RESUMO
Popeye domain-containing (POPDC) proteins selectively bind cAMP and mediate cellular responses to sympathetic nervous system (SNS) stimulation. The first discovered human genetic variant (POPDC1S201F) is associated with atrioventricular (AV) block, which is exacerbated by increased SNS activity. Zebrafish carrying the homologous mutation (popdc1S191F) display a similar phenotype to humans. To investigate the impact of POPDC1 dysfunction on cardiac electrophysiology and intracellular calcium handling, homozygous popdc1S191F and popdc1 knock-out (popdc1KO) zebrafish larvae and adult isolated popdc1S191F hearts were studied by functional fluorescent analysis. It was found that in popdc1S191F and popdc1KO larvae, heart rate (HR), AV delay, action potential (AP) and calcium transient (CaT) upstroke speed, and AP duration were less than in wild-type larvae, whereas CaT duration was greater. SNS stress by ß-adrenergic receptor stimulation with isoproterenol increased HR, lengthened AV delay, slowed AP and CaT upstroke speed, and shortened AP and CaT duration, yet did not result in arrhythmias. In adult popdc1S191F zebrafish hearts, there was a higher incidence of AV block, slower AP upstroke speed, and longer AP duration compared to wild-type hearts, with no differences in CaT. SNS stress increased AV delay and led to further AV block in popdc1S191F hearts while decreasing AP and CaT duration. Overall, we have revealed that arrhythmogenic effects of POPDC1 dysfunction on cardiac electrophysiology and intracellular calcium handling in zebrafish are varied, but already present in early development, and that AV node dysfunction may underlie SNS-induced arrhythmogenesis associated with popdc1 mutation in adults.
Assuntos
Bloqueio Atrioventricular , Cálcio , Adulto , Animais , Humanos , Cálcio/metabolismo , Peixe-Zebra/genética , Peixe-Zebra/metabolismo , Nó Atrioventricular/metabolismo , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Bloqueio Atrioventricular/complicações , Arritmias Cardíacas/genética , Doença do Sistema de Condução CardíacoRESUMO
Catheter ablation is a treatment modality which has been increasingly used for cardiac arrhythmias. However, it is not complication-free, and cardiac perforation is one of its most life-threatening complications. As surgery is usually not the first-line treatment for this emergent episode, there were only very few sporadic surgical reports in the literature. This systemic review primarily aims to collect different surgical approaches for catheter-induced cardiac perforation to help surgeons manage this kind of uncommon and critical patients. Of the 452 initially screened articles, 22 studies (38 patients) were included in the systemic review. Of all the included patients, 84% (32/38) were found to have pericardial effusion acutely following catheter-related procedures, and 16% (6/38) experienced delayed-onset episodes. Regarding the surgical procedures, four patients underwent removal of clots only, eight patients underwent suture repair of the left ventricle (LV), nine patients underwent suture repair of the right ventricle (RV), five patients underwent suture repair of the LA, and four patients underwent sutureless repair of the LV and pulmonary vein (LV 1, RV 1, pulmonary vein 1). In addition to repair of perforation sites, the concomitant combined procedures included repair of intercostal vessels (complication of pericardiocentesis) for one patient, cryoablation for two patients, and maze procedure for one patient. For cardiac perforation following catheter ablation or electrophysiology study, although the majority of the patients are treated with pericardiocentesis and medical management at first, cardiovascular surgeons have to prepare to take over if the bleeding is persistent or if the cardiac tamponade is not relieved.
Assuntos
Ablação por Cateter/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Traumatismos Cardíacos/cirurgia , Traumatismos Cardíacos/etiologia , Humanos , Veias Pulmonares/lesões , Veias Pulmonares/cirurgia , SuturasRESUMO
AIMS: Radiation use in medicine has significantly increased over the last decade, and cardiologists are among the specialists most responsible for X-ray exposure. The present study investigates a broad range of aspects, from specific European Union directives to general practical principles, related to radiation management among a national cohort of cardiologists. METHODS AND RESULTS: A voluntary 31-question survey was run on the Italian Arrhythmology and Pacing Society (AIAC) website. From June 2019 to January 2020, 125 cardiologists, routinely performing interventional electrophysiology, participated in the survey. Eighty-seven (70.2%) participants are aware of the recent European Directive (Euratom 2013/59), although only 35 (28.2%) declare to have read the document in detail. Ninety-six (77.4%) participants register the dose delivered to the patient in each procedure, in 66.1% of the cases both as fluoroscopy time and dose area product. Years of exposition (Pâ=â0.009) and working in centers performing pediatric procedures (Pâ=â0.021) related to greater degree of X-ray equipment optimization. The majority of participants (72, 58.1%) did not recently attend radioprotection courses. The latter is related to increased awareness of techniques to reduce radiation exposure (96% vs. 81%, Pâ=â0.022), registration of the delivered dose in each procedure (92% vs. 67%, Pâ=â0.009), and X-ray equipment optimization (50% vs. 36%, Pâ=â0.006). CONCLUSION: Italian interventional cardiologists show an acceptable level of radiation awareness and knowledge of updated European directives. However, there is clear space for improvement. Comparison to other health professionals, both at national and international levels, is needed to pursue proper X-ray management and protect public health.
Assuntos
Técnicas Eletrofisiológicas Cardíacas , Exposição Ocupacional , Exposição à Radiação , Gestão da Segurança , Eletrofisiologia Cardíaca/normas , Cardiologia/normas , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/métodos , Técnicas Eletrofisiológicas Cardíacas/normas , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Itália , Exposição Ocupacional/análise , Exposição Ocupacional/prevenção & controle , Exposição Ocupacional/estatística & dados numéricos , Exposição à Radiação/análise , Exposição à Radiação/prevenção & controle , Exposição à Radiação/estatística & dados numéricos , Gestão da Segurança/métodos , Gestão da Segurança/organização & administração , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Three-dimensional electroanatomic mapping systems have demonstrated a significant reduction in radiation exposure during radiofrequency catheter ablation procedures. We aimed to investigate the safety, feasibility and efficacy of a completely zero-fluoroscopy approach for catheter ablation of supraventricular tachycardia using the Ensite NavX navigation system compared with a conventional fluoroscopy approach. METHODS: A multicenter prospective non-randomized registry study was performed in seven centers from January 2013 to February 2018. Consecutive patients referred for catheter ablation of supraventricular tachycardia were assigned either to a completely zero-fluoroscopic approach (ZF) or conventional fluoroscopy approach (CF) according to the operator's preference. Patients with atrial tachycardia were excluded. RESULTS: Totally, 1020 patients were enrolled in ZF group; 2040 patients ablated by CF approach were selected for controls. There was no significant difference between the zero-fluoroscopy group and conventional fluoroscopy group as to procedure time (60.3 ± 20.3 vs. 59.7 ± 22.6 min, P = 0.90), immediate success rate of procedure (98.8% vs. 99.2%, P = 0.22), arrhythmia recurrence (0.4% vs. 0.5%, P = 0.85), total success rate of procedure (98.4% vs. 98.8%, P = 0.39) or complications (1.1% vs. 1.5%, P = 0.41). Compared with the conventional fluoroscopy approach, the zero-fluoroscopy approach provided similar outcomes without compromising the safety or efficacy of the procedure. CONCLUSION: The completely zero-fluoroscopy approach demonstrated safety and efficacy comparable to a conventional fluoroscopy approach for catheter ablation of supraventricular tachycardia, and mitigated radiation exposure to both patients and operators. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03042078; first registered February 3, 2017; retrospectively registered.
Assuntos
Ablação por Cateter/instrumentação , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Exposição à Radiação/prevenção & controle , Radiografia Intervencionista , Cirurgia Assistida por Computador/instrumentação , Taquicardia Supraventricular/cirurgia , Potenciais de Ação , Adulto , Ablação por Cateter/efeitos adversos , China , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Feminino , Fluoroscopia , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Exposição à Radiação/efeitos adversos , Radiografia Intervencionista/efeitos adversos , Recidiva , Sistema de Registros , Fatores de Risco , Cirurgia Assistida por Computador/efeitos adversos , Taquicardia Supraventricular/diagnóstico por imagem , Taquicardia Supraventricular/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: There are only limited data about peri-interventional pain during cardiac electrophysiological procedures without analgosedation. In this study, peri-interventional pain and recollection of it after the intervention were evaluated. METHODS: A total of 101 patients (43 electrophysiological/ablation procedures and 58 device surgeries) reported pain on a numerical rating scale (NRS; 0-10) before (pre), during (peri), and after (post) the intervention. Maximum pain (maxNRS) and the average of pain (meanNRS) were used for statistical analysis. Peri-interventional pain was compared with postinterventional data of the recollection of peri-interventional pain (peri-post). Patients were allocated into 2 groups (with 51 and 50 patients, respectively) to evaluate the mode of patient-staff interaction on pain recollection. Depressive, anxiety, and somatic symptom scales (Patient Health Questionnaire-15, Generalized Anxiety Disorder-7, and Patient Health Questionnaire-15) were used to analyze their influence on pain recollection. RESULTS: In total, 49.6% of patients (n = 50) complained of moderate to severe pain (maxNRS) at least once during the procedure. The comparison between peri and peri-post data revealed the following (median (range)-maxNRS, peri: 3 (0-10) versus peri-post: 4 (0-9) (ns), and meanNRS, peri: 1.4 (0-7) versus peri-post: 2.0 (0-6) (ns). The mode of patient-staff interaction had no influence on pain. No effect was found for psychosocial factor concerning pain and the recollection of pain. The results of the linear regression showed no influence of low-dose midazolam on recollection of pain. CONCLUSION: Half of the patients reported moderate to severe pain at least once during cardiac electrophysiological procedures without analgosedation. However, on average, patients reported only low pain levels. Postinterventional derived data on discomfort reflect the peri-interventional situation.
Assuntos
Dispositivos de Terapia de Ressincronização Cardíaca/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Dor Processual/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Processual/epidemiologia , Questionário de Saúde do Paciente , Projetos Piloto , Estudos ProspectivosRESUMO
AIMS: The use of electroanatomical mapping (EAM) systems can reduce radiation exposure (RX) and it can also completely eliminate the use of RX. Radiation exposure related to conventional radiofrequency ablation procedures can have a stochastic and deterministic effect on health. The main aim of this study was to evaluate the safety and feasibility of an entirely nonfluoroscopic approach to catheter ablation (CA) using EAM CARTO3. METHODS: In 2011 we started an RX-minimization programme in all procedures using the CARTO system with the deliberate intention to not resort to the aid of RX unless strictly necessary. We divided procedures into two groups (group 1: from 2011 to 2013; group 2: from 2014 to 2017). The only exclusion criteria were the need for transseptal puncture, and nonidiopathic ventricular tachycardia (VT). RESULTS: From a total of 525 procedures, we performed CA entirely without RX in 78.5% of cases. From 2011 to 2013, we performed CA without RX in 38.5% of cases; from 2014 to 2017, we performed 96.2% of cases with zero RX. The use of RX was significantly reduced in group 2 (group 2: 1.4 ± 19.6 seconds vs group 1: 556.92 ± 520.76 seconds; P < .001). These differences were irrespective of arrhythmia treatment. There were no differences between the two groups in acute success, complications, or duration of procedures. CONCLUSION: CA of supraventricular tachycardia and VT entirely without RX, guided by the CARTO system, is safe, feasible, and effective. After an adequate learning curve, CA can be performed entirely without RX.
Assuntos
Arritmias Cardíacas/cirurgia , Ablação por Cateter , Técnicas Eletrofisiológicas Cardíacas , Doses de Radiação , Exposição à Radiação/prevenção & controle , Radiografia Intervencionista , Cirurgia Assistida por Computador , Potenciais de Ação , Adulto , Idoso , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Flutter Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Competência Clínica , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Feminino , Fluoroscopia , Frequência Cardíaca , Humanos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Exposição à Radiação/efeitos adversos , Radiografia Intervencionista/efeitos adversos , Fatores de Risco , Cirurgia Assistida por Computador/instrumentação , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico , Taquicardia por Reentrada no Nó Atrioventricular/fisiopatologia , Taquicardia por Reentrada no Nó Atrioventricular/cirurgia , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/fisiopatologia , Taquicardia Supraventricular/cirurgia , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/cirurgia , Fatores de Tempo , Resultado do Tratamento , Complexos Ventriculares Prematuros/diagnóstico , Complexos Ventriculares Prematuros/fisiopatologia , Complexos Ventriculares Prematuros/cirurgiaRESUMO
BACKGROUND: Only a few studies have systematically evaluated fluoroscopy data of electrophysiological and device implantation procedures. Aims of this study were to quantify ionizing radiation exposure for electrophysiological/device implantation procedures in a large series of patients and to analyze the x-ray exposure trend over years and radiation exposure in patients undergoing atrial fibrillation ablation considering different technical aspects. METHODS AND RESULTS: We performed a retrospective analysis of all electrophysiological/device implantation procedures performed during the past 7 years in a modern, large-volume laboratory. We reported complete fluoroscopy data on 8150 electrophysiological/device implantation procedures (6095 electrophysiological and 2055 device implantation procedures); for each type of procedure, effective dose and lifetime attributable risk of cancer incidence and mortality were calculated. Over the 7-year period, we observed a significant trend reduction in fluoroscopy time, dose area product, and effective dose for all electrophysiological procedures (P<0.001) and a not statistically significant trend reduction for device implantation procedures. Analyzing 2416 atrial fibrillation ablations, we observed a significant variability of fluoroscopy time, dose area product and effective dose among 7 different experienced operators (P<0.0001) and a significant reduction of fluoroscopy use over time (P<0.0001) for all of them. Considering atrial fibrillation ablation techniques, fluoroscopy time was not different (P = 0.74) for radiofrequency catheter ablation in comparison with cryoablation, though cryoablation was still associated with higher dose area product and effective dose values (P<0.001). CONCLUSIONS: Electrophysiological procedures involve a nonnegligible x-ray use, leading to an increased risk of malignancy. Awareness of radiation-related risk, together with technological advances, can successfully optimize fluoroscopy use.
Assuntos
Arritmias Cardíacas/terapia , Cateterismo Cardíaco , Exposição Ocupacional , Doses de Radiação , Exposição à Radiação , Radiografia Intervencionista , Idoso , Arritmias Cardíacas/diagnóstico , Cateterismo Cardíaco/efeitos adversos , Ablação por Cateter/efeitos adversos , Criocirurgia/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Feminino , Fluoroscopia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/efeitos adversos , Saúde Ocupacional , Duração da Cirurgia , Implantação de Prótese/efeitos adversos , Exposição à Radiação/efeitos adversos , Radiografia Intervencionista/efeitos adversos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
INTRODUCTION: Cardiac arrhythmias are challenging diseases in childhood. Most of them in pediatric subjects (90.2%) are atrioventricular reentrant tachycardias and atrioventricular nodal reentrant tachycardias. The standard 12-lead ECG is a highly accurate diagnostic tool but an invasive electrophysiological study is often required. The main concern about this kind of procedures is their invasive nature and the need of radiations, so antiarrhythmic agents are currently the first line therapy. However, they often show side effects and can be insufficient for the rate control. MATERIALS AND METHODS: We performed a systematic research on Embase and PubMed. We found 563 articles and selected the most representative 50. DISCUSSION: Management of cardiac arrhythmias could be very difficult in several scenarios, especially in children with body weight <15 kg and age <4 years. In general, pediatric subjects show a cumulative risk of malignancy greater than adults, having greater life expectancy. On this basis the guiding principle during radiation delivery in electrophysiological procedures is "as low as reasonably achievable" (acronym: ALARA). The development of 3-dimensional (3D) electroanatomical mapping systems allowed significant reduction of exposure. The most recently reported experiences demonstrate safety and feasibility of fluoroless ablation in the most common arrhythmias in children, even in challenging conditions. CONCLUSION: The first reasonable approach in cardiac arrhythmias involving younger patients seems to be pharmacological. However antiarrhythmic drugs pose problems both in terms of side effects and often have poor efficacy. Expertise in electrophysiological techniques is constantly increasing and the development of new technologies allow us to encourage the use of electroanatomical mapping systems in order to reduce the radiation exposure in children undergoing to catheter ablation, especially for accessory pathways.
Assuntos
Antiarrítmicos/uso terapêutico , Ablação por Cateter , Técnicas Eletrofisiológicas Cardíacas , Sistema de Condução Cardíaco/fisiopatologia , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico , Taquicardia por Reentrada no Nó Atrioventricular/terapia , Potenciais de Ação/efeitos dos fármacos , Adolescente , Idade de Início , Antiarrítmicos/efeitos adversos , Ablação por Cateter/efeitos adversos , Criança , Pré-Escolar , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Sistema de Condução Cardíaco/efeitos dos fármacos , Frequência Cardíaca/efeitos dos fármacos , Humanos , Lactente , Recém-Nascido , Valor Preditivo dos Testes , Doses de Radiação , Exposição à Radiação/efeitos adversos , Fatores de Risco , Taquicardia por Reentrada no Nó Atrioventricular/epidemiologia , Taquicardia por Reentrada no Nó Atrioventricular/fisiopatologia , Resultado do TratamentoRESUMO
INTRODUCTION: Expert societies recently published strong recommendations to reduce the exposure of patients and staff to ionizing radiation (IR) during interventional and electrophysiology (EP) procedures. However, adherence to these guidelines remains difficult and the impact of implementing such recommendations is poorly characterized. METHODS AND RESULTS: We conducted a single-center cohort study to quantify radiation exposure over time in three EP laboratories at the Montreal Heart Institute during 5,546 consecutive procedures from 2012 to 2015 by 11 primary operators. Overall, 2,618 (47.2%) procedures were catheter-based and 2,928 (52.8%) were device interventions. Interventions to reduce radiation exposure included educational initiatives to raise awareness (i.e., limiting cine acquisition, patient position, table height), slower frame rate, lower radiation dose per pulse, collimation, and integration with 3-D mapping systems and/or MediGuide technology. An 85% reduction in IR exposure was observed from 2012 to 2015, with the mean dose-area-product (DAP) decreasing from 7.65 ± 0.05 Gy·cm2 to 1.15 ± 0.04 Gy·cm2 (P < 0.001). This was true for catheter-based procedures (mean DAP 16.99 ± 0.08 to 2.00 ± 0.06 Gy·cm2 , P < 0.001) and device interventions (mean DAP 4.18 ± 0.06 to 0.64 ± 0.05 Gy·cm2 , P < 0.001). The median effective dose of IR recorded per quarter by 282 cervical dosimeters on EP staff decreased from 0.57 (IQR 0.18, 1.03) mSv in 2012 to 0.00 (IQR 0.00, 0.19) mSv in 2015, P < 0.001. CONCLUSION: Enforcing good clinical practices with simple measures and low-dose fluoroscopy settings are highly effective in reducing IR exposure in the EP lab. These promising results should encourage other EP labs to adopt similar protective measures.
Assuntos
Cateterismo Cardíaco/métodos , Técnicas Eletrofisiológicas Cardíacas , Exposição Ocupacional/prevenção & controle , Implantação de Prótese/métodos , Doses de Radiação , Exposição à Radiação/prevenção & controle , Radiografia Intervencionista/métodos , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Humanos , Exposição Ocupacional/efeitos adversos , Saúde Ocupacional , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Fatores de Proteção , Exposição à Radiação/efeitos adversos , Proteção Radiológica , Radiografia Intervencionista/efeitos adversos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de TempoAssuntos
Técnicas Eletrofisiológicas Cardíacas , Exposição Ocupacional/prevenção & controle , Saúde Ocupacional , Complicações na Gravidez/prevenção & controle , Doses de Radiação , Exposição à Radiação/prevenção & controle , Lesões por Radiação/prevenção & controle , Radiografia Intervencionista , Saúde da Mulher , Mulheres Trabalhadoras , Consenso , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/normas , Feminino , Humanos , Exposição Ocupacional/efeitos adversos , Exposição Ocupacional/normas , Saúde Ocupacional/normas , Gravidez , Complicações na Gravidez/etiologia , Fatores de Proteção , Exposição à Radiação/efeitos adversos , Exposição à Radiação/normas , Lesões por Radiação/etiologia , Monitoramento de Radiação/normas , Proteção Radiológica/normas , Radiografia Intervencionista/efeitos adversos , Radiografia Intervencionista/normas , Medição de Risco , Fatores de Risco , Saúde da Mulher/normasRESUMO
Introduction: Advances in 3D electroanatomic-mapping technologies have resulted in a safe and effective profile of radiofrequency (RF) catheter ablation. The aim of this study was to evaluate a different catheter ablation approach in patients with left-sided accessory pathways (APs). Methods and results: From January 2015 to December 2015, 30 patients (median age 11 years, median weight 45 kg) with manifest or concealed left-sided APs underwent RF catheter ablation with a new protocol. All procedures were performed with the CARTO UNIVU™ system, integrating electroanatomic maps with fluoroscopic views. A 7 Fr ablation catheter was inserted into the right femoral vein and advanced into the right atrium. Geometrical reconstruction and activation map of the right atrium, tricuspid annulus, and coronary sinus were acquired. The ablation catheter was then inserted into the left femoral artery and advanced through the aorta and aortic valve, creating an activation map of the mitral annulus. Catheter ablation was targeted to the site of the earliest activation. No complications occurred. The median procedure and fluoroscopy times were 130 min and 6 s, with a median fluoroscopy dose 0.5 mGy. An average of two catheters was used. Long-term success rate was 97% (29/30) at a median follow-up of 9.6 months. This approach reduced fluoroscopy time, dose and number of catheters used compared with manifest or concealed left-sided AP ablation using CARTO 3™ (P < 0.05). Conclusions: This new ablation protocol seems to be promising in reducing fluoroscopy exposure and number of catheters used during left-sided AP ablation in children.
Assuntos
Feixe Acessório Atrioventricular , Arritmias Cardíacas/cirurgia , Técnicas Eletrofisiológicas Cardíacas/métodos , Radiografia Intervencionista/métodos , Potenciais de Ação , Adolescente , Fatores Etários , Arritmias Cardíacas/diagnóstico por imagem , Arritmias Cardíacas/fisiopatologia , Ablação por Cateter/efeitos adversos , Criança , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Feminino , Fluoroscopia , Frequência Cardíaca , Humanos , Masculino , Duração da Cirurgia , Valor Preditivo dos Testes , Doses de Radiação , Exposição à Radiação , Interpretação de Imagem Radiográfica Assistida por Computador , Radiografia Intervencionista/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
AIMS: This study presents and evaluates the impact of a new lowest-dose fluoroscopy protocol (Siemens AG), especially designed for electrophysiology (EP) procedures, on X-ray dose levels. METHODS AND RESULTS: From October 2014 to March 2015, 140 patients underwent an EP study on an Artis zee angiography system. The standard low-dose protocol was operated at 23 nGy (fluoroscopy) and at 120 nGy (cine-loop), the new lowest-dose protocol was operated at 8 nGy (fluoroscopy) and at 36 nGy (cine-loop). Procedural data, X-ray times, and doses were analysed in 100 complex left atrial and in 40 standard EP procedures. The resulting dose-area products were 877.9 ± 624.7 µGym² (n = 50 complex procedures, standard low dose), 199 ± 159.6 µGym² (n = 50 complex procedures, lowest dose), 387.7 ± 36.0 µGym² (n = 20 standard procedures, standard low dose), and 90.7 ± 62.3 µGym² (n = 20 standard procedures, lowest dose), P < 0.01. In the low-dose and lowest-dose groups, procedure times were 132.6 ± 35.7 vs. 126.7 ± 34.7 min (P = 0.40, complex procedures) and 72.3 ± 20.9 vs. 85.2 ± 44.1 min (P = 0.24, standard procedures), radiofrequency (RF) times were 53.8 ± 26.1 vs. 50.4 ± 29.4 min (P = 0.54, complex procedures) and 10.1 ± 9.9 vs. 12.2 ± 14.7 min (P = 0.60, standard procedures). One complication occurred in the standard low-dose and lowest-dose groups (P = 1.0). CONCLUSION: The new lowest-dose imaging protocol reduces X-ray dose levels by 77% compared with the currently available standard low-dose protocol. From an operator standpoint, lowest X-ray dose levels create a different, reduced image quality. The new image quality did not significantly affect procedure or RF times and did not result in higher complication rates. Regarding radiological protection, operating at lowest-dose settings should become standard in EP procedures.
Assuntos
Arritmias Cardíacas/cirurgia , Ablação por Cateter/métodos , Cineangiografia/métodos , Angiografia Coronária/métodos , Técnicas Eletrofisiológicas Cardíacas , Doses de Radiação , Exposição à Radiação/prevenção & controle , Radiografia Intervencionista/métodos , Adulto , Idoso , Arritmias Cardíacas/diagnóstico por imagem , Arritmias Cardíacas/fisiopatologia , Cateteres Cardíacos , Ablação por Cateter/efeitos adversos , Ablação por Cateter/instrumentação , Cineangiografia/efeitos adversos , Angiografia Coronária/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Estudos de Viabilidade , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Exposição à Radiação/efeitos adversos , Radiografia Intervencionista/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. More and more complex procedures have the risk to increase the radiation exposure, both for the patients and the operators. The professional lifetime attributable excess cancer risk may be around 1 in 100 for the operators, the same as for a patient undergoing repetitive complex procedures. Moreover, recent reports have also hinted at an excess risk of brain tumours among interventional cardiologists. Apart from evaluating the need for and justifying the use of radiation to assist their procedures, physicians have to continuously explore ways to reduce the radiation exposure. After an introduction on how to quantify the radiation exposure and defining its current magnitude in electrophysiology compared with the other sources of radiation, this position paper wants to offer some very practical advice on how to reduce exposure to patients and staff. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. Finally, we suggest further improvements that can be implemented by both the physicians and the industry in the future. We are confident that these suggestions are able to reduce patient and operator exposure by more than an order of magnitude, and therefore think that these recommendations are worth reading and implementing by any electrophysiological operator in the field.
Assuntos
Cateterismo Cardíaco/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Exposição Ocupacional/normas , Implantação de Prótese/normas , Doses de Radiação , Lesões por Radiação/prevenção & controle , Radiografia Intervencionista/normas , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Desenho de Equipamento , Fluoroscopia/normas , Humanos , Exposição Ocupacional/efeitos adversos , Exposição Ocupacional/prevenção & controle , Saúde Ocupacional/normas , Segurança do Paciente/normas , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Lesões por Radiação/etiologia , Monitoramento de Radiação/normas , Proteção Radiológica/normas , Radiografia Intervencionista/efeitos adversos , Radiografia Intervencionista/instrumentação , Medição de Risco , Fatores de Risco , Fluxo de TrabalhoRESUMO
The standard transvenous electrocardiostimulation (ECS) is currently used in many specialized hospitals. The authors offered and launched systematic application of simple but available technique of epymiocardiac ECS using pericardoscopy since middle of 80th. According to this principle, the authors developed some diversities of manipulation which are distinctive due to their availability, reliability and supersafety. The method could be recommended for wide-spread usage in practice because of high efficacy, few complications and absence of fatal outcomes in correct intervention. Described methods used in treatment of considerable quantity of patients and adapted to real work conditions of public health hospitals.
Assuntos
Arritmias Cardíacas/terapia , Técnicas Eletrofisiológicas Cardíacas , Complicações Pós-Operatórias , Toracoscopia , Arritmias Cardíacas/diagnóstico , Pesquisa Comparativa da Efetividade , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Técnicas Eletrofisiológicas Cardíacas/métodos , Humanos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Reprodutibilidade dos Testes , Toracoscopia/efeitos adversos , Toracoscopia/métodosRESUMO
This review attempts to give practical advice for invasive electrophysiologists on personal radiation protection. Applying all measures of the "As low as reasonably achievable" ALARA concept should be a daily and indeed routine practice for all staff in the electrophysiology laboratory. A substantial number of technical options have been recently introduced which may enable the physician to lower the total radiation exposure significantly, but all require a substantial learning curve. Using these measures can arrive at very low or indeed close to ZERO fluoroscopy exposure even in complex ablation cases.
Assuntos
Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Exposição Ocupacional/prevenção & controle , Proteção Radiológica/métodos , Radiografia Intervencionista/efeitos adversos , Ablação por Cateter/métodos , Técnicas Eletrofisiológicas Cardíacas/métodos , Fluoroscopia/efeitos adversos , Pessoal de Saúde , Humanos , Doses de Radiação , Radiografia Intervencionista/métodos , Gestão da Segurança/métodosRESUMO
AIMS: Fluoroscopy remains a cornerstone imaging technique in contemporary electrophysiology practice. We evaluated the impact of collimation to the 'minimal required field size' on clinically significant parameters of radiation exposure. METHODS AND RESULTS: Radiation dose measured by dose area product (DAP) and radiation dose rate measured by DAP per minute of fluoroscopy were determined for all 571 electrophysiology procedures performed in a single electrophysiology laboratory from January 2010 to December 2010. Data from 205 procedures performed by one interventional electrophysiologist, who instituted a practice of routinely collimating to the minimum required visual fluoroscopy field on a case-by-case basis, were compared with data from 366 procedures performed by the three other experienced interventional electrophysiologists using the laboratory who continued their existing practice of ad hoc collimation. Significant reductions in radiation exposure were seen with the practice of routine maximal collimation. The largest reductions were seen during 'simple' ablation procedures. CONCLUSION: A practice of routinely collimating to the minimum required visual fluoroscopy field results in significant reductions in radiation exposure when compared with a usual approach to collimation. This may have important implications for risk of malignancy in patients and operators.
Assuntos
Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Exposição Ocupacional/efeitos adversos , Exposição Ocupacional/prevenção & controle , Saúde Ocupacional , Segurança do Paciente , Doses de Radiação , Proteção Radiológica/métodos , Radiografia Intervencionista/efeitos adversos , Fluoroscopia , Humanos , Neoplasias Induzidas por Radiação/etiologia , Neoplasias Induzidas por Radiação/prevenção & controle , Doenças Profissionais/etiologia , Doenças Profissionais/prevenção & controle , Monitoramento de Radiação , Estudos Retrospectivos , Fatores de TempoRESUMO
Radiation exposure of the operator during cardiac catheter ablation procedures was assessed for an experienced cardiologist adopting various measures of radiation protection and utilised electroanatomic navigation. Chip thermoluminescent dosemeters were placed at the eyes, chest, wrists and legs of the operator. The ranges of fluoroscopy time and air kerma area product values associated with cardiac ablation procedures were wide (6.3-48.3 min and 1.7-80.3 Gy cm(2), respectively). The measured median radiation doses per procedure for each monitored position were 23.6 and 21.3 µSv to the left and right wrists, respectively, 25.3 and 30.4 µSv to the left and right legs, respectively. The doses to the eyes were below the minimum detectable dose of 9 µSv. The estimated median effective dose was 22.5 µSv. Considering the actual workload of the operator, the calculated annual doses to the hands, legs and eyes, as well as the annual effective dose, were all below the corresponding limits. The findings of this study indicate that cardiac ablation procedures performed at a modern laboratory do not impose a high radiation hazard to the operator when radiation protection measures are routinely adopted.
Assuntos
Arritmias Cardíacas/terapia , Ablação por Cateter/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Exposição Ocupacional/prevenção & controle , Proteção Radiológica , Adulto , Idoso , Ablação por Cateter/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Olho/efeitos da radiação , Feminino , Fluoroscopia , Humanos , Perna (Membro)/efeitos da radiação , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/análise , Radiografia Intervencionista , Dosimetria Termoluminescente , Tórax/efeitos da radiação , Punho/efeitos da radiação , Adulto JovemRESUMO
BACKGROUND: Percutaneous epicardial access and mapping/ablation of cardiac arrhythmias are being increasingly performed. Although complications such as pericardial effusion are relatively common, other unusual complications may occur due to the complex anatomic architecture of the heart and surrounding tissues. In this report, we report a series of rare and unusual complications related to percutaneous epicardial procedures. METHODS AND RESULTS: Between 2006 and 2011, 334 patients underwent attempts at percutaneous, subxiphoid access for epicardial mapping/ablation at 5 experienced centers. Seven selected complications are highlighted in this case series. Patient 1 had a 1-cm right ventricular pseudoaneurysm after several unsuccessful attempts at epicardial access. This was successfully managed conservatively. Patient 2 had intra-abdominal bleeding related to puncture of the left lobe of the liver during access that required surgical repair. Patient 3 had a subcapsular hepatic hematoma that was probably related to percutaneous access and was successfully managed conservatively. Patient 4 had severe pericardial bleeding followed by ventricular fibrillation, immediately after obtaining percutaneous epicardial access. A lacerated middle cardiac vein was repaired surgically. However, the patient ultimately died of complications. Patient 5 had a history of cardiothoracic surgery and developed a right ventricle-abdominal fistula after multiple attempts at percutaneous access. This was surgically repaired without major sequelae. Patient 6 had cardiac tamponade caused by a lacerated coronary sinus branch during epicardial catheter ablation and required surgical repair. Patient 7 had severe left coronary vasospasm and ventricular fibrillation during catheter manipulation in the pericardium. This complication was successfully managed with intracoronary nitrates. CONCLUSIONS: Though generally safe, percutaneous epicardial access and mapping/ablation can result in uncommon complications. Awareness of these rare complications may facilitate early detection and successful management.
Assuntos
Arritmias Cardíacas/cirurgia , Ablação por Cateter/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Pericárdio/cirurgia , Complicações Pós-Operatórias/etiologia , Adolescente , Idoso , Falso Aneurisma/etiologia , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Tamponamento Cardíaco/etiologia , Vasoespasmo Coronário/etiologia , Fístula do Sistema Digestório/etiologia , Eletrocardiografia , Evolução Fatal , Feminino , Aneurisma Cardíaco/etiologia , Traumatismos Cardíacos/etiologia , Traumatismos Cardíacos/terapia , Hematoma/etiologia , Humanos , Fígado/lesões , Masculino , Pessoa de Meia-Idade , Pericárdio/fisiopatologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Hemorragia Pós-Operatória/etiologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Fibrilação Ventricular/etiologiaRESUMO
AIMS: Ablation for persistent atrial fibrillation (AF) remains a difficult and time-consuming procedure with varying degrees of success. We evaluated the long-term effects of a novel approach for ablation of persistent AF using multi-electrode catheters. METHODS AND RESULTS: In 89 patients with longstanding persistent AF (>1 year), multi-electrode ablation was performed with a pulmonary vein ablation catheter (PVAC), a multi-array septal catheter (MASC), and a multi-array ablation catheter (MAAC) for ablation of complex-fractionated atrial electrograms (CFAE) at the septum, left atrial (LA) roof, floor, posterior wall, and mitral isthmus. Follow-up was performed at 6 and 12 months with electrocardiogram, 7 days Holter, and occasionally ambulant event recordings. Average procedure and fluoroscopy times were 112 ± 32 and 21 ± 10 min. The pre-specified endpoint of pulmonary vein isolation and LA CFAE ablation was reached in all patients. No procedural complications were observed. At 12 months after a single treatment 44 of 89 (49%) remained in sinus rhythm, including direct current cardioversion in 12 patients. At 12 months, after a redo PVAC/MASC/MAAC, an additional 6 of 15 patients (40%) were free of AF. In 18 of 89 (20%) patients AF was changed to paroxysmal. CONCLUSIONS: In this single centre study, ablation for longstanding persistent AF with the PVAC/MASC/MAAC resulted in 56% freedom of AF at 1 year after 1.2 ± 0.4 procedures. This approach is time efficient and has a favourable safety profile.