The presence of epicardial connections (ECs) between the pulmonary veins (PVs) and atrium may contribute to atrial fibrillation (AF) recurrence. This study aimed to determine the impact of ...sleep-disordered breathing (SDB) on the presence of ECs and the interplay between SDB and ECs on AF recurrence.We retrospectively reviewed 400 consecutive non-valvular AF patients. Among them, 235 patients exhibiting a 3% oxygen desaturation index (ODI) of ≥ 10 events/hour underwent polysomnography to evaluate the SDB severity, measured by the apnea-hypopnea index (AHI). To facilitate the ablation of AF and ECs, a high-density mapping catheter (HDMC) was employed. AF recurrence was evaluated over a 12-month period post-AF ablation.The key findings included: 1) 63% of AF patients with ECs had SDB with an AHI ≥ 20 events/hour. 2) Despite achieving complete PV isolations and precise EC ablation using an HDMC, SDB presence was associated with an increased AF recurrence. 3) Continuous positive airway pressure therapy for SDB improved AF recurrence among the AF patients with both ECs and SDB (57% versus 73%; P = 0.016). 4) AHI (odds ratio OR = 1.91, ≥ 28.4 events/hour) and left atrial volume (LAV) (OR = 1.42, ≥ 128.3 mL) were independent predictors of the presence of ECs, and AHI (OR = 1.44, ≥ 27.8 events/hour) was an independent predictor of the presence of AF recurrence.It is essential for physicians to recognise the potential complexity of ECs and SDB in AF patients. Thus, screening and treating SDB in AF patients presenting with ECs might play a pivotal role in suppressing AF recurrence.
ZusammenfassungDie kardiale Magnetresonanztomographie (CMR) zählt mittlerweile zu den etablierten diagnostischen Verfahren in der Abklärung kardialer Krankheitsbilder. In der heutigen klinischen ...Elektrophysiologie ermöglicht die Bildgebungsmethode abseits der kardialen Basisdiagnostik bei Patienten vor interventionellen Eingriffen die Erstellung von dreidimensionalen Modellen der kardialen Zielstrukturen des geplanten ablativen Verfahrens, was Effizienz und Sicherheit des Eingriffs maßgeblich verbessern kann. Des Weiteren besitzt die CMR einen wesentlichen Stellenwert in der Risikostratifizierung im Rahmen der ICD(implantierbarer Kardioverter-Defibrillator)-Evaluation. Neben einer genauen Bestimmung der Pumpfunktion sind dank der detaillierten Gewebecharakterisierung die Darstellung und Quantifizierung von fibrotischen Arealen bzw. Narben als potenziellen arrhythmogenen Triggern möglich. Diese anatomische Zuordnung erlaubt zudem eine erhöhte Treffsicherheit im Rahmen der Ablation von substratgebundenen Arrhythmien. Im Vergleich hierzu stellt die interventionelle CMR als direkte Schnittstelle zwischen invasiver Elektrophysiologie und CMR-Bildgebung ein noch recht neues Betätigungsfeld dar. Erste klinische Erfahrungen im Bereich der Ablation von typischem Vorhofflattern konnten nicht nur die Machbarkeit des Konzepts belegen, sondern auch die klaren Vorteile einer bildgebungsgesteuerten elektrophysiologischen Prozedur erkennen lassen.
IMPORTANCE: Ablation of persistent atrial fibrillation (AF) remains a challenge. Left atrial fibrosis plays an important role in the pathophysiology of AF and has been associated with poor procedural ...outcomes. OBJECTIVE: To investigate the efficacy and adverse events of targeting atrial fibrosis detected on magnetic resonance imaging (MRI) in reducing atrial arrhythmia recurrence in persistent AF. DESIGN, SETTING, AND PARTICIPANTS: The Efficacy of Delayed Enhancement-MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation of Atrial Fibrillation trial was an investigator-initiated, multicenter, randomized clinical trial involving 44 academic and nonacademic centers in 10 countries. A total of 843 patients with symptomatic or asymptomatic persistent AF and undergoing AF ablation were enrolled from July 2016 to January 2020, with follow-up through February 19, 2021. INTERVENTIONS: Patients with persistent AF were randomly assigned to pulmonary vein isolation (PVI) plus MRI-guided atrial fibrosis ablation (421 patients) or PVI alone (422 patients). Delayed-enhancement MRI was performed in both groups before the ablation procedure to assess baseline atrial fibrosis and at 3 months postablation to assess for ablation scar. MAIN OUTCOMES AND MEASURES: The primary end point was time to first atrial arrhythmia recurrence after a 90-day blanking period postablation. The primary safety composite outcome was defined by the occurrence of 1 or more of the following events within 30 days postablation: stroke, PV stenosis, bleeding, heart failure, or death. RESULTS: Among 843 patients who were randomized (mean age 62.7 years; 178 21.1% women), 815 (96.9%) completed the 90-day blanking period and contributed to the efficacy analyses. There was no significant difference in atrial arrhythmia recurrence between groups (fibrosis-guided ablation plus PVI patients, 175 43.0% vs PVI-only patients, 188 46.1%; hazard ratio HR, 0.95 95% CI, 0.77-1.17; P = .63). Patients in the fibrosis-guided ablation plus PVI group experienced a higher rate of safety outcomes (9 2.2% vs 0 in PVI group; P = .001). Six patients (1.5%) in the fibrosis-guided ablation plus PVI group had an ischemic stroke compared with none in PVI-only group. Two deaths occurred in the fibrosis-guided ablation plus PVI group, and the first one was possibly related to the procedure. CONCLUSIONS AND RELEVANCE: Among patients with persistent AF, MRI-guided fibrosis ablation plus PVI, compared with PVI catheter ablation only, resulted in no significant difference in atrial arrhythmia recurrence. Findings do not support the use of MRI-guided fibrosis ablation for the treatment of persistent AF. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02529319
RADNI ODNOSI Petrošević, Ivan
Sigurnost,
10/2022, Letnik:
64, Številka:
4
Journal Article
Poslodavac je prijavio ozljedu na radu Hrvatskom zavodu za zdravstveno osiguranje, a u toj prijavi je u izvješću dr. medicine rada navedeno da je tužitelj, noseći grede osjetio bol u oku i da mu je ...dijagnosticirana ablatio retinae deks te da se radi o ozljedi na radu. Tijekom prvostupanjskog postupka utvrdeno je: * da je tužitelj dana 16. travnja 2010. pomagao kolegama u nošenju greda unutar prostora tuženika, da je tijekom nošenja greda osjetio trenutnu bol u oku, da mu je vid bio mutan, odnosno da bi mu na desnom oku slika bila „u dva dijela", od kojih je jedan dio bio bistar a drugi mutan, no da je smatrao da će navedeno proći jer je inače kratkovidan i nosi leće, a o svemu je obavijestio kolege s kojima je radio; * da je u bolnicu otišao nakon 9 dana po ovom dogadaju jer mu nije bilo bolje; * da je vještakinja Z. H. u nalazu i mišljenju navela da je moguće da kod kratkovidne osobe poput tužitelja, zbog dizanja većeg tereta dode do ablacije retine koja uzrokuje da osoba trenutno ne vidi ili ispred sebe vidi veliku zavjesu, a da je moguće da nastane rupica koja, u slučaju da nije liječena odmah, dovede do ablacije retine, s tim da je vještakinja navela da ne može utvrditi da je u konkretnom slučaju dizanje tereta dovelo do ablacije retine jer je tužitelj na liječenje došao tek 9 dana nakon što je dizao predmetni teret, no isto tako je tvrdila da do ove ozljede može doći i bez ikakvog dizanja tereta kod kratkovidnih osoba poput tužitelja; * da vještakinja unatoč izričitoj uputi suda nije osobno pregledala tužitelja; * da je prvostupanjski sud ocijenio da je nalaz i mišljenje vještakinje Z. H., koji je utemeljen isključivo na pisanoj dokumentaciji i bez pregleda tužitelja, dan protivno pravilima struke i nepotpuno, zbog čega je odredio novo vještačenje po vještaku iste specijalizacije i to specijalistu oftalmologije prof. dr. B. C.; * da je stalni sudski vještak B. C. osobno pregledao tužitelja i medicinsku dokumentaciju te je naveo da je dizanje teških tereta poznati čimbenik za razvoj ablacije mrežnice, a to stoga što dizanje takvog tereta dovodi do naglog povećanja očnog tlaka a utječe i na arterijski, abdominalni i intraokularni tlak, dok latencija i postupnost razvoja ablacije retine može biti kraća ili dulja, pa ako je tužitelj relativno mlada osoba, takva osoba ima kompaktniju staklovinu i bolju adheziju prema mrežnici, zbog čega razvoj ablacije može potrajati; * da je kratkovidnost važan čimbenik rizika, i da kao takva može dovesti do retinskih degenerativnih promjena, pa i do ablacije ako postoje sile naprezanja, no da činjenica da se liječniku javio 9 dana kasnije ne znači da podizanje tereta nije uzrok ablacije retine, stoga što se pacijenti obično jave liječniku tek kada shvate da im je ugrožen centralni vid; * da je tužitelj zaposlen kod tuženika kao mesar i da je osposobljen za rad na radnom mjestu mesar, a koje po logici stvari ne podrazumijeva da se na tom radnom mjestu nose grede, dakle ne poduzima teži fizički napor; * da je tužitelj zbog ove ozljede trpio fizičke bolove jakog intenziteta 2 dana, srednjeg intenziteta u trajanju 4 dana, sve zbog kirurške intervencije, kao i fizičke bolove slabog intenziteta u trajanju 3 tjedna, a koji su u vezi s liječničkom intervencijom; * da je tužitelj zbog ozljedivanja i posljedica ozljedivanja trpio strah jačeg stupnja u trajanju od 8 dana, potom strah srednjeg stupnja u trajanju 1 mjesec, a u vezi sa zabrinutosti za zdravlje, kao i strah lakog stupnja u trajanju od 4 mjeseca zbog bojazni i strahovanja za ishod liječenja; * da je kod tužitelja zaostalo oštećenje vida koje je stabilizirano na 0,2 vida, a kako je utvrdeno 23. svibnja 2012., koje se zbog glaukoma i rizika reablacije može i pogoršati, a ocjena je vještaka da s osnove teškog oštećenja vida na desnom oku tužitelj ima trajne posljedice procijenjene na 26,4 % koje ga ometaju u dnevnim aktivnostima u smislu odmaranja kod napora vida na blizinu, slabije procjene dubine prostora, nužnosti okretanja glave da zapazi nekoga tko mu prilazi s desne strane; * da je tužitelju nakon bolničkog liječenja trebala tuda nestručna pomoć i njega u svakodnevnom životu, u obliku obavljanja poslova po kući i oko kuće, u prašini, na visini, nabavi i odlascima liječniku, i to u trajanju od 6 tjedana po 4 sata dnevno te potom kroz 5 mjeseci 8 sati tjedno, dakle ukupno 328 sati; * da je cijena sata naknade za nestručnu pomoć i njegu prema podacima S. centra. Visinu imovinske štete, tj. naknade za tudu pomoć i njegu utvrdio je na temelju podataka zadobivenih od S. centra o cijeni sata za nestručnu tudu pomoć i njegu, a potreban broj sati utvrdio je vještačenjem po vještaku B. C. Na temelju svega navedenoga, prvostupanjski sud naložio je tuženiku isplatiti tužitelju naknadu neimovinske štete u iznosu od 60.000,00 kuna sa zateznom kamatom na ime pravične novčane naknade za tjelesno i duševno zdravlje te naknadu imovinske štete u iznosu od 9.840,00 kuna sa zateznom kamatom na ime naknade za tudu pomoć i njegu. Zakona o radu (N.N., br. 149/09. - u daljnjem tekstu: ZR), članak 15. Kako smo već pisali, za štetu koju radnik pretrpi na radu ili u svezi s radom odgovara poslodavac po općim propisima obveznog prava (članak 103. stavak 1.
Background: Pulmonary vein isolation (PVI) is the gold standard management for patients with atrial fibrillation (AF) refractory to medical therapy. Contact-force (CF) sensing very-high-power ...short-duration (vHPSD) radiofrequency (RF) ablation (90 W/4 seconds) has emerged as a novel ablation modality. Previous RF ablation utilized Ablation Index (AI) as a surrogate marker of lesion quality to guide the operator, which is not utilized in QMODE+ (vHPSD) and thus, there is limited guidance on effective lesion formation. In this study, we investigated the correlation between certain lesion parameters to identify relationships and potential determinants for effective lesion formation. Furthermore, we studied the relationship between different anatomical locations on these parameters to gain further insight. Method: A total of 60 consecutive AF patients (42 males, age 61.5 ± 9.06 years, 63% paroxysmal AF) underwent first-time PVI using QMODE+. All wide antral circumferential ablation (WACA) QMODE+ lesions (n=6040) were analysed for force-time integral (FTI), impedance drop, average CF, maximum temperature attained, and anatomical location. The anatomical regions assessed across both left and right WACA were posterior-superior (region 1-2), posterior-inferior (region 3-4), anterior-inferior (region 5-6), and anterior-superior (region 7-8), and pulmonary vein carina (region 9). All pulmonary veins (PVs) were subsequently checked with pacing manoeuvres to examine for gaps in ablation lesions and adenosine for acute pulmonary vein reconnection post-ablation. Results: PVI was successful in all patients while first-pass isolation was observed in 30 patients (50%). A total of 6,040 lesions were performed, with 2,968 and 3,072 lesions in the left and right WACA, respectively. The average CF exhibited a positive correlation with maximum temperature attained and impedance drop (p<0.0001) while displaying a negative correlation with FTI (p<0.0001) (Figure 1). The PV carina (region 9) of the right WACA had the smallest impedance drop (p<0.0001) while the PV carina of the left WACA exhibited the lowest average CF and temperature attained (p<0.0001) (Figure 2). The highest number of gaps or acute reconnection (17 out of 30 patients) were seen in the region of the left pulmonary vein carina (p<0.0001). Conclusion: To our knowledge, this is the first study that has investigated the characteristics of vHPSD ablation lesions according to different anatomical regions in the left atrium. CF was positively correlated with maximum temperature and impedance drop but negatively correlated with FTI. This is very unique to temperature-controlled ablation to reduce complications. Furthermore, ablation at both right and left PV carina demonstrated lower impedance drop and average CF which may explain difficult catheter positioning as well as thicker tissue. This study elucidates the relationship between the anatomical region, contact force, temperature and impedance drop, and will facilitate optimization for effective vHPSD lesion formation. ❑ Image Omitted
Background: Transseptal puncture is a key component of cardiac ablation and structural interventional procedures. The VersaCross RF transseptal puncture (TSP) platform (Baylis Medical) is a novel ...system comprising a blunt radiofrequency (RF) wire rather than a needle, passed through a malleable sheath/dilator. The wire forms a pigtail on deployment and is firm enough to exchange over. This study details the first experience of the use of this novel technology in Europe, and the first worldwide without echocardiographic guidance. Methods: Consecutive patients undergoing TSP were included in the VersaCross group followed by a control group using standard equipment. All 5 operators used the VersaCross system in 2–3 cases prior to data inclusion in the study. Interventions were performed under general anaesthetic or sedation, with transoesophageal echo (TOE) used in a subset to guide the puncture. TSP and fluoroscopy times were prospectively recorded from the point when the drop down from the superior vena cava (SVC) was started until the VersaCross sheath was passed into the left atrium (LA). For double transseptal access, the latter was taken as the time the second separate transseptal puncture was completed or, based on the operator’s preference, a second sheath had been passed into the LA through the initial puncture. Also recorded were the number of drop downs from the SVC and number of RF applications or needle deployments on the septum. Immediate and post-discharge complications were recorded. Results: The VersaCross (n=50) and control (n=25) groups had a mean age of 61.9 ± 11.1 years vs 64.2 ± 11.3 years; 54% vs 68% male; BMI of 29.1 ± 5.3 vs 29.3 ± 5.1; 34 vs 28% with prior TSP procedures; 98 vs 100% on anticoagulation; 10 vs 16% with pacemakers; and 38 vs 40% under TOE guidance (p>0.05 for all). Ablations for AF predominated in both groups (86 vs 92%), of which approximately half were cryoablations (49% vs 56%). The remaining cases were for atrial or ventricular tachycardia. For both single or dual transseptal access, there was no correlation between transseptal or fluoroscopy time and procedure number in the VersaCross group. There was no difference in transseptal or fluoroscopy time between the VersaCross and control groups (p>0.05 for all) (Figure 1). VersaCross cases needed an average of 1.5 ± 1 drop downs and 1 ± 0.7 RF application per TSP. For control cases this was 1.5 ± 0.9 and 1 ± 0.6 deployments, respectively (p>0.05 for both). In the VersaCross group, four minor complications occurred: one case of atrioventricular block lasting seconds on application of transseptal RF and three small pericardial effusions not requiring intervention. One of these was diagnosed 23 days after the procedure, and another was in a patient with a temporary pacing wire placed pre-ablation. Of the three effusions, two occurred in cases performed without TOE but this was not statistically significant (p=0.5). There was one major complication in this group of haemothorax requiring chest drain insertion. In all VersaCross cases, TSP was completed without converting to another technology, whilst two needed to be abandoned in the control group – one due to patient discomfort and another due to cardiac tamponade. There were no other complications in the control group. Conclusions: The VersaCross transseptal system can be used in a variety of ablation procedures with or without echo guidance. No quantitative learning curve was evident and, compared with conventional TSP technology, no difference in TSP or fluoroscopy time. Image Omitted
Background
The use of ultrasound‐guided ablation procedures to treat both benign and malignant thyroid conditions is gaining increasing interest. This document has been developed as an international ...interdisciplinary evidence‐based statement with a primary focus on radiofrequency ablation and is intended to serve as a manual for best practice application of ablation technologies.
Methods
A comprehensive literature review was conducted to guide statement development and generation of best practice recommendations. Modified Delphi method was applied to assess whether statements met consensus among the entire author panel.
Results
A review of the current state of ultrasound‐guided ablation procedures for the treatment of benign and malignant thyroid conditions is presented. Eighteen best practice recommendations in topic areas of preprocedural evaluation, technique, postprocedural management, efficacy, potential complications, and implementation are provided.
Conclusions
As ultrasound‐guided ablation procedures are increasingly utilized in benign and malignant thyroid disease, evidence‐based and thoughtful application of best practices is warranted.
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