Recent advances in ablation technology 2014 slideshare
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Recent advances in ablation technology
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Recent advances in ablation technology 2014 slideshare
- 1. Recent advances in ablation technology Troy Watts St Bartholomew’s Hospital London troy.watts@bartshealth.nhs.uk
- 2. Novel ablation • Contact – Smart touch/Tacticath/Verisense Contiguous lesion • Endoscopic ablation systems – laser balloon – virtual electrode catheter • Mayo balloon Deeper lesion • Bipolar ablation • Infusion needle RF catheter
- 3. Laser balloon • First human case published by Reddy et al. Circulation 2009 Jul 7;120(1):12-20
- 4. Dukkipati SR et al. Circ Arrhythm Electrophysiol. 2010,3:266-73 Chronic Histology (10 PVs/120 sections) Circumferentiality 100% 96.7% of sections were transmural
- 5. • Multicentre non-randomised trial with 200 patients • ‘PV isolation can be achieved in virtually all patients using a single VGLA catheter with an efficacy similar to radiofrequency ablation’. Dukkipatti etal, Circ EP 2013 Europace. 2014 Jul 16. pii: euu168 194 patients between Jan 2009 & May 2013
- 6. • Multicentre non-randomised trial with 200 patients • ‘PV isolation can be achieved in virtually all patients using a single VGLA catheter with an efficacy similar to radiofrequency ablation’. Dukkipatti etal, Circ EP 2013 • Heartlight study (NCT01456000) • Prospective randomised against RF • 150 patients 5 European centres
- 7. Direct endocardial visualization catheter now ceased-Voyage Medical no longer Journal of Cardiovascular Electrophysiology Volume 23, Issue 1, pages 88-95, 13 SEP 2011 Heart Rhythm 2011 8, 361-367
- 8. Saline acts as virtual electrode rather than conducting heat – DEV greater surface area -16W 2xRF – no difference in depth – no difference in transmurality – 12W ablation same as 30W RF RF 30W vs DEV catheter 14W&16W
- 9. Ablation in patients Heart Rhythm 2011 8, 361-367
- 10. Desimone et al Translational Research July 2014 • Pace • Ablate with RF or DC energy • Drug elution – antiproliferative agent • DC energy for electroporation (7.5mA, 7kHz, 60-300sec) • 2 balloons – inner inflated with air, outer with heparinised saline
- 11. • Ablation 30-50W Desimone et al Translational Research July 2014
- 12. Deeper lesions Korean Circ J 2014;44(4):210-217
- 13. Bipolar ablation Catheter ablation of the ventricular septum with radiofrequency energy Ring et al. Am Heart J. 1989 Jun;117(6):1233-40. Unipolar ablation Bipolar ablation no-contact 50W Bipolar ablation 50W Bipolar ablation 20W Bipolar ablation misaligned 50W Pacing and Clinical Electrophysiology Vol 33;1:pages 16-26, 28 DEC 2009
- 14. Heart Rhythm Volume 9, Issue 12, Pages 1932-1941 (December 2012) Koruth et al Bipolar irrigated radiofrequency ablation: A therapeutic option for refractory intramural atrial and ventricular tachycardia circuits
- 15. • Basal LV free wall max thickness • Unipolar 50W 25ml/min • Bipolar 50W 25ml/min All bipolar ablations achieved transmurality Gizurarson S et al. Europace 2014 Feb 19 Unipolar n=9 Bipolar n=4 Depth mm 6.1 (+/-1.7) 14.8(+/-0.5) P<0.001 Width mm 7.8(+/-3.4) 9.8(+/-1.9) P=ns 9 explanted human hearts Some small series, all patients with failed unipolar ablation
- 16. Teh et al • 4 patients • 24-45K PVCs/day • RVOT & Ao root pre QRS • Initially failed unipolar ablation at earliest sites J Cardiovasc Electrophysiol. 2014 Jun 2 20mm between ablation tips Patient 1 2 3 4 Median 4/12 f/u No PVCs EF 44-62% No PVCs EF 30-44% PVCs 0.6% failed
- 17. Heart Rhythm 2012 9, 1932-1941 Koruth et al Bipolar irrigated radiofrequency ablation: A therapeutic option for refractory intramural atrial and ventricular tachycardia circuits No. pts No. circuits targeted w bipolar abl Circuits terminated Pts w recurrence Pts requiring repeat proc Pts w recurrence after last proc Afl 3 5 5 3 3 1(AF) Septal VT 4 6 5 2 1 1 Free-wall VT 2 3 2 0 0 0
- 18. • 27 gauge needle • Extends to 12mm Sapp J L et al. Circulation. 2013;128:2289-2295 Irrigated RF needle ablation Journal of Cardiovascular Electrophysiology Volume 17, Issue 6, pages 657-661, 1 MAR 2006 DOI: 10.1111/j.1540-8167.2006.00439.x
- 20. Use in VT ablation
- 21. Concluding… • New ablation technologies are getting better at forming contiguous and deeper lesions ?transmural • Rapid introduction of new technologies makes comparison difficult • Epicardial & hybrid approaches • Focus on shorter procedure times with better ablation but without new or more frequent complications
- 22. Thank you
Notas del editor
- Not approved by FDA Available in Europe
- 15 pigs PV divided into 120 sections
- http://www.news-medical.net/news/20130625/European-study-to-evaluate-CardioFocus-HeartLight-Endoscopic-Ablation-System-in-AF-patients.aspx
- http://www.news-medical.net/news/20130625/European-study-to-evaluate-CardioFocus-HeartLight-Endoscopic-Ablation-System-in-AF-patients.aspx
- 13.5 French shaft 8mm inflatable hood Saline flush provides clear medium for fibreoptic viewing The IRIS™ Direct Endocardial Visualization ablation catheter consists of a steerable 13.5 Fr shaft with a self‐deploying hood of 8 mm diameter. The virtual electrode can be conceptualized as the 3 mm hood aperture in contact with the endocardial surface. The saline within the hood conducts electrical current from the proximal metal ring electrode to this virtual electrode. The endoscopic light source and camera connections are located at the proximal handle.
- Most lesions could be seen forming in real time thermochromic
- Average lesion 47 secs, power 20W
- These bursts of electricity increase the resting transmembrane potential (TMP), so that nanopores form in the plasma membrane. When the electricity applied to the tissue is above the electric field threshold of the target tissue, the cells become permanently permeable from the formation of nanopores. As a result, the cells are unable to repair the damage and die due to a loss of homeostasis.
- BRIEF REPORT Novel balloon catheter device with pacing, ablating, electroporation, and drug-eluting capabilities for atrial fibrillation treatment—preliminary efficacy and safety studies in a canine model CHRISTOPHER V. DESIMONE ROCHESTER AND ROGERS, MINNESOTA 4 dogs Ablated SVC, IVC, LAA, RAA, 1xLSPV, 2 lumens
- NOT FIRST LINE – SMALL NUMBER OF PATIENTS
- Agar phantom modeling lesions. All lesions were photographed at 120 seconds of ablation, with the change in color on the embedded thermochromic liquid display representative of the area heated (50–80°C). Panels A and B show unipolar ablations. Panel C (50 W) and panel D (20 W) show bipolar transmural ablations. Panel E shows a 50‐W ablation with both catheters not in contact with the agar, and panel F shows a 50‐W lesion with the catheters in contact but misaligned. Both irrigated caths The safety and feasibility of performing catheter ablation of the ventricular septum with radiofrequency energy was assessed in a closed-chest canine model. Radiofrequency energy (750 kHz) was delivered in a bipolar manner via the distal electrodes of two quadripolar catheters positioned across the ventricular septum in 10 dogs at two sites. Each site received from 159 to 823 joules of delivered energy over one to three applications. Four additional dogs underwent unipolar radiofrequency ablation with 331 to 767 joules of delivered energy to each septal site. No significant acute or latent arrhythmias were noted. Dogs were killed at 1 day, and at 1, 2, and 4 weeks after the procedure. Out of a possible 40 potential ablation sites on each side of the septum after bipolar ablation, 21 (53%) discrete endocardial lesions were identified, ranging in size from 4 x 3 x 1.5 to 10 x 8 x 4 mm. When 352 joules or more delivered energy was applied per site, lesions were located at 18 of 28 (64%) possible sites. After unipolar radiofrequency ablation, similarly sized lesions were identified at 15 of 16 (94%) ablation sites. Histologic examination demonstrated well-delineated round or ovoid-shaped lesions with microscopic thrombi overlying two lesions. In conclusion, catheter ablation of the ventricular septum with radiofrequency energy appears capable of safely producing discrete areas of necrosis and may provide an alternative to direct current (DC) energy for catheter ablation of ventricular tachycardia originating from the septum.
- 27 gauge needle - extends 12mm. Bipolar EGM needle to ring electrode, unipolar needle to IVC electrode.
- no biggie if CRT-D insitu