Outcomes of repeat catheter ablation using magnetic navigation or conventional ablation

The First Evaluation of Remote Magnetic Navigation-Guided Pediatric Ventricular Arrhythmia Ablation

Catheter ablation (CA) is an important treatment option for ventricular arrhythmias (VA) in pediatric cardiology. Currently, various CA techniques are available, including remote magnetic navigation (RMN)-guided radiofrequency (RF) ablation. However, no studies evaluate RMN-guided ablative therapy outcomes in children with VA yet. This study aimed to compare procedural and long-term outcomes between RMN-guided and manual (MAN)-guided VA ablation in children. This single-center, retrospective study included all CA procedures for VA performed in children with or without structural heart disease from 2008 until 2020. Two study groups were defined by CA technique: RMN or MAN. Primary outcome was recurrence of VA. Baseline clinical, procedural and safety data were also evaluated. This study included 22 patients, who underwent 30 procedures, with a median age of 15 (IQR 14-17; range 1-17) years and a mean weight of 57 ± 20 kg. In total, 14 procedures were performed using RMN and 16 using MAN (22 first and 8 redo procedures). Regarding first procedures, recurrence rates were significantly lower in RMN compared to MAN (20% versus 67%, P = 0.029), at a mean follow-up of 5.2 ± 3.0 years. Moreover, fluoroscopy dosages were significantly lower in RMN compared to MAN [20 (IQR 14-54) versus 48 (IQR 38-62) mGy, P = 0.043]. In total, 20 patients (91%) were free of VA following their final ablation procedure. This is the first study to investigate the use of RMN in pediatric VA ablation. RMN showed improved outcomes compared to MAN, resulting in lower VA recurrence and reduced fluoroscopy exposure.

Dipole charge density mapping integrated in remote magnetic navigation: First-in-human feasibility study

Aims

Robotic magnetic navigation (RMN) provides increased catheter precision and stability. Formerly, only the CARTO 3 mapping system was integrated with the RMN system (CARTO-RMN). Recently, a novel high-resolution non-contact mapping system (AcQMap) has been integrated with the RMN system (AcQMap-RMN) for the treatment of atrial fibrillation (AF) and atrial tachycardias (AT). We aim to compare the safety, efficiency, and efficacy of AcQMap-RMN with CARTO-RMN guided catheter ablation (CA) procedures.

Material and methods

In this prospective registry, procedural safety efficiency and outcome data from total of 238 consecutive patients (147 AcQMap-RMN and 91 CARTO-RMN patients) were compared.

Results

AcQMap-RMN is non-inferior in the primary endpoint of safety as compared to CARTO-RMN across the whole group (overall procedural complications in 5 (3.4%) vs. 3 (3.3%) patients, p = 1.0). Overall procedure durations were longer and associated with more fluoroscopy use with AcQMap-RMN (172.5 vs. 129.6 min, p < 0.01; 181.0 vs. 131.0 mGy, p = 0.02, respectively). Procedure duration and fluoroscopy use decreased significantly between the first 30 and the last 30 AcQMap-RMN procedures. The AcQMap-RMN system had fewer recurrences after persistent AF ablations and was non-inferior in paroxysmal AF patients compared to CARTO-RMN at 12 months (36.6% vs. 75.0%, p = 0.04, PAF 6.6% vs. 12.5%, p = 0.58; respectively). CA of AT outcomes were better using the AcQMap-RMN system (1 year recurrence 17.1% vs. 38.7%, p < 0.05).

Conclusion

AcQMap-RMN integration has no negative impact on the excellent safety profile of RMN guided ablations. It improves outcomes of CA procedures for persAF and AT but requires longer procedure times and higher fluoroscopy use during the initial learning phase.

Remote magnetic navigation compared to contemporary manual techniques for the catheter ablation of ventricular arrhythmias in structural heart disease

BACKGROUND

There are limited data comparing remote magnetic navigation (RMN) to contemporary techniques of manual-guided ventricular arrhythmia (VA) catheter ablation.

OBJECTIVES

We compared acute and long-term outcomes of VA ablation guided by either RMN or contemporary manual techniques in patients with structural heart disease.

METHODS

From 2010-2019, 192 consecutive patients, with ischemic cardiomyopathy (ICM) or non-ischemic cardiomyopathy (NICM) underwent catheter ablation for sustained ventricular tachycardia (VT) or premature ventricular complexes (PVCs), using either RMN (n = 60) or manual (n = 132) guided techniques. Acute success and VA-free survival were compared.

RESULTS

In ICM, acute procedural success was comparable between the 2 techniques (manual 43.5% vs. RMN 29%, P = 0.11), as was VA-free survival (manual 83% vs. RMN 74%, P = 0.88), and survival free from cardiac transplantation and all-cause mortality (manual 88% vs. RMN 87%, P = 0.47), both at 12-months after final ablation. In NICM, manual compared to RMN guided, had superior acute procedural success (manual 46% vs. RMN 19%, P = 0.003) and VA-free survival 12-months after final ablation (manual 79% vs. RMN 41%, P = 0.004), but comparable survival free from cardiac transplantation and all-cause mortality 12-months after final ablation (manual 95% vs. RMN 90%, P = 0.52). Procedural duration was shorter in both subgroups undergoing manual guided ablation, whereas fluoroscopy dose and complication rates were comparable.

CONCLUSION

RMN provides similar outcomes to manual ablation in patients with ICM. In NICM however, acute success, and long-term VA-free survival was better with manual ablation. Prospective, multi-centre randomised trials comparing contemporary manual and RMN systems for VA catheter ablation are needed.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: executive summary

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Outcomes of manual versus remote magnetic navigation for catheter ablation of ventricular tachycardia: a systematic review and updated meta-analysis

PURPOSE

Ventricular tachycardia (VT) ablation is a complex procedure that requires remarkable catheter manipulation skill, great mapping accuracy and catheter stability, and can expose patients to serious complications. Magnetic navigation system (RMN)-guided ablation and contact force-sensing (CFS) catheters have the potential to overcome these obstacles. We performed a systematic review and updated meta-analysis of all available studies evaluating the outcomes of VT ablation by using RMN-guided compared to manual navigation (MAN)-guided, with and without CFS catheters.

METHODS

MEDLINE/PubMed, Cochrane, and Google Scholar were searched for randomized controlled trials (RCT) or observational studies with multivariate adjustment comparing RMN-guided versus MAN-guided VT ablation.

RESULTS

Thirteen studies enrolling 1348 patients (656 RMN-guided vs. 692 MAN-guided) were included. CFS catheter were used in 14% of MAN-guided patients. In comparison to MAN-guided and CFS-guided, RMN-guided VT ablation was associated with a significant higher acute ablation success (OR 2.32, 1.66-3.23 and OR 2.91, 1.29-6.53, respectively) but similar results in term of long-term VT recurrence (OR 0.75, 0.56-1.01 and OR 0.79, 0.27-2.36, respectively). RMN-guided showed a better safety profile (for all complications, OR 0.52, 0.34-0.81) and allowed a significant x-ray reduction compared to MAN-guided (OR 0.21, 0.14-0.32) and CFS-guided VT ablation (OR 0.23, 0.11-0.52, all 95% CI).

CONCLUSIONS

RMN-guided was superior to MAN-guided and CFS-guided VT ablation in term of acute ablation success, all complications endpoint, and reduction of fluoroscopy exposure, but did not reduce long-term VT recurrence. Large prospective multicenter randomized trials are needed to confirm these findings.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Remote magnetic navigation versus manual control navigation for atrial fibrillation ablation: A systematic review and meta-analysis

BACKGROUND

The aim of this review was to evaluate the efficacy and safety between remote magnetic navigation (RMN) and manual control navigation (MCN) for atrial fibrillation (AF) ablation.

METHODS

We searched the PubMed, EMBASE and Cochrane library databases using the key words AF, ablation and magnetic navigation.

RESULTS

Eighteen studies were identified in this analysis including 4046 patients comparing RMN and MCN in AF ablation, which were all non-randomized controlled studies. No significant difference of AF recurrence rate (40% vs. 38%, OR 1.00, 95% CI 0.82-1.22, p = 0. 97) and acute success rate in achieving pulmonary vein isolation (91% vs. 93%, OR 0.44, 95% CI 0.16-1.17, p = 0.10) was found between RMN and MCN. However, compared with MCN, RMN was associated with significantly lower complication rate (2% vs. 5%, OR 0.44, 95% CI 0.28-0.69, p = 0. 0003) and shorter fluoroscopy time (MD -9.71 min, 95% CI -15.80 to -3.63, p = 0.002). Procedure time (MD 47.05 min, 95% CI 27.5-66.58, p < 0.00001) and ablation time (MD 15.90 min, 95% CI 9.62-22.18, p < 0.00001) of RMN guided AF ablation were significantly longer than those of MCN.

CONCLUSION

The results of this study suggest that RMN is as effective as MCN in achieving pulmonary vein isolation and freedom from AF recurrence, and has superior safety with less complications and shorter fluoroscopy time.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Repeat ablation of refractory ventricular arrhythmias in patients with nonischemic cardiomyopathy: Impact of midmyocardial substrate and role of adjunctive ablation techniques

INTRODUCTION

Multiple ablations are often necessary to manage ventricular arrhythmias (VAs) in nonischemic cardiomyopathy (NICM) patients. We assessed characteristics and outcomes and role of adjunctive, nonstandard ablation in repeat VA ablation (RAbl) in NICM.

METHODS AND RESULTS

Consecutive NICM patients undergoing RAbl were analyzed, with characteristics of the last VA ablations compared between those undergoing 1 versus multiple-repeat ablations (1-RAbl vs. >1RAbl), and between those with or without midmyocardial substrate (MMS). VA-free survival was compared. Eighty-eight patients underwent 124 RAbl, 26 with > 1RAbl, and 26 with MMS. 1-RAbl and > 1-RAbl groups were similar in age (57 ± 16 vs. 57 ± 17 years; P = 0.92), males (76% vs. 69%; P = 0.60), LVEF (40 ± 17% vs. 40 ± 18%; P = 0.96), and amiodarone use (31% vs. 46%, P = 0.22). One-year VA freedom between 1-RAbl vs. > 1RAbl was similar (82% vs. 80%; P = 0.81); adjunctive ablation was utilized more in >1RAbl (31% vs. 11%, P = 0.02), and complication rates were higher (27% vs. 7%, P = 0.01), most due to septal substrate and anticipated heart block. >1-RAbl patients had more MMS (62% vs. 16%, P < 0.01). Although MMS was associated with worse VA-free survival after 1-RAbl (43% vs. 69%, P = 0.01), when >1RAbl was performed, more often with nonstandard ablation, VA-free survival was comparable to non-MMS patients (85% vs. 81%; P = 0.69). More RAbls were required in MMS versus non-MMS patients (2.00 ± 0.98 vs. 1.16 ± 0.37; P < 0.001).

CONCLUSION

For NICM patients with recurrent, refractory VAs despite previous ablation, effective arrhythmia control can safely be achieved with subsequent ablation, although >1 repeat procedure with adjunctive ablation is often required, especially with MMS.

Atrial Fibrillation Ablation Using Magnetic Navigation Comparison With Conventional Approach During Long-Term Follow-Up

Atrial fibrillation (AF) ablation targeting the circumferential isolation of pulmonary veins (PVI) is an established therapeutic alternative in symptomatic AF patients resistant to anti-arrhythmic medications. The procedure is technically challenging and multiple difficulties must be overcome in order to achieve a successful outcome. The magnetic navigation system (MNS) is a remote catheter control technology which has advantages such as a traumatic catheter design improving the procedural safety, a reduced amount of radiation exposure to both the patient and physician, unrestricted and reproducible catheter maneuverability that allows the access to difficult anatomical situations, and an improved catheter stability leading to better energy delivery. Due to these advantages, MNS is increasingly being used for AF ablation and both acute and chronic success rates are comparable with the conventional technique. The new developments in navigation systems, catheters and new three-dimensional mapping systems are very promising to obviate these concerns. However, MNS is related to longer radiofrequency (RF) application duration and procedure time.

Safety and Clinical Outcome of Catheter Ablation of Ventricular Arrhythmias Using Contact Force Sensing: Consecutive Case Series

BACKGROUND

Poor catheter-to-myocardial contact can lead to ineffective ablation lesions and suboptimal outcome. Contact force (CF) sensing catheters in ventricular tachyarrhythmia (VT) ablations have not been studied for their long-term efficacy.

PURPOSE

The aim of this study was to compare CF ablation to manual ablation (MAN) and remote magnetic navigation (RMN) ablation for safety and efficacy in acute and long-term outcome.

METHODS

A total of 239 consecutive patients who underwent VT ablation with the use of MAN, CF, or RMN catheters were included in this single-center cohort study from January 2007 until March 2014. The primary endpoints were procedural success, acute major complications, and VT recurrences at follow-up. The median follow-up period was 25 months.

RESULTS

Acute success was achieved in 182 out of 239 procedures (76%). Acute success in manual ablation, CF ablation and RMN ablation was 71%, 71%, and 86%, respectively (P = 0.03). Major complications occurred in 3.3% and there were less major complications (P = 0.04) in the RMN group. After an initial successful procedure, 66 of 182 patients (36%) had a recurrence during follow-up. This was not significantly different between groups. Using an intention-to-treat analysis, 124 patients (52%) had a recurrence. The recurrence rate was lowest in the RMN group.

CONCLUSION

The use of CF sensing catheters did not improve procedural outcome or safety profile in comparison to non-CF sensing ablation in this observational study of ventricular arrhythmia ablations.

Remotely controlled steerable sheath improves result and procedural parameters of atrial fibrillation ablation with magnetic navigation

Aims

The magnetic navigation (MN) system may be coupled with a new advancement system that fully controls both the catheter and a robotic deflectable sheath (RSh) or with a fixed-curve sheath and a catheter-only advancement system (CAS). We aimed to compare these approaches for atrial fibrillation (AF) ablation.

Methods and results

Atrial fibrillation ablation patients (45, 23 paroxysmal and 22 persistent) performed with MN–RSh (RSh group) were compared with a control group (37, 18 paroxysmal and19 persistent) performed with MN–CAS (CAS group). Setup duration was measured from the procedure's start to operator transfer to control room. Ablation step duration was defined as the time from the beginning of the first radiofrequency (RF) pulse to the end of the last one and was separately acquired for the left and the right pulmonary vein (PV) pairs. Clinical characteristics, left atrial size, and AF-type distribution were similar between the groups. Setup duration as well as mapping times was also similar. Ablation step duration for the left PVs was similar, but was shorter for the right PVs in RSh group (46 ± 9 vs. 63 ± 12 min, P < 0.0001). Radiofrequency delivery time (34 ± 9 vs. 40 ± 11 min, P = 0.007) and procedure duration (227 ± 36 vs. 254 ± 62 min, P = 0.01) were shorter in RSh group. No complication occurred in RSh group. During follow-up, there were five recurrences (11%) in RSh group and 11 (29%) in CAS group (P = 0.027).

Conclusion

The use of the RSh for AF ablation with MN is safe and improves outcome. Right PV isolation is faster, RF delivery time and procedure time are reduced.