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Since direct current high energy shock fulguration was initially performed in the mid 1980s, ablation of cardiac arrhythmias has come to widespread use. Today the most frequently used energy source for catheter ablation is radio frequency (RF). It was the German engineer Peter Osypka who made available the HAT 100 as the first simple commercial RF ablator.
Nevertheless, in the first years of ablation, physicians were effectively working in the dark. Until today with an increasing understanding of arrhythmia mechanisms, both at the atrial and ventricular levels, this curative technology has made tremendous progress. Now, due to crucial improvement of RF ablation generators, temperature and contact force sensor catheters in combination with non-flouroscopic electroanatomical mapping technologies, computerized temperature and impedance controlled radiofrequency catheter ablation can be used to cure all types of arrhythmias including atrial and ventricular fibrillation. For the latter, cooled ablation by saline solution irrigated catheters has been developed to a widely used standard method. This procedure resulting in pulmonary vein isolation requires transseptal puncture and is technically demanding. Nevertheless, it has shown to be more effective than antiarrhythmic drug therapy.
While earliest RF ablations were performed with non-steerable catheters, today are used steerable sensor catheters without or with external and internal cooling and tips of 4mm or 8mm length. Further innovations like integration of mapping and cardiac imaging give exact information of the number of pulmonary veins and branching patterns and help to correlate electrical signals with anatomical structures.
The magnetic navigation significantly improved the success rates and safety of catheter ablation. Thus, in most cases RF catheter ablation has developed in the treatment of supraventricular arrhythmias from an alternative approach to drug therapy into the first therapeutic choice providing low complication rates.
In future, robotic navigation will further simplify procedures and reduce radiation exposure of this curative approach.
Introduction: Radiofrequency ablation allows successful treatment of most supraventricular reentrant and focal tachycardias and an increasing number of ventricular tachycardias. Different catheter tips are used. While AV nodal reentrant tachycardias require catheters with a tip of 4mm length, an 8 mm tip electrodes will be used for atrial flutter. A pulmonary vein isolation will be performed using 4 mm irrigated tip electrodes to achieve larger and deeper lesions. The need of a tubing set and pump for saline transfusion is a disadvantage of this technique. Gold tip electrodes can alternatively be used to produce increases in lesion size. Aim of this study was to compare RF ablation catheters of exactly the same geometry with either platin-iridum or gold tip.
Methods: Gold provides an almost four-fold thermal conductivity compared with platinum-iridium. The Cerablate G flutter (Osypka AG, Rheinfelden-Herten) is a newly designed radiofrequency ablation catheter with an 8 mm gold tip. Its power delivery was compared with the Cerablate flutter of same geometry but platin-iridium tip. Therefore, in-vitro RF ablations were performed using pork meat in a 0.9% saline solution at 37°C temperature. A pulsed volume flow was generated using a pump to simulate the blood flow. Temperature controlled ablations of 60 seconds using 45, 55 and 65°C and a maximum of 70W RF power were performed.
Results: Using the Osypka HAT300smart ablator, cumulative power of 167, 474 and 672W was delivered with gold tip against 121, 227 and 310 W with platin-iridium tip. By the Stockert SmartAblate G4 ablator, 202, 546 and 1075W was delivered with gold tip against 117, 246 and 394W with platin-iridium using 45, 55 and 65°C temperature.
Conclusion: During in-vitro investigations, the gold tip electrodes allowed a in power delivery increase of 117 up to 173%. Thus, gold tips can be used to increase lesion depth and diameter without cooling equipment.
Non-fluoroscopic Imaging with MRT/CT Image Integration - Catheter Positioning with Double Precision
(2014)
Introduction: When antiarrhythmic drug therapy has failed, different approaches of pulmonary vein isolation are considered a reasonable option in the treatment of atrial fibrillation. It will be performed predominantly by radiofrequency catheter ablation. As the individual anatomy of left atrium and the pulmonary veins differs considerably, accurate visualization of these structures is essential during catheter positioning. Using non-fluoroscopic electroanatomic mapping system with image integration, electroanatomic mapping can be combined with highly detailed anatomical MRT or CT information on complex left atrial structures. This may facilitate catheter navigation during ablation for atrial fibrillation.
Methods: The CARTO XP electroanatomic system was used in a project during biomedical engineering study to practice image integration of anonymized real patients that underwent pulmonary vein isolation by CARTO XP and a MRT/CT procedure. Using the image integration software, MRT or CT images were imported into the CARTO XP system. The next process was segmentation of the acquired images. It involves dividing the images into different regions in order to select the structures of interest. In clinical routine, this segmentation has to be performed before catheter ablation. Then, the segmented images were aligned with the reconstructed electroanatomic maps. This consists of several steps, including selection of the left atrium, scaling of the reconstructed geometry, fusion of the structures using landmarks, and optimization of the integration by adjusting the reconstructed geometry of the left atrium.
Results: In the 3 months lasting period of the project, image integration was trained in 13 patients undergoing catheter ablation for atrial fibrillation. Within this period, time consumption for the process decreased from about 90 minutes at the beginning to about 35 minutes at the end for one patient.
Conclusion: Image integration into non-fluoroscopic electroanatomic map is a sophisticated tool in cardiac radiofrequency catheter ablation. Intensive training is necessary to control the procedure.