)00356-7] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The objective of this study was to identify factors that predict fluoroscopy duration and radiation exposure during catheter ablation procedures. The patient population included 859 patients who participated in the Atakr Ablation System clinical trial at 1 of 9 centers (398 male and 461 female patients, aged 36 +/- 21 years). Each patient underwent catheter ablation of an accessory pathway, the atrioventricular junction, or atrioventricular nodal reentrant tachycardia using standard techniques. The duration of fluoroscopy was 53 +/- 50 minutes. Factors identified as independent predictors of fluoroscopy duration included patient age and sex, the success or failure of the ablation procedure, and the institution at which the ablation was performed. Catheter ablation in adults required longer fluoroscopy exposure than it did in children. Men required longer durations of fluoroscopy exposure than did women. The mean estimated "entrance" radiation dose was 1.3 +/- 1.3 Sv. The dose needed to cause radiation skin injury was exceeded during 22% of procedures. The overall mean effective absorbed dose from catheter ablation procedures was 0.025 Sv for female patients and 0.017 Sv for male patients. This degree of radiation exposure would result in an estimated 1,400 excess fatal malignancies in female patients and 2,600 excess fatal malignancies in male patients per 1 million patients.
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Affiliation(s)
- L S Rosenthal
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Scanavacca M, d'Avila A, Velarde JL, Reolão JB, Sosa E. Reduction of radiation exposure time during catheter ablation with the use of pulsed fluoroscopy. Int J Cardiol 1998; 63:71-4. [PMID: 9482147 DOI: 10.1016/s0167-5273(97)00278-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED Prolonged exposure to radiation during radiofrequency catheter ablation implies a potential risk of radiodermatitis, neoplasm and genetic defects to the patient and to the operator-physician. The use of pulsed fluoroscopy is thought to reduce such a risk because the radiation dose decreases for the same period of time. The aim of the present study was to compare the radiation exposure time during pulse and continuous radiofrequency catheter ablation. METHODS Procedures were divided according to the sort of fluoroscopy utilized and the last four cases of atrioventricular (AV) junction ablation, four of atrial flutter, five of atrial tachycardia, 16 of AV node reentrant tachycardia, 16 of AV tachycardia and 10 of ventricular tachycardia in which pulsed and continuous fluoroscopy were utilized were respectively separated into Group I (pulse fluoroscopy) and Group II (continuous fluoroscopy) with 55 patients in each group. Fluoroscopy was generated by the same device in the two groups. Continuous fluoroscopy used 2 mA and automatic kV adjustment (automatic brightness stabilizer) ranging from 70 to 110 kV. Pulsed fluoroscopy was set at 7 squares/s with 25 mA and automatic kV adjustment. Fluoroscopy time was registered by the fluoroscopy device counter. RESULTS Procedure duration, success rate and complications did not differ between Groups I and II. Fluoroscopy time, however, was 4.4+/-4 min during pulsed fluoroscopy and 27+/-23 min during continuous fluoroscopy (p=0.001). CONCLUSION During radiofrequency catheter ablation procedures, the use of pulsed fluoroscopy set at 7 squares/s, decreases the radiation exposure time by 80% as compared to continuous fluoroscopy without changing procedure duration and success rate.
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Affiliation(s)
- M Scanavacca
- Heart Institute, University of São Paulo Medical School, Brazil
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26
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Park TH, Eichling JO, Schechtman KB, Bromberg BI, Smith JM, Lindsay BD. Risk of radiation induced skin injuries from arrhythmia ablation procedures. Pacing Clin Electrophysiol 1996; 19:1363-9. [PMID: 8880801 DOI: 10.1111/j.1540-8159.1996.tb04216.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Catheter guided ablation of cardiac arrhythmias is an effective and safe procedure for the treatment of most supraventricular and selected ventricular tachycardias. Because catheter manipulation is fluoroscopically guided, there is risk of radiation induced injury, especially during prolonged procedures. The Food and Drug Administration has recently issued a bulletin warning of the risks of acute skin injury occurring during fluoroscopically guided procedures that result in an exposure level exceeding 2 Gray units (Gy). This study was performed as an investigation into the risk of radiation induced skin injury during arrhythmia ablation procedures. The amount of radiation exposure for 500 patients who underwent ablation was calculated based upon fluoroscopy times and the entrance dose of radiation (0.02 Gy/min). The mean radiation exposure was 0.93 +/- 0.62 Gy. Although 5.6% of patients (n = 28) received enough radiation exposure to reach the threshold dose (2 Gy) for early transient erythema, no clinical manifestations of acute radiation induced skin injury were observed. No patients achieved the threshold dose for irreversible skin injury. Patients undergoing AV node ablation or modification received significantly less radiation (0.39 +/- 0.40 Gy and 0.79 +/- 0.44 Gy, respectively) than patients undergoing other ablation procedures (0.94-1.45 Gy, P < 0.05). There was no association between the magnitude of radiation exposure and the presence of underlying heart disease. Patients undergoing ablation of accessory pathways were exposed to more radiation if there was a right-sided pathway (1.69 +/- 0.93 Gy) compared to other sites (0.87-1.24 Gy, P < 0.05). This study demonstrates that the risk of significant radiation induced skin injury during arrhythmia ablation procedures is low provided that precautions are taken to minimize radiation exposure.
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Affiliation(s)
- T H Park
- Adult Cardiology Division, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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