Cost Effectiveness of External Beam Radiation Therapy versus Percutaneous Image-Guided Cryoablation for Palliation of Uncomplicated Bone Metastases.

PURPOSE: To evaluate the cost effectiveness of incorporating cryoablation in the treatment regimens for uncomplicated bone metastases using radiation therapy (RT) in single-fraction RT (SFRT) or multiple-fraction RT (MFRT) regimens. MATERIALS AND METHODS: A Markov model was constructed using 1-month cycles over a lifetime horizon to compare the cost effectiveness of multiple strategies, including RT followed by RT (RT-RT) for recurrent pain, RT followed by cryoablation (RT-ablation), and cryoablation followed by RT (ablation-RT). RT-RT consisted of 8 Gy in 1 fraction/8 Gy in 1 fraction (SFRT-SFRT) and 30 Gy in 10 fractions/20 Gy in 5 fractions (MFRT-MFRT). Probabilities and utilities were extracted from a search of the medical literature. Costs were calculated from a payer perspective using 2017 Medicare reimbursement in an outpatient setting. Incremental cost effectiveness ratios (ICERs) were calculated using strategies evaluated for willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY). To account for model uncertainty, one-way and probabilistic sensitivity analyses were performed. RESULTS: In the base case analysis, SFRT-ablation was cost effective relative to SFRT-SFRT at $96,387/QALY. MFRT-ablation was cost effective relative to MFRT-MFRT at $85,576/QALY. Ablation-SFRT and ablation-MFRT were not cost effective with ICERs >$100,000/QALY. In one-way sensitivity analyses, results were highly sensitive to variation in multiple model parameters, including median survival (base: 9 months), with SFRT-SFRT favored at median survival ≤8.7 months. Probabilistic sensitivity analysis examining SFRT-based regimens showed that SFRT-ablation was preferred in 36.9% of simulations at WTP of $100,000/QALY. CONCLUSIONS: Cryoablation is a potentially cost-effective alternative to reirradiation with RT for recurrent of pain following RT; however, no strategy incorporating initial cryoablation was cost effective.

A novel ablation strategy of premature ventricular contractions originating from summit guided by CartoUNIVU module.

BACKGROUND: Premature ventricular contractions (PVCs) from left ventricular (LV) summit remain challenging for the risk of coronary artery injury. Computed tomographic or intracardiac echocardiography may be helpful, but both still have many limitations. CartoUNIVU module has rarely been used in PVC ablation. METHODS: A total of 22 patients (14 men: mean age 56.4 ± 13.3 years) with an electrocardiogram indication of summit PVCs were included in the two centers study. A novel strategy ablation with the Image Integration Module CartoUNIVUTM module was performed for all the patients with PVCs originating from LV summit area, especially to prevent the coronary artery injury. RESULTS: The procedure time was 78.6 ± 22.7 minutes, and the fluoroscopy time was 12.5 ± 3.1 minutes. The distance between the target and nearest coronary artery was 8.0 ± 3.1 mm. Three patients with the distance to the nearest coronary artery <5 mm. During a mean follow-up of 11.0 ± 1.7 months, 21/22 (95.5%) patients were free from clinical PVC. No coronary artery injury was detected in the all the ablation procedures. CONCLUSION: The novel strategy ablation with the Image Integration Module CartoUNIVU module is safe and effective for PVCs originating from LV summit area, especially to prevent the coronary artery injury.

Zero-fluoroscopy atrial fibrillation ablation in the presence of a patent foramen ovale: a multicentre experience.

INTRODUCTION: Atrial fibrillation ablation has historically been guided by fluoroscopy, with the related enhanced risk deriving from radiation. Fluoroscopy exposure may be confined to guide the transseptal puncture. Small sample size study presented a new methodology to perform a totally fluoroless atrial fibrillation ablation in the case of a patent foramen ovale (PFO). We evaluated this methodology in a large sample size of patients and a multicentre experience. METHODS AND RESULTS: Two hundred and fifty paroxysmal atrial fibrillation patients referred for first atrial fibrillation ablation with a CARTO3 electroanatomic mapping system were enrolled. In 58 out of 250 patients, a PFO allowed crossing of the interatrial septum, and a completely fluoroless ablation was performed applying the new method (Group A). In the remaining patients, a standard transseptal puncture was performed (Group B). Pulmonary vein isolation was achieved in all patients with comparable procedural and clinical outcomes at short- and long-term follow-up. CONCLUSION: The presence of a PFO may allow a completely fluoroless well tolerated and effective atrial fibrillation ablation. Probing the fossa ovalis looking for the PFO during the procedure is desirable, as it is not time-consuming and can potentially be done in every patient undergoing atrial fibrillation ablation.

Zero-fluoroscopy approach for ablation of supraventricular tachycardia using the Ensite NavX system: a multicenter experience.

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.

Total knee arthroplasties from the origin to navigation: history, rationale, indications.

Since the early 1970s, total knee arthroplasties have undergone many changes in both their design and their surgical instrumentation. It soon became apparent that to improve prosthesis durability, it was essential to have instruments which allowed them to be fitted reliably and consistently. Despite increasingly sophisticated surgical techniques, preoperative objectives were only met in 75% of cases, which led to the development, in the early 1990s, in Grenoble (France), of computer-assisted orthopaedic surgery for knee prosthesis implantation. In the early 2000s, many navigation systems emerged, some including pre-operative imagery ("CT-based"), others using intra-operative imagery ("fluoroscopy-based"), and yet others with no imagery at all ("imageless"), which soon became the navigation "gold standard". They use an optoelectronic tracker, markers which are fixed solidly to the bones and instruments, and a navigation workstation (computer), with a control system (e.g. pedal). Despite numerous studies demonstrating the benefit of computer navigation in meeting preoperative objectives, such systems have not yet achieved the success they warrant, for various reasons we will be covering in this article. If the latest navigation systems prove to be as effective as the older systems, they should give this type of technology a well-deserved boost.

Treatment of left accessory cardiac pathway conduction disorders using radiofrequency catheter ablation under the guidance of the Ensite NavX 3D mapping system: a retrospective study.

To investigate the effectiveness and safety of using the Ensite NavX three-dimensional (3D) mapping system during Radiofrequency catheter ablation (RFCA) of left accessory pathway (AP) disorders. A total of 227 patients having their left AP treated by RFCA, were classified into study group (n = 112) and the control group (n = 115). X-ray irradiation time and exposure doses during the course of the operations were recorded. Time taken to place the mapping catheter along with total duration of operations and procedural complications were compared. The X-ray irradiation time and exposure doses in the course of manipulating the ablation catheters were significantly lower in the study group compared to control (5.1 ± 2.3 min vs. 13.1 ± 3.1 min; P < 0.05 and 5.7 ± 2.6 mGy vs. 17.8 ± 4.3 mGy; P < 0.05, respectively). The total duration of operation was also significantly shorter in the study group compared to control (53.1 ± 18.8 min vs. 62.3 ± 20.6 min; P < 0.05). No procedural complications were reported in both groups. The irradiation time and exposure dose along with total operation duration was significantly reduced when the Ensite NavX mapping system was used during RFCA in comparison with traditional X-ray fluoroscopy method.

Safety and efficacy of ultrasound-guided percutaneous thermal ablation in treating low-risk papillary thyroid microcarcinoma: A pilot and feasibility study.

OBJECTIVE: This study aimed to evaluate the safety and efficacy of thermal ablation in treating low-risk unifocal papillary thyroid microcarcinoma (PTMC). MATERIALS AND METHODS: Patients with unifocal PTMC were enrolled in this study, and thermal ablations were performed. Contrast-enhanced ultrasound was used to estimate the extent of ablation immediately after thermal ablation; complications were recorded. The size and volume of the ablated area and thyroid hormones were measured, and the clinical evaluations were performed at 1, 3, 6, 12, and 18 months after thermal ablation. From July 2016 to July 2017, the prospective study was conducted involving 107 patients. Thermal ablation was well tolerated without serious complications. RESULTS: Compared with the volume immediately after thermal ablation, the mean volume reduction ratio (VRR) of ablated lesions was 0.457 ± 0.218 (range: 0.040-0.979), 0.837 ± 0.150 (range: 0.259-1), 0.943 ± 0.090 (range: 0.491-1), 0.994-0.012 (range: 0.938-1), and 0.999 ± 0.002 (range: 0.992-1) at 1, 3, 6, 12, and 18 months after thermal ablation, respectively. Significant differences in the VRR were found between every two follow-up visits (P < 0.01). Results of patients' thyroid function test before thermal ablation and at 1 month after thermal ablation were normal, and no significant differences were observed (P > 0.05). No tumor regrowth, local recurrence, or distant metastases were detected during follow-up visits. CONCLUSION: Thermal ablation is a short-term safe and effective method in treating low-risk small PTMCs, which can be considered a potential alternative therapy for patients with PTMC.

Comparison of robotic magnetic navigation-guided and manual catheter ablation of ventricular arrhythmias arising from the papillary muscles.

Aims: Due to the complex anatomy of the left ventricular (LV) and right ventricular (RV) papillary muscles (PMs), PM ventricular arrhythmias (VAs) can be challenging to target with ablation. We sought to compare the outcomes of robotic magnetic navigation-guided (RMN) ablation and manual ablation of VAs arising from the LV and RV PMs. Methods and results: We evaluated 35 consecutive patients (mean age 65 ± 12 years, 69% male) who underwent catheter ablation of 38 VAs originating from the LV and RV PMs as confirmed by intracardiac echocardiography. Catheter ablation was initially performed using RMN-guidance in 24 (69%) patients and manual guidance in 11 (31%) patients. Demographic and procedural data were recorded and compared between the two groups. The VA sites of origin were mapped to 20 (53%) anterolateral LV PMs, 14 (37%) posteromedial LV PMs, and 4 (11%) RV PMs Acute successful ablation was achieved for 20 (74%) VAs using RMN-guided ablation and 8 (73%) VAs using manual ablation (P = 1.000). Fluoroscopy times were significantly lower among patients undergoing RMN ablation compared to patients undergoing manual ablation [median 7.3, interquartile range (IQR) 3.9-18 vs. 24 (16-44) min; P = 0.005]. Retrograde transaortic approach was used in 1 (4%) RMN patients and 5 (46%) manual patients (P = 0.005). No procedural complications were seen in study patients. Conclusion: Use of an RMN-guided approach to target PM VAs results in comparable success rates seen with manual ablation but with lower fluoroscopy times and decreased use of transaortic retrograde access.

Procedural and long-term outcome after catheter ablation of idiopathic outflow tract ventricular arrhythmias: comparing manual, contact force, and magnetic navigated ablation.

Aims: Currently, comparative data on procedural and long-term clinical outcome of outflow tract (OT) idiopathic ventricular arrhythmia (IVA) ablation with manual (MAN), contact force (CF), and magnetic navigation system (MNS) ablation are lacking. The aim of this study was to compare the procedural and long-term clinical outcome of MAN, CF, and MNS ablation of OT IVAs. Methods and results: Seventy-three patients (31 MAN, 17 CF, and 25 MNS patients; consecutive per group) with OT IVA, who underwent catheter ablation in our centre were analysed. Procedural success rates (success at the end of the procedure), procedural data and long-term follow-up data were compared. Baseline patient demographics were comparable. Procedural success rates were similar (MAN 81%, 71% CF, and MNS 92%; P = 0.20). Median fluoroscopy time was shorter in the MNS group: MAN 29 (16-38), CF 37 (21-46), and MNS 13 (10-20) min (P = 0.002 for MNS vs. CF and MAN). The overall complication rate was: MAN 10%, CF 0%, and MNS 0% (P = 0.12). Median follow-up was: MAN 2184 (1672-2802), CF 1721 (1404-1913), and MNS 3031 (2524-3286) days (P <0.001). Recurrences occurred in MAN 46%, CF 50%, and MNS 46% (P = 0.97). Repeat procedures were performed in MAN 20%, CF 40%, and MNS 33% (P = 0.32). Conclusion: Procedural and long-term clinical outcome of OT IVA ablation are equal for MAN, CF, and MNS. MNS has a favourable procedural safety profile due to the shorter fluoroscopy time compared with MAN and CF.

Early and long-term outcomes after manual and remote magnetic navigation-guided catheter ablation for ventricular tachycardia.

Aims: Remote magnetic navigation (RMN) is a safe and effective means of performing ventricular tachycardia (VT) ablation. It may have advantages over manual catheter ablation due to ease of manoeuvrability and catheter stability. We sought to compare the safety and efficacy of RMN vs. manual VT ablation. Methods and results: Retrospective study of procedural outcomes of 139 consecutive VT ablation procedures (69 RMN, 70 manual ablation) in 113 patients between 2009 and 2015 was performed. Remote magnetic navigation was associated with overall higher acute procedural success (80% vs. 60%, P = 0.01), with a trend to fewer major complications (3% vs. 9% P = 0.09). Seventy-nine patients were followed up for a median of 17.0 [interquartile range (IQR) 3.0-41.0] months for the RMN group and 15.5 (IQR 6.5-30.0) months for manual ablation group. In the ischaemic cardiomyopathy subgroup, RMN was associated with longer survival from the composite endpoint of VT recurrence leading to defibrillator shock, re-hospitalization or repeat catheter ablation and all-cause mortality; single-procedure adjusted hazard ratio (HR) 0.240 (95% CI 0.070-0.821) P = 0.023, multi-procedure HR 0.170 (95% CI 0.046-0.632) P = 0.002. In patients with implanted defibrillators, multi-procedure VT-free survival was superior with RMN, HR 0.199 (95% CI 0.060-0.657) P = 0.003. Conclusion: Remote magnetic navigation may improve clinical outcomes after catheter ablation of VT in patients with ischaemic cardiomyopathy. Further prospective clinical studies are required to confirm these findings.

Oesophageal injury following magnetically guided single-catheter ablation for atrial fibrillation: insights from the MAGNA-AF registry.

Aims: Oesophagogastroduodenoscopy (OGD) after catheter ablation (CA) of atrial fibrillation (AF) revealed a high rate of procedure related oesophageal lesions. We hypothesized that magnetically guided CA with careful radiofrequency energy titration at the posterior left atrial (LA) wall limits the incidence of oesophageal tissue damage. Methods and results: As a part of the prospective "Remote MAGNetic catheter Ablation for Atrial Fibrillation" (MAGNA-AF) registry, 251 out of 266 consecutive patients underwent OGD after magnetically guided single-CA for AF. All detected pathologies were analysed. Simultaneous pacing and ablation from the tip of the magnetically guided catheter was found to be a safe and feasible method for energy titration. Post-interventional OGD documented midoesophageal tissue damage in four (1.6%) patients. Although a thermal origin of these injuries must be discussed, none of them was located at the anterior oesophageal wall. Risk factors for midoesophageal lesions were female gender and concomitant acetylsalicylic acid (ASA) treatment. Mechanical lesions in 16 patients were attributed to periprocedural transoesophageal echocardiography (TOE). There was no atrio-oesophageal fistula (AOF). Five hundred and one incidental pathologies were found endoscopically, most frequent axial oesophageal herniation (71%), oesophagitis (22%), and gastritis (57%). Conclusion: Magnetically guided CA for AF with careful energy titration at the posterior LA wall and no oesophageal temperature monitoring is not associated with an increased incidence of oesophageal thermal injury. The routine use of periprocedural TOE may cause a low rate of mechanical oesophageal lesions but reliably prevents major complications like transient ischaemic attack, stroke, or cardiac tamponade. An observed high prevalence of upper digestive system inflammation (63%) may further support the recommendation for a routine post-interventional treatment with a proton-pump-inhibitor.

Image-Guided Thermal Ablative Therapies in the Treatment of Sarcoma.

OPINION STATEMENT: Percutaneous thermal ablation, including microwave ablation (MWA), radiofrequency ablation (RFA), and cryoablation, is a well-established focal treatment option for primary and metastatic malignancies. While published literature specific to ablation of sarcomas is relatively lacking compared with non-sarcomatous malignancies, what is available is promising. In situations where a focal treatment option is desired, strong consideration should be given to percutaneous thermal ablation, in addition to surgery and radiation therapy. A significant advantage of percutaneous thermal ablation over surgery and radiation includes the repeatability of ablation, as there is no absolute limit on the number of times an ablation can be performed. Compared with surgery, ablation offers the potential of decreased recovery time, a less invasive procedure, and is often performed in patients deemed not medically fit for surgery.

Direct Comparison of Point-by-Point and Rapid Ultra-High-Resolution Electroanatomical Mapping in Patients Scheduled for Ablation of Atrial Fibrillation.

INTRODUCTION: Three-dimensional electroanatomical mapping (EAM) is an established tool facilitating catheter ablation. In this context, the novel Rhythmia system sets a new bar in fast high-resolution mapping. The aim of this study was to directly compare point-by-point versus rapid ultra-high-resolution EAM in patients scheduled for ablation of atrial fibrillation (AF) with focus on procedural data, acute success, and midterm clinical outcome. METHODS AND RESULTS: A total number of 74 consecutive patients (48/74 male) with symptomatic AF were scheduled to undergo pulmonary vein isolation (PVI) using either Carto or Rhythmia. The Carto-guided procedures were performed using point-by-point acquisition according to our routine approach, whereas for Rhythmia, fast anatomical mapping was utilized. Comparing Rhythmia- versus Carto-guided ablation approaches, we observed a significantly longer total mapping time (P = 0.001), longer total fluoroscopy time (P = 0.001), more delivered RF-applications (P = 0.019), and longer total RF-duration (P = 0.002). There was no difference regarding total ablation time (P = 0.707), total procedure duration (P = 0.99), and acute procedural success. During follow-up, 84.8% of patients remained free from any AF/AT-recurrence using Carto versus 88.2% when using Rhythmia (P = 0.53). From Kaplan-Meier analysis, the event rate estimations were 15% versus 13.5%, respectively. CONCLUSION: The present study reports our first clinical experience using Rhythmia in direct comparison with the established Carto system for AF ablation. Our data clearly demonstrate that Rhythmia was proved to be effective and well applicable but more data will be mandatory before final conclusions can be drawn.

Treatment of Recurrent Nonparoxysmal Atrial Fibrillation Using Focal Impulse and Rotor Mapping (FIRM)-Guided Rotor Ablation: Early Recurrence and Long-Term Outcomes.

INTRODUCTION: A patient-tailored ablation approach focused on the elimination of both pulmonary vein triggers as well as substrate drivers may result in favorable outcomes in recurrent persistent AF patients. OBJECTIVE: We evaluated the long-term outcomes of rotor ablation combined with conventional pulmonary vein isolation (PVI) in patients with recurrent nonparoxysmal AF. METHODS: Fifty-eight consecutive patients underwent FIRM-guided rotor ablation followed by conventional PVI for the treatment of recurrent nonparoxysmal AF. A software algorithm was used to display rotational activity at rotor sites by creating propagation maps from unipolar electrograms recorded using a 64-electrode basket catheter. These rotor sites were targeted for ablation, followed by conventional PVI. RESULTS: All patients had nonparoxysmal AF (83% longstanding persistent) and a previously failed conventional ablation procedure. Stable rotors were identified in all patients (mean of 3.0 ± 1.6 per patient), with 55.2% having right atrial rotors and 96.6% left atrial rotors, respectively. Complications occurred in 5.2% of patients, none related to the FIRM procedure. The median follow-up was 12 months. At 6 and 12 months of follow-up, 73.2% and 76.9% of patients remained free from AF/AT, respectively. Excluding 2 patients who underwent a successful redo ablation procedure/electrical cardioversion, at 12 months of follow-up, 69.2% were free from any AF/AT and 73.1% were free from AF after a single FIRM-guided ablation procedure. CONCLUSION: A high degree of success was observed in this cohort of primarily longstanding persistent AF patients treated for recurrent AF with FIRM-guided rotor ablation. Prospective randomized controlled trials are needed.

The efficacy of radio-frequency ablation for metastatic lung or liver tumors of male germ cell tumors as an alternative minimally invasive therapy after salvage chemotherapy.

BACKGROUND: The aim of this study was to assess the efficacy of radio-frequency ablation (RFA) for metastatic lung or liver tumors of germ cell tumors (GCTs) after chemotherapy. METHODS: RFA with computed tomography guidance and monitoring was performed in 24 patients with 48 metastatic lung or liver tumors of GCTs. Group A consisted of 9 patients with tumor marker normalization after salvage chemotherapy and group B consisted of 15 patients without tumor marker normalization in spite ofintensive treatment. RESULTS: Out of 48 tumors, 41 tumors in 21 patients were evaluated for the efficacy of the RFA treatment. Of the 41 tumors, successful ablation was achieved in 34 (82.9 %). The patients in group A had significantly better survival than the patients in group B (p = 0.0003). In group A, all 9 patients are still alive with no evidence of disease (NED). Patients with a solitary tumor had significantly better survival than those with multiple tumors (p = 0.0247). In group B, 2 patients are alive with NED, 1 patient is alive with disease, and the remaining 12 patients have died a tumor-related death. Three cases of pneumothorax requiring intubation were observed. CONCLUSIONS: RFA is less invasive than surgery and is an effective treatment option for curative and palliative therapy as an alternative to invasive salvage surgery for post-chemotherapeutic metastatic lung or liver lesions from GCT.

The use of an integrated electroanatomic mapping system and intracardiac echocardiography to reduce radiation exposure in children and young adults undergoing ablation of supraventricular tachycardia.

AIMS: Non-fluoroscopic imaging (NFI) devices are increasingly used in ablations. The objective was to determine the utility of intracardiac echocardiography (ICE) in ablating paediatric supraventricular tachycardias (SVTs) and assess whether its integrated use with electroanatomic mapping (EAM) resulted in lower radiation exposure than use of EAM alone. METHODS AND RESULTS: Prospective, controlled, single-centre study of patients (pts) age ≥10 years, weight ≥35 kg, with SVT and normal cardiac anatomy. Patients were randomized to ICE + EAM (ICE) or EAM only (no ICE). Both had access to fluoroscopy as needed. Eighty-four pts were enroled (42 ICE, 42 no ICE). Median age was 15 years (range 10.4-23.7 years); 57% had accessory pathways, 42% atrioventricular nodal reentry tachycardia. There was no difference in radiation dose (9 mGy ICE vs. 23 mGy no ICE, P = 0.37) or fluoroscopy time (1.1 min ICE vs. 1.5 min no ICE, P = 0.38). Transseptal punctures were performed in 25 pts (16 ICE, 9 no ICE), with ICE reducing radiation (8 mGy ICE vs. 62 mGy no ICE, P = 0.002) and fluoroscopy time (1.1 min ICE vs. 4.5 min no ICE, P = 0.01). Zero fluoroscopy was achieved in 13 pts (15% of total, 5 ICE, 8 no ICE), and low-dose cases (<50 mGy) in 57 pts (68% of total, 33 ICE, 24 no ICE). Acute success was 95% for ICE, 88% for no ICE. CONCLUSION: Use of an integrated EAM/ICE system was no better than EAM alone in limiting radiation, but can be helpful for transseptal punctures. Given the low dose savings, use of ICE may be weighed against its financial cost. Low-fluoroscopy cases are performed in most NFI procedures.

Remote-controlled magnetic pulmonary vein isolation using a new three-dimensional non-fluoroscopic navigation system: a single-centre prospective study.

BACKGROUND: Catheter ablation of atrial fibrillation (AF) focuses on pulmonary vein isolation (PVI), but the procedure is associated with significant X-ray exposure. Few data exist concerning the combination of remote magnetic navigation (RMN) and a new three-dimensional non-fluoroscopic navigation system (Carto(®) 3), which facilitates precise catheter navigation and limits X-ray exposure. AIMS: To assess the efficacy and extent of fluoroscopic exposure associated with the combination of RMN and the Carto 3 system in patients requiring AF ablation. METHODS: Between January and September 2011, catheter ablation was performed remotely using the Carto 3 system in 81 consecutive patients who underwent PVI for symptomatic drug-refractory AF. The radiofrequency generator was set to a fixed power ≤ 35W. The primary endpoint was wide-area circumferential PVI confirmed by spiral catheter recording during ablation and including additional lesion lines (left atrial roof and coronary sinus defragmentation) or complex fractionated atrial electrograms for persistent AF. Secondary endpoints included procedural data, complications and freedom from atrial tachycardia (AT)/AF. RESULTS: Mean age was 60 ± 9 years; 20% were women; 73% had symptomatic paroxysmal AF; 27% had persistent AF. The CHA2DS2-VASc score was 1.2 ± 1. Median procedure time was 3.5 ± 1 hours; median total X-ray exposure time was 13 ± 7 minutes; transseptal puncture and catheter positioning took 8 ± 4 minutes, left atrium electroanatomical reconstruction 1 ± 4 minutes and catheter ablation 3.5 ± 5minutes. Recurrences were AT (n=3; 3.7%), paroxysmal AF (n=8; 9.9%) and persistent AF (n=4; 4.9%); redo ablation was performed in these 15 (19%) patients. After a median follow-up of 15 ± 6 months and a single procedure, 71% of patients were free of symptoms; 84% remained asymptomatic after two procedures. CONCLUSIONS: RMN with irrigated catheters combined with the Carto 3 system can be effectively performed in patients requiring AF ablation with minimal use of fluoroscopy, but larger randomized studies are warranted.

Treatment of osteoid osteoma with CT-guided percutaneous radiofrequency thermoablation.

Osteoid osteoma is a benign bone tumor with a male predominance occurring mainly in children and young adults. The most common symptom is intermittent pain that worsens at night and is at least partially relieved by nonsteroidal anti-inflammatory drugs. The purpose of this study was to assess the long-term effectiveness of computed tomography-guided percutaneous radiofrequency thermoablation in patients with a minimum follow-up of 2 years. Twenty patients with osteoid osteoma (15 men and 5 women) with a mean age of 20.7 years (range, 4-61 years; 12 patients aged 20 years or younger) underwent computed tomography-guided percutaneous radiofrequency thermoablation. Lesion sites were the femur (n=9), tibia (n=7), pelvis (n=1), talus (n=1), cuneiform bone (n=1), and humerus (n=1). Mean follow-up was 44 months (range, 3-106 months). Pain relief was significant in 95% of patients; it disappeared within 24 hours in 14 patients, within 3 days in 4, and within 7 days in 1. The patient with persistent symptoms underwent another percutaneous radiofrequency thermoablation procedure that was successful. The difference between pre- and postoperative pain was significant (P ≤ .01). No recurrences occurred. Computed tomography-guided percutaneous radiofrequency thermoablation is a safe, minimally invasive, and economical procedure with high technical and clinical success rates, and it effectively and durably enhances quality of life.