支持部分由公司Magnetecs（Inglewood，加利福尼亚，美国）在与马德​​里自治区和拉巴斯大学医院合作。我们感谢他们的帮助，插图中的数字和视频编辑伊万菲尔盖拉斯罗摩和海梅·帕洛莫Cousido的。

患者进行消融的左或右心房扑基板（ 表1）。在场的失代偿期或严重的全身性疾病，血栓左心房内，肾功能衰竭，年龄&lt;18岁，体重指数&gt; 40，怀孕排除标准。该协议的一部分，最初的安全性和可行性协议，由该机构研究和伦理委员会批准。无房颤的程序，包括在此协议。所有患者给予知情同意。 1。机器人磁导航系统说明导管制导控制和成像系统（CGCI）采用8个强大的电磁铁产生高度灵活的优化集中，并包含磁场内磁腔几乎完全在有效控制区域的磁场（0.16特斯拉）。磁腔默默工作，有没有移动部件，冷却电磁铁线圈与无毒的矿物油。磁腔线圈电流调节放大器提供电源。该系统产生的磁场强度的10〜20倍比磁共振成像和无磁场时产生的，所以不能在磁性引导模式。磁场发生器提供用于移动，定位和引导的导管的前端配有三个连接到其前端的永久磁铁颗粒的扭矩和力。 机器人系统包括一个操作台，CGCI控制器计算机和电动线性导管推进机制。该系统使用一个标准的3轴操纵杆，这是用来旋转磁场和手动推进或缩回导管。 3D控制器是用来推导管在任何屏幕化的方向发展。 C臂X射线可旋转或摘录在操作控制台使用的X射线对话框。操作系统的控制台上的统一的显示的CGCI系统，电解剖标测系统，EP记录系统，心腔内超声（ICE），和X-射线。它允许直接在电解剖标测系统和EP录音系统的键盘和鼠标控制。通常情况下，用于屏幕中心的电解剖标测系统画面，CGCI图形叠加。 2。病人的准备承认病人到医院的当天或前一天的程序。隔夜空腹状态下是必需的。 <ol><li>在手术台上的病人，护理人员cannulates外周静脉导管手术前的位置。 </li><li>外磁室，医务人员获得左，右股静脉用利多卡因局部麻醉下访问。将护套导引器，分为左，右股静脉。我们建议指导左心房使用intracard基板的IAC介绍，通过探头9法语（FR）超声心动图，左股静脉鞘，并定位到右心房。 </li><li>对于左心房基板，辖首次静脉注射和重复剂量肝素保持250-300第活化凝血时间。 </li><li>辖2毫克咪达唑仑，然后持续静脉丙泊酚镇静和在操作过程中间歇性静脉注射盐酸吗啡了初始剂量。 </li></ol> 3。传统的电生理研究<ol><li>位置标准导管通过股鞘引荐入右心腔的常规诊断的电生理研究。使用透视检查指导，在手动定位。 </li><li>放置10极导管进入冠状动脉窦和一个螺丝在导管右心房隔。 </li><li>介绍一个特殊的可操纵鞘沿其末端的3个电极通过右股静脉（ 图1A），并将其放置于下腔静脉或右心房较低。 </li><li>一个7神父磁化的导管引入到心脏腔室通过特殊的鞘（ 图1A，图1B）。接下来，执行常规工作心律失常的机制。 </li><li>如果需要（例如，左心房扑动的机制），反式间隔进入左心房是通过使用反式间隔鞘和连续ICE监测。左心房扑动程序也放置一个多极化的导管进入左心房，通过跨室间隔穿刺。 </li></ol> 4。准备为远程导航。导管，护套和导管推进机制大会<ol><li>的电动线性的导管推进机构由进行灭菌轮驱动齿轮箱的电动机底座。它还包括一个一次性鞘剪辑和腿部的安装（ 图2A）。该设备添加或删除Ş导管松弛。 </li><li>安装在剪辑鞘，将导管插入鞘，手动前进到左/右心房。后者是由映射系统和X线透视确认。对于左心房基板位置鞘在右心房房间隔接近。 </li><li>接下来，放置导管的辊轴之间的四轮驱动变速箱通过拇指杆拉回。 </li><li>内磁室，X光C臂移动到其工作位置。现在前进到患者的表在磁场内定位胸廓。 </li><li>操作员离开手术室，从操作控制台进行控制。 </li><li>现在的中心屏幕上显示的磁导​​管和特殊电极护套。 CGCI所有电解剖标测系统运作功能是可供的CGCI操作控制台。 </li></ol> 5。远程Navigation和映射<ol><li>执行的电气耦合指标体系的导管接触校准。最大和最小的接触值被设置在控制面板上。 </li><li>与电解剖标测系统和闭环伺服系统的完全集成，允许远程导航和3D几何重建的右/左心腔，它允许以最小的X射线曝光的过程继续。 </li><li>使用右手的三维控制器引导导管的特定网站内的右/左心房，通过改变磁场的方向（ 图2B）。黄色的磁性箭头指示的方向的磁场。使用左手的3轴操纵杆量来控制导管松弛（ 图2C）。在病人的腿下的机动装置，允许添加和缩回导管松弛（ 图2A）。 </li><li>快速变化的磁场强度，可怕产率CTION，梯度推/拉和/或扭矩（弯曲）运动中的导管的远端部分。实时远程导航评估基于电场矢量调整和随后的反应中的导管的尖端。磁图标显示颜色线圈功率值。绿色表示强烈的正面磁场，红色表示一个强烈的负场（ 图3）。 </li><li>导管尖端并列的磁通密度的向量方向。磁场梯度产生的力控制的导管是到0.7T/meter，一个最大的垂直施加的力为25g。 </li><li>执行从4极的磁化导管的几何点收购，一边慢慢移动导管心房室周围。可以得到三维EAM重建的几分钟后（ 图3A，3B）。 </li><li>转向护套定位在右心房的远程导航服务器允许Reaching右下肺静脉可以直接偏转导管穿过房间隔时或之后的一个循环中的相对的壁，然后指向朝向右下肺静脉的导管。 </li><li>生成激活，电压和第一间隔起搏后的地图来表征的折返电路（ 图4A，4B）。确定消融的目标和定位他们对3D几何。 </li></ol> 6。消融。手动和自动导管定位于目标网站<ol><li>在自动磁感应模式，运营商可以自动引导导管电解剖标测系统标签上双击的具体目标。这代表一个重要的功能来创建远程和自动消融线。 </li><li>在自动模式下，对于每个独立的目标和CGCI系统运行，驱动导管的目标点（ 图4C中）。在自动模式下，系统会显示一个目标对话框。这表明预期的目标，范围，时间和目标搜索状态。 </li><li>精度自动定位在目标上的导管也被测量的初始手动定位的导管中的最终位置的距离。以毫米测量距离，并认为是显著的，如果大于3毫米。导管导航精度要求使用电解剖标测系统领域的缩放工具。 </li><li>手动干预自动搜索可以通过使用操纵杆或3D控制器。 </li><li>要终止心律失常射频能量特定的网站标记为目标点，无论是手动或自动引导。心律失常终止折返（ 图4C，4D）中断后恢复窦性心律。快速心房起搏诱导无需重新确认消除心律失常。 </li></ol>

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何塞·L.美利奴博士收到临床研究从Magnetecs公司和波士顿科学的补助。何塞·L.美利奴博士担任圣裘德医疗扬声器。刚博士和约书亚沙哈尔有权益在Magnetecs公司

这是第一次使用CGCI远程导航系统的临床报告。它显示了重要的技术特点，方便导航和消融左，右心房基板。该系统可能潜在地克服前磁基于奈厄布的系统的一些设计上的限制。[10]因此，心内膜接触力和导航的心脏腔室内部可以极大提高0.08特斯拉相比，所增加的强度的磁场强度0.16特斯拉中尼俄柏体系。连续和快速成型和重塑的磁场，而不是移动的外部磁铁磁场的改变，13,14提供瞬时传输变化的磁化导致几乎实时远程导航导管的前端。以自动模式CGCI系统还提供了一个真正的闭环伺服系统，有能力保持在所需的解剖导管尖端目标17通过不断调整的磁场的方向和强度。 老师系统，心脏内的操作，通过机械的机器人手臂的转向护套的基础上，允许实时导管的活动12，但使用的机械力来驱动导管不超过手动操作代表了技术进步。使用Sensei系统的初步报告提出的关注率较高，心包填塞，比传统的手动射频交付，18,19可能已经涉及到远程操纵僵硬导向工匠导管（汉森医疗，山景，CA，USA） 。填塞率都优于传统的手工方式，可能会更关系到不同的温度和功率，更多的经验和引进一种具有特殊功能的系统来间接估算导管接触力的组织（智能感知）射频设置20 CGCI系统不需要实验室与特定的磁隔离，因为磁场对病人的躯干高度集中。此外，电生理室可以使用，也可以作为一个传统的电生理实验室，或作为磁性实验室从其常规位置向所述磁性室通过移动病人的表。后者可以手动或通过遥控完成。严重的并发症，如心包积液和心包填塞的情况下，虽然没有大的并发症已经存在的初步经验，将可以消除病人从磁腔≈15秒。 一般缺点，如缺乏实时接触力监测或病变可视化仍然适用的CGCI系统。结合机器人导航与实时接触力导管直接可视化的心房腔，可能是一个未来可行的方法，以增加长期成功消融病变和减少并发症的风险。迄今为止，CGCI系统使用在猪的实验数据已经证实再现的导航和准确，快速的导管定位于心房腔室在选定的消融目标17，一旦消融靶点本地化，该系统具有导航的能力，导管尖端选定的目标，尽管心脏运动和解剖违规行为。此外，在同一动物的尸检研究显示，大多数射频病变透壁[17]在此第一次报告在人类该系统还示出再现的导航和定位准确，快速的导管内的右侧或左侧心房室在选定的消融目标。迅速的磁场调整的使用可能会增强导管尖端在较少的射频应用中的稳定性和结果，以及更少的主要并发症。虽然结果和后续的初步经验是令人鼓舞的，未来的大型随机临床试验患者复杂的导管消融程序都需要证明这些潜在的好处。

不同类型的心律失常，心律失常的导管消融已成为一种有效的治疗。1,2抗心律失常药物疗效有限，常常需要，由于二次效应或亲心律失常被撤回。3因此，为消融术是唯一的机会在许多患者的彻底治疗。消融手术需要移动血管系统和心脏导管内室，以进一步确定心律失常基板消融前。正确的导管操作需要一个熟练的电生理透视引导下工作。这可能会导致显着的X射线曝光，这是为患者和医务人员的危险。在过去的二十年中，导致电解剖图（EAM）能够创造出不同的导航系统，以减少X射线曝光4更好地了解心律失常的基板。5-8然而，移动和放置导管eters到特定区域的心脏仍然需要手动引导，这使得这些程序高度依赖于操作者的技能。此外，恒定的心脏跳动使得稳定性的一个射频交纳一定的目标的心脏区域存在的主要问题。新的远程导航系统最近已被开发的，目的是克服这些限制，并允许运营商相差的X射线源，而他们正在内的心血管系统的导管。9-11两个远程导航系统目前市售机器人导管控制系统（医疗，汉森老师系统）12和磁的导管导航系统（系统奈厄布，立体定向）。13,14前者是基于两个转向护套任何常规的导管，通过它可以引入以进行进一步操作通过拉线机构由机器人臂固定在一个标准的X线透视表中。的S&#39;第二系统是基于两个永久磁铁定位在病人的身体的每一侧，以产生均匀的磁场。磁铁固定到其前端的特殊导管的心脏腔室之内，可以进行导航，通过改变外部磁场的方向。在Sensei和奈厄布分别存在一些缺点，如安全性和类似的手动导航或组织的接触力较弱，缺乏实时导管响应。 在这份报告中，我们描述了最近开发的导航系统，导管指导，控制和成像（CGCI）的特性和潜在的消融能力。15,16

<table border="1">
<tbody>
 <tr>
 <td>Name of Reagent/ Equipment</td>
 <td>Company</td>
 <td>Catalog Number</td>
 <td>Comments</td>
 </tr>
 <tr>
 <td>Radiofocus Introducer II 7 Fr.</td>
 <td>Terumo</td>
 <td>RS*R70N10MQ</td>
 <td></td>
 </tr>
 <tr>
 <td>Radiofocus Introducer II 6 Fr.</td>
 <td>Terumo</td>
 <td>RS*R60N10MQ</td>
 <td></td>
 </tr>
 <tr>
 <td>Avanti+ Introducer 9 Fr.</td>
 <td>Cordis, Johnson &amp; Johnson</td>
 <td>504-609X</td>
 <td></td>
 </tr>
 <tr>
 <td>Pecutaneous Transeptal Catheter Introducer Set 8 Fr.</td>
 <td>Medtronic</td>
 <td>008591</td>
 <td></td>
 </tr>
 <tr>
 <td>Brockenbrough Curved Needle</td>
 <td>Medtronic</td>
 <td>003994</td>
 <td></td>
 </tr>
 <tr>
 <td>Percutaneuos Transeptal Catheter Introducer Agilis ES</td>
 <td>St. Jude Medical</td>
 <td>3271521</td>
 <td></td>
 </tr>
 <tr>
 <td>BRK Transeptal Curved Needle</td>
 <td>St. Jude Medical</td>
 <td>407205;</td>
 <td></td>
 </tr>
 <tr>
 <td>Extension Set</td>
 <td>Sendal</td>
 <td>L-303/100</td>
 <td></td>
 </tr>
 <tr>
 <td>Extension Tube (25 cm)</td>
 <td>Iberhospitex S.A</td>
 <td>0044402</td>
 <td></td>
 </tr>
 <tr>
 <td>BD Eclipse Needle 25G x 5/8 (0.5 mm x 16 mm)</td>
 <td>BD</td>
 <td>305760</td>
 <td></td>
 </tr>
 <tr>
 <td>BD Eclipse Needle 21G x 1 1/2 TW (0.8 mm x 40 mm)</td>
 <td>BD</td>
 <td>305895</td>
 <td></td>
 </tr>
 <tr>
 <td>Surgical Gloves Sterile</td>
 <td>Semperit Technische Produkte Gesellschaft m. b. H. Division Sempermed</td>
 <td>826054720</td>
 <td></td>
 </tr>
 <tr>
 <td>Adult Cannula with 2.1 m Tubing</td>
 <td>Wolfram Droh GmbH</td>
 <td>MDRNC-03N</td>
 <td></td>
 </tr>
 <tr>
 <td>Oxygen Mask</td>
 <td>Carburos Medica Grupo Air Products</td>
 <td>75098</td>
 <td></td>
 </tr>
 <tr>
 <td>Saline</td>
 <td>Baxter S.L.</td>
 <td>PE1324</td>
 <td></td>
 </tr>
 <tr>
 <td>Saline </td>
 <td>Laboratorios Grifols</td>
 <td>3033986</td>
 <td></td>
 </tr>
 <tr>
 <td>Sterile Disposable Scalpel</td>
 <td>Sovereign </td>
 <td>D16390</td>
 <td></td>
 </tr>
 <tr>
 <td>I.V. Set for Gravity Infusion</td>
 <td>Sendal</td>
 <td>NT-820-ELL180</td>
 <td></td>
 </tr>
 <tr>
 <td>Sterile Banded Bag</td>
 <td>Barrier</td>
 <td>705845</td>
 <td></td>
 </tr>
 <tr>
 <td>Sterile Gauzes</td>
 <td>Ortopedia y Cirug&iacute;a, S.L.</td>
 <td>0323</td>
 <td></td>
 </tr>
 <tr>
 <td>Sterile Syringe</td>
 <td>BD Plastipak</td>
 <td>302188</td>
 <td></td>
 </tr>
 <tr>
 <td>Infusion Set. Anti-Siphon Valve 15 &mu;m Filter</td>
 <td>Alaris</td>
 <td>273-002</td>
 <td></td>
 </tr>
 <tr>
 <td>Infusion Pump (x4)</td>
 <td>CardinalHealth</td>
 <td>25042ESD1</td>
 <td></td>
 </tr>
 <tr>
 <td>Povidone-iodine (antiseptic for topical application) </td>
 <td>Lainco, S.A.</td>
 <td>619791.2 EFP</td>
 <td></td>
 </tr>
 <tr>
 <td>Morfine Hydrochloride 1%</td>
 <td>B. Braun</td>
 <td>451062</td>
 <td></td>
 </tr>
 <tr>
 <td>Propofol </td>
 <td>Fresenius Kani</td>
 <td>600514</td>
 <td></td>
 </tr>
 <tr>
 <td>Heparin</td>
 <td>Hospira Productos Farmac&eacute;uticos y Hospitalarios, S.L.</td>
 <td>Q63004</td>
 <td></td>
 </tr>
 <tr>
 <td>Lidocaine 1%</td>
 <td>B. Braun</td>
 <td>645598</td>
 <td></td>
 </tr>
 <tr>
 <td>Midazolam</td>
 <td>B. Braun</td>
 <td>602567</td>
 <td></td>
 </tr>
 <tr>
 <td>Iodixanol Injection 320 mgI/mL</td>
 <td>GE Healthcare</td>
 <td>687251.2</td>
 <td></td>
 </tr>
 <tr>
 <td>Pre-gelled Electrosurgical Plate</td>
 <td>Blayco</td>
 <td>2125-5</td>
 <td></td>
 </tr>
 <tr>
 <td>Single Patient Use ECG Electrodes</td>
 <td>Ambu</td>
 <td>SP-00-S/50</td>
 <td></td>
 </tr>
 <tr>
 <td>Irrigated Magnetic Navigation Catheter MagnoFlush Gold Tip 4 mm.</td>
 <td>MedFact Engineering GmbH</td>
 <td>100-002</td>
 <td></td>
 </tr>
 <tr>
 <td>Screw-in Catheter. Temporary Transcenous Pacing Lead System</td>
 <td>Medtronic</td>
 <td>6416-200</td>
 <td></td>
 </tr>
 <tr>
 <td>Extension Cable</td>
 <td>Medtronic</td>
 <td>9670560</td>
 <td></td>
 </tr>
 <tr>
 <td>Extension Cable (Number of pins 10) (x2)</td>
 <td>Bard Electrophysiology</td>
 <td>560004A</td>
 <td></td>
 </tr>
 <tr>
 <td>Extension Cable (Number of pins 4)</td>
 <td>Bard Electrophysiology</td>
 <td>560002P</td>
 <td></td>
 </tr>
 <tr>
 <td>Extension Cable </td>
 <td>St. Jude Medical</td>
 <td>ESI-42-04644-001</td>
 <td></td>
 </tr>
 <tr>
 <td>Extension Cable </td>
 <td>St. Jude Medical</td>
 <td>SJM 100011418</td>
 <td></td>
 </tr>
 <tr>
 <td>Connection Cable from IBI-Generator to MedFact RF-Ablation Catheter</td>
 <td>MedFact Engineering GmbH</td>
 <td>100-013</td>
 <td></td>
 </tr>
 <tr>
 <td>Decapolar Catheter Bard Viking 6F Josephson 115 cm</td>
 <td>Bard Electrophysiology</td>
 <td>400034</td>
 <td></td>
 </tr>
 <tr>
 <td>Multipolar (24 poles) Woven Diagnostic Electrode Catheter</td>
 <td>Bard Electrophysiology</td>
 <td>6FMC00798</td>
 <td></td>
 </tr>
 <tr>
 <td>Ensite NavX System (Version 8.1)</td>
 <td>St. Jude Medical</td>
 <td>100022310</td>
 <td></td>
 </tr>
 <tr>
 <td>Ensite System Patient Interface Unit</td>
 <td>St. Jude Medical</td>
 <td>75-05049-001</td>
 <td></td>
 </tr>
 <tr>
 <td>Ensite NavX Surface Electrode Kit</td>
 <td>St. Jude Medical</td>
 <td>EN0010-002</td>
 <td></td>
 </tr>
 <tr>
 <td>Irrigation Qiona Pump</td>
 <td>MollerMedical GmbH. Biotronik SE &amp; Co.</td>
 <td>363270</td>
 <td></td>
 </tr>
 <tr>
 <td>External Defibrillator/Monitor LifePaK12</td>
 <td>Medtronic </td>
 <td>073-20719-10</td>
 <td></td>
 </tr>
 <tr>
 <td>X-Ray C-Arm Ziehm Vision2 FD Vario</td>
 <td>Ziehm Imaging</td>
 <td>TS04_001a</td>
 <td></td>
 </tr>
 <tr>
 <td>Cardiac Ablation Generator. Software Version V3.0</td>
 <td>Irvine Biomedical, Inc. A St. Jude Medical Company</td>
 <td>IBI-1500T11</td>
 <td></td>
 </tr>
 <tr>
 <td>IBI-1500T11 Remote Control</td>
 <td>Irvine Biomedical, Inc. A St. Jude Medical Company</td>
 <td>85524</td>
 <td></td>
 </tr>
 <tr>
 <td>Dispersive Electrode Filter </td>
 <td>St. Jude Medical</td>
 <td>3183417</td>
 <td></td>
 </tr>
 <tr>
 <td>Stimulus Generator Unit for EPS 320 Cardiac Stimulator Models</td>
 <td>Micropace Pty. Ltd.</td>
 <td>MP3008</td>
 <td></td>
 </tr>
 <tr>
 <td>Lab System Pro EP Recording System</td>
 <td>Bard Electrophysiology</td>
 <td></td>
 <td>The system includes several components provided by the company</td>
 </tr>
 <tr>
 <td>NEC Multisync LCD Screen</td>
 <td>Micropace Pty. Ltd.</td>
 <td>3892D240</td>
 <td></td>
 </tr>
 <tr>
 <td>Whole Blood Microcoagulation System. Hemochron Jr.</td>
 <td>International Technidyne Corporation (ITC)</td>
 <td>HJ7023</td>
 <td></td>
 </tr>
 <tr>
 <td>Cuvettes for ACT for performance on the Hemochron</td>
 <td>International Technidyne Corporation (ITC)</td>
 <td>FB5033</td>
 <td></td>
 </tr>
 <tr>
 <td>Ultrasound Catheter ViewFlex PLUS 9 Fr.</td>
 <td>St. Jude Medical</td>
 <td>VF-PM</td>
 <td></td>
 </tr>
 <tr>
 <td>ViewFlex Catheter Interface Module</td>
 <td>St. Jude Medical</td>
 <td>20-1783-0000</td>
 <td></td>
 </tr>
 <tr>
 <td>HD11 Digital Ultrasound Machine</td>
 <td>Philips</td>
 <td>US30975460</td>
 <td></td>
 </tr>
 <tr>
 <td>CGCI, Magnetic Navigation System, Catheter Guidance, Control and Imaging System</td>
 <td>Magnetecs Corporation</td>
 <td></td>
 <td>The system includes several components provided by the company. Further support and information may be obtained at: 
 <ul>
 	<li> EU Service and Technical Support: support@magnetecs.com </li>
 <li>USA Service and Technical Support: support@magnetecs.com USA Tel. 310-649-9000</li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>

remote magnetic navigation for accurate, real-time catheter positioning and ablation in cardiac electrophysiology procedures

已经开发新的远程导航系统，以改善目前的限制，传统的手动引导基材如左心房扑动在复杂的心脏导管消融。本协议描述所有的临床和在人体的电生理研究和消融导管指导，控制和成像系统（CGCI）评估的准确性，安全性和实时导航微创介入步骤进行。患者进行消融的左或右心房扑基板都包括在内。具体来说，从三个左心房扑动和两个逆时针右心房扑动程序的数据在本报告中。一位代表左心房扑动过程显示在电影中。该系统是基于8个线圈芯电磁铁，生成了一个动态的磁场集中在心脏上。 （毫秒）的急剧变化中的磁场的大小和一个非常灵活的磁化导管一个远程导航LLOW闭环实时整合和精确，稳定的定位和消融致心律失常基板。

这种新的远程磁导航系统允许远程实时导航导管内左，右心房室，无论是在操作模式或自动模式。后者得到几乎是瞬时的扭矩的方向和强度的磁场矢量调整后，弯曲，旋转，和场梯度的轴向推 - 拉运动（为了说明，请参阅视频）。 该系统允许终止心律失常射频交货的缺乏主要并发症（心包填塞，肺栓塞或重大出血）后，在此初始消融经验（ 图4）。 自动化导管远程导航是高度重复性，准确，快速定位所需的目标，并保持导管尖端。基于五个最初的实验程序导航95.7％的重复性，平均精度为1.9±0.9毫米的平均时间达到的目标为23.28±14.8秒。我们考虑了九个目标在右心房（冠状静脉窦，2处高右心房，三尖瓣环的位置，他的上腔静脉和下腔静脉），在左心房的九个目标（2个位置在左边心耳，二尖瓣环和3个位置，一个位置，在每个人的肺静脉），在右心室的六个目标网站（2处右心室流出道，心尖部，右心室游离壁，下壁及室间隔）和五个在左心室的多个目标（先端，前壁，侧壁，隔垫和左心室流出道）。无论是时间，达到目标站点的准确性或再现室和目标显着差异。 <table border="1"><tbody><tr><td> 心律失常的类型 </td><td> 心房基质 </td><td> 消融类型 </td><td><stron<html> g&gt;的急性成功</td><td> 程序源性并发症*** </td><td> 复发 </td></tr><tr><td rowspan="3"> LA扑组（n = 3） </td><td>右肺静脉</td><td>后壁线</td><td>是</td><td>无</td><td>第6个月付</td></tr><tr><td> “左”的PV </td><td>车顶线条</td><td>是* </td><td>无</td><td>第4个月付</td></tr><tr><td>劣质侧壁</td><td>焦距射频交付</td><td>有** </td><td>无</td><td>第3个月付</td></tr><tr><td rowspan="2"> RA扑（N = 2） </td><td rowspan="2">逆时针的Cavo tricuspidIsthmus的依赖RA扑</td><td rowspan="2"> CAVO tricuspidIsthmus线</td><td>是</td><td>无</td><td>第10个月付</td></tr><tr><td>是</td><td>无</td><td>第11个月付</td></tr></tbody></table>_content“&gt; 表1。心房基板和消融结果CGCI系统。FU：跟进。LA：左心房。RF：射频。RA：右心房。PV：肺静脉。* 2更多的非持续，非临床感应LA扑形态。** LA扑不再重新诱导。诱导房颤研究结束。***腔内超声评估整个过程中存在心包积液。 <img src="/files/ftp_upload/3658/3658fig1.jpg" alt="图1" /> 图1。敏锐ES护套（A）和MedFact磁化，用于灌溉金尖导管（B）在左，右心房室的几何重建和消融。 <img src="/files/ftp_upload/3658/3658fig2.jpg" alt="图2" /> 图2。远程导航组件。A，电动线性导管推进机制进行灭菌 ​​轮传动齿轮箱和电机基地。它包括一个一次性鞘剪辑和腿部安装。磁化的导管鞘插入到右/左心房和手动先进乙 ，右手三维控制器用于引导导管心房腔室，通过改变磁场的方向，特定网站内：C，左手3轴操纵杆来控制导管松弛量。 <img src="/files/ftp_upload/3658/3658fig3.jpg" alt="图3" /> 图3。三维电解剖标测左心房和肺静脉的几何形状的几何点收购内使用白尖和覆盖黄色箭头表示磁化的导管，左心房。磁图标显示线圈断电的valUES颜色：绿色表示强烈的正面磁场，红色表示一个强烈的负场。蓝色的导管进入冠状动脉窦。在红色的螺丝导管置于右心房隔。多极导管显示为黄色。 乙 ，最终视图的三维解剖重建左心房。 MA;二尖瓣环。 <img src="/files/ftp_upload/3658/3658fig4.jpg" alt="图4"/> 图4。左心房扑动后自动引导射频能量传送到特定的网站在左心房后壁右侧肺静脉周围电路中断，电压地图显示密集的疤痕在左心房后壁（灰色）第一篇文章，B，起搏间隔产生表征折返，这是本地化右侧肺静脉周围（后路视图是地图hown）。白色和红色的表示第一起搏后的时间间隔&lt;30毫秒，C和D，在自动模式中，导管被驱动到目标点和心律失常终止线完成后，在左心房后壁，折返电路中断<a href="http://www.jove.com/files/ftp_upload/3658/3658fig4large.jpg" target="_blank">点击这里查看大图</a> 。

Watch this Scientific Journal Video about Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures at JoVE.com

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

这份报告提供了一个新的远程导航系统的基础上磁驱动力量，最近已引入一个新的机器人工具，用于人类心脏电生理程序的详细说明。

遥控磁导航导管定位准确，实时和心脏电生理消融程序

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

remote-magnetic-navigation-for-accurate-real-time-catheter

Research

JoVE Journal

Medicine

27.5K 次观看.  La Paz University Hospital. 这份报告提供了一个新的远程导航系统的基础上磁驱动力量，最近已引入一个新的机器人工具，用于人类心脏电生理程序的详细说明。

视频: Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6.
Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8.
The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16.
Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 18. This device received the Conformit&eacute; Europ&eacute;enne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy 19.
Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding 20 or other warfarin-associated problems.
The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1 21. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.

Catheter ablation is combined with placement of the WATCHMAN Left Atrial Appendage Closure Device to prevent ischemic stroke in a patient with non-valvular atrial fibrillation.

结合消融房颤左心耳封堵

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and ...

科研

医学

Direct Pressure Monitoring Accurately Predicts Pulmonary Vein Occlusion During Cryoballoon Ablation

Cryoballoon ablation (CBA) is an established therapy for atrial fibrillation (AF). Pulmonary vein (PV) occlusion is essential for achieving antral contact and PV isolation and is typically assessed by contrast injection. We present a novel method of direct pressure monitoring for assessment of PV occlusion.
Transcatheter pressure is monitored during balloon advancement to the PV antrum. Pressure is recorded via a single pressure transducer connected to the inner lumen of the cryoballoon. Pressure curve characteristics are used to assess occlusion in conjunction with fluoroscopic or intracardiac echocardiography (ICE) guidance. PV occlusion is confirmed when loss of typical left atrial (LA) pressure waveform is observed with recordings of PA pressure characteristics (no A wave and rapid V wave upstroke). Complete pulmonary vein occlusion as assessed with this technique has been confirmed with concurrent contrast utilization during the initial testing of the technique and has been shown to be highly accurate and readily reproducible.
We evaluated the efficacy of this novel technique in 35 patients. A total of 128 veins were assessed for occlusion with the cryoballoon utilizing the pressure monitoring technique; occlusive pressure was demonstrated in 113 veins with resultant successful pulmonary vein isolation in 111 veins (98.2%). Occlusion was confirmed with subsequent contrast injection during the initial ten procedures, after which contrast utilization was rapidly reduced or eliminated given the highly accurate identification of occlusive pressure waveform with limited initial training.
Verification of PV occlusive pressure during CBA is a novel approach to assessing effective PV occlusion and it accurately predicts electrical isolation. Utilization of this method results in significant decrease in fluoroscopy time and volume of contrast.

Effective pulmonary vein isolation utilizing a cryoballoon depends on complete pulmonary vein occlusion. The point of occlusion can be effectively predicted by direct analysis of pulmonary vein pressure waveform analysis during balloon inflation using a simple and reproducible technique.

直接压力监测准确预测在Cryoballoon消融肺静脉阻塞

Cryoballoon  ablation (CBA) is an established therapy for atrial fibrillation (AF).  Pulmonary vein (PV) occlusion is essential for achieving antral ...

Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that the application of this non-fluoroscopic catheter visualization system (NFCV) reduces fluoroscopy time and dose by 90-95% in a variety of electrophysiology (EP) procedures. This can be of relevance not only to the patients, but also to the nurses and physicians working in the EP lab. Furthermore, in a subset of indications such as supraventricular tachycardias, NFCV enables a fully non-fluoroscopic procedure and allows the lab staff to work without wearing lead aprons. With this protocol, we demonstrate that even complex procedures such as ablations of atrial fibrillation, that are typically associated with fluoroscopy times of &#62;30 min in conventional settings, can safely be performed with a reduction of &#62;90% in fluoroscopy exposure by the additional use of NFCV.

Radiation exposure is an underestimated risk in complex ablation procedures. Here, we describe a protocol to significantly decrease fluoroscopy time and dosage for both the patient and the lab staff by using a novel non-fluoroscopic catheter visualization system.

非透视导管跟踪透视减少介入电

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that ...

Cardiac Magnetic Resonance Imaging at 7 Tesla

CMR at an ultra-high field (magnetic field strength B0&#160;&#8805; 7 Tesla) benefits from the signal-to-noise ratio (SNR) advantage inherent at higher magnetic field strengths and potentially provides improved signal contrast and spatial resolution. While promising results have been achieved, ultra-high field CMR is challenging due to energy deposition constraints and physical phenomena such as transmission field non-uniformities and magnetic field inhomogeneities. In addition, the magneto-hydrodynamic effect renders the synchronization of the data acquisition with the cardiac motion difficult. The challenges are currently addressed by explorations into novel magnetic resonance technology. If all impediments can be overcome, ultra-high field CMR may generate new opportunities for functional CMR, myocardial tissue characterization, microstructure imaging or metabolic imaging. Recognizing this potential, we show that multi-channel radio frequency (RF) coil technology tailored for CMR at 7 Tesla together with higher order B0 shimming and a backup signal for cardiac triggering facilitates high fidelity functional CMR. With the proposed setup, cardiac chamber quantification can be accomplished in examination times similar to those achieved at lower field strengths. To share this experience and to support the dissemination of this expertise, this work describes our setup and protocol tailored for functional CMR at 7 Tesla.

The sensitivity gain inherent to ultrahigh field magnetic resonance holds promise for high spatial resolution imaging of the heart. Here, we describe a protocol customized for functional cardiovascular magnetic resonance (CMR) at 7 Tesla using an advanced multi-channel radio-frequency coil, magnetic field shimming and a triggering concept.

7号特斯拉的心脏磁共振成像

CMR at an ultra-high field (magnetic field strength B0&#160;&#8805; 7 Tesla) benefits from the signal-to-noise ratio (SNR) advantage inherent at higher ...

Impact of Intracardiac Neurons on Cardiac Electrophysiology and Arrhythmogenesis in an Ex Vivo Langendorff System

Since its invention in the late 19th century, the Langendorff ex vivo heart perfusion system continues to be a relevant tool for studying a broad spectrum of physiological, biochemical, morphological, and pharmacological parameters in centrally denervated hearts. Here, we describe a setup for the modulation of the intracardiac autonomic nervous system and the assessment of its influence on basic electrophysiology, arrhythmogenesis, and cyclic adenosine monophosphate (cAMP) dynamics. The intracardiac autonomic nervous system is modulated by the mechanical dissection of atrial fat pads-in which murine ganglia are located mainly&#8212;or by the usage of global as well as targeted pharmacological interventions. An octapolar electrophysiological catheter is introduced into the right atrium and the right ventricle, and epicardial-placed multi-electrode arrays (MEA) for high-resolution mapping are used to determine cardiac electrophysiology and arrhythmogenesis. F&#246;rster resonance energy transfer (FRET) imaging is performed for the real-time monitoring of cAMP levels in different cardiac regions. Neuromorphology is studied by means of antibody-based staining of whole hearts using neuronal markers to guide the identification and modulation of specific targets of the intracardiac autonomic nervous system in the performed studies. The ex vivo Langendorff setup allows for a high number of reproducible experiments in a short time. Nevertheless, the partly open nature of the setup (e.g., during MEA measurements) makes constant temperature control difficult and should be kept to a minimum. This described method makes it possible to analyze and modulate the intracardiac autonomic nervous system in decentralized hearts.

Impact of Intracardiac Neurons on Cardiac Electrophysiology and Arrhythmogenesis in an Ex Vivo Langendorff System

Here, we present a protocol for the modulation of the intracardiac autonomic nervous system and the assessment of its influence on basic electrophysiology, arrhythmogenesis, and cAMP dynamics using an ex vivo Langendorff setup.

心内神经元对体外 Langendorff 系统心脏电生理和心脏交感神经的影响

Since its invention in the late 19th century, the Langendorff ex vivo heart perfusion system continues to be a relevant tool for studying a broad spectrum ...

Cardiac Magnetic Resonance for the Evaluation of Suspected Cardiac Thrombus: Conventional and Emerging Techniques

We present the conventional cardiac magnetic resonance (CMR) protocol for evaluating a suspected thrombus and highlight emerging techniques.&#160;The appearance of a mass on certain magnetic resonance (MR) sequences can help differentiate a thrombus from competing diagnoses such as a tumor. T1 and T2 signal characteristics of a thrombus are related to the evolution of hemoglobin properties. A thrombus typically does not enhance following contrast administration, which also helps differentiation from a tumor. We also highlight the emerging role of T1 mapping in the evaluation of a thrombus, which can add another level of support in diagnosis. Prior to any CMR exam, patient screening and interviews are critical to ensure safety and to optimize patient comfort. Effective communication during the exam between the technologist and the patient promotes proper breath holding technique and higher quality images. Volumetric post processing and structured reporting are helpful to ensure that the radiologist answers the ordering services&#39; question and communicates these results effectively. Optimal pre-MR safety evaluation, CMR exam execution, and post exam processing and reporting allow for delivery of high quality radiological service in the evaluation of a suspected cardiac thrombus.

The goal of this article is to describe how cardiac magnetic resonance can be used for the evaluation and diagnosis of a suspected cardiac thrombus. The method presented will describe data acquisition as well as the pre-procedure and post-procedure protocol.

心脏磁共振评估疑似心脏血栓:常规和新兴技术

We present the conventional cardiac magnetic resonance (CMR) protocol for evaluating a suspected thrombus and highlight emerging techniques.&#160;The ...

Real-Time Assessment of Spinal Cord Microperfusion in a Porcine Model of Ischemia/Reperfusion

Spinal cord injury is a devastating complication of aortic repair. Despite developments for the prevention and treatment of spinal cord injury, its incidence is still considerably high and therefore, influences patient outcome. Microcirculation plays a key role in tissue perfusion and oxygen supply and is often dissociated from macrohemodynamics. Thus, direct evaluation of spinal cord microcirculation is essential for the development of microcirculation-targeted therapies and the evaluation of existing approaches in regard to spinal cord microcirculation. However, most of the methods do not provide real-time assessment of spinal cord microcirculation. The aim of this study is to describe a standardized protocol for real-time spinal cord microcirculatory evaluation using laser-Doppler needle probes directly inserted in the spinal cord. We used a porcine model of ischemia/reperfusion to induce deterioration of the spinal cord microcirculation. In addition, a fluorescent microsphere injection technique was used. Initially, animals were anesthetized and mechanically ventilated. Thereafter, laser-Doppler needle probe insertion was performed, followed by the placement of cerebrospinal fluid drainage. A median sternotomy was performed for exposure of the descending aorta to perform aortic cross-clamping. Ischemia/reperfusion was induced by supra-celiac aortic cross-clamping for a total of 48 min, followed by reperfusion and hemodynamic stabilization. Laser-Doppler Flux was performed in parallel with macrohemodynamic evaluation. In addition, automated cerebrospinal fluid drainage was used to maintain a stable cerebrospinal pressure. After completion of the protocol, animals were sacrificed, and the spinal cord was harvested for histopathological and microsphere analysis. The protocol reveals the feasibility of spinal cord microperfusion measurements using laser-Doppler probes and shows a marked decrease during ischemia as well as recovery after reperfusion. Results showed comparable behavior to fluorescent microsphere evaluation. In conclusion, this new protocol might provide a useful large animal model for future studies using real-time spinal cord microperfusion assessment in ischemia/reperfusion conditions.

Spinal cord microcirculation plays a pivotal role in spinal cord injury. Most methods do not allow real-time assessment of spinal cord microcirculation, which is essential for the development of microcirculation-targeted therapies. Here, we propose a protocol using Laser-Doppler-Flow Needle probes in a large animal model of ischemia/reperfusion.

猪缺血/再灌注模型中脊髓微灌注的实时评估

Spinal cord injury is a devastating complication of aortic repair. Despite developments for the prevention and treatment of spinal cord injury, its ...

Real-Time Dynamic Navigation System for the Precise Quad-Zygomatic Implant Placement in a Patient with a Severely Atrophic Maxilla

Zygomatic implants (ZIs) are an ideal way to address cases of a severely atrophic edentulous maxilla and maxilla defects because they replace extensive bone augmentation and shorten the treatment cycle. However, there are risks associated with the placement of ZIs, such as penetration of the orbital cavity or infra-temporal fossa. Furthermore, the placement of multiple ZIs makes this surgery risky and more difficult to perform. Potential intraoperative complications are extremely dangerous and may cause irreparable losses. Here, we describe a practical, feasible, and reproducible protocol for a real-time surgical navigation system for precisely placing quad-zygomatic implants in the severely atrophic maxilla of patients with residual bone that does not meet the requirements of conventional implants. Hundreds of patients have received ZIs at our department based on this protocol. The clinical outcomes have been satisfactory, the intraoperative and postoperative complications have been low, and the accuracy indicated by infusion of the designed image and postoperative three-dimensional image has been high. This method should be utilized during the entire surgical procedure to ensure ZI placement safety.

Here, we present a protocol to achieve precise quad-zygomatic implant placement in patients with severely atrophic maxilla using a real-time dynamic navigation system.

实时动态导航系统，用于在严重萎缩性上颌骨患者中精确放置四颧植入物

Zygomatic implants (ZIs) are an ideal way to address cases of a severely atrophic edentulous maxilla and maxilla defects because they replace extensive ...

Tissue Preparation Techniques for Contrast-Enhanced Micro Computed Tomography Imaging of Large Mammalian Cardiac Models with Chronic Disease

Structural remodeling is a common consequence of chronic pathological stresses imposed on the heart. Understanding the architectural and compositional properties of diseased tissue is critical to determine their interactions with arrhythmic behavior. Microscale tissue remodeling, below the clinical resolution, is emerging as an important source of lethal arrhythmia, with high prevalence in young adults. Challenges remain in obtaining high imaging contrast at sufficient microscale resolution for preclinical models, such as large mammalian whole hearts. Moreover, tissue composition-selective contrast enhancement for three-dimensional high-resolution imaging is still lacking. Non-destructive imaging using micro-computed tomography shows promise for high-resolution imaging. The objective was to alleviate sufferance from X-ray over attenuation in large biological samples. Hearts were extracted from healthy pigs (N = 2), and sheep (N = 2) with either induced chronic myocardial infarction and fibrotic scar formation or induced chronic atrial fibrillation. Excised hearts were perfused with: a saline solution supplemented with a calcium ion quenching agent and a vasodilator, ethanol in serial dehydration, and hexamethyldisilizane under vacuum. The latter reinforced the heart structure during air-drying for 1 week. Collagen-dominant tissue was selectively bound by an X-ray contrast-enhancing agent, phosphomolybdic acid. Tissue conformation was stable in air, permitting long-duration microcomputed tomography acquisitions to obtain high-resolution (isotropic 20.7 &#181;m) images. Optimal contrast agent loading by diffusion showed selective contrast enhancement of the epithelial layer and sub-endocardial Purkinje fibers in healthy pig ventricles. Atrial fibrillation (AF) hearts showed enhanced contrast accumulation in the posterior walls and appendages of the atria, attributed to greater collagen content. Myocardial infarction hearts showed increased contrast selectively in regions of cardiac fibrosis, which enabled the identification of interweaving surviving myocardial muscle fibers. Contrast-enhanced air-dried tissue preparations enabled microscale imaging of the intact large mammalian heart and selective contrast enhancement of underlying disease constituents.

Here, we present a protocol to obtain high resolution micro computed tomography images of healthy and pathological large mammalian whole hearts with collagen-selective contrast enhancement.

用于慢性病大型哺乳动物心脏模型对比增强显影显微计算机断层扫描的组织制备技术

Structural remodeling is a common consequence of chronic pathological stresses imposed on the heart. Understanding the architectural and compositional ...

Real-Time Electrocardiogram Monitoring During Treadmill Training in Mice

Regular physical exercise is a major contributor to cardiovascular health, influencing various metabolic as well as electrophysiological processes. However, in certain cardiac diseases such as inherited arrhythmia syndromes, e.g., arrhythmogenic cardiomyopathy (ACM) or myocarditis, physical exercise may have negative effects on the heart leading to a proarrhythmogenic substrate production. Currently, the underlying molecular mechanisms of exercise-related proarrhythmogenic remodeling are largely unknown, thus it remains unclear which frequency, duration, and intensity of exercise can be considered safe in the context of disease(s).
The proposed method allows to study proarrhythmic/antiarrhythmic effects of physical exercise by combining treadmill training with real-time monitoring of the ECG. Implantable telemetry devices are used to continuously record the ECG of freely moving mice over a period of up to 3 months both at rest and during treadmill training. Data acquisition software with its analysis modules is used to analyze basic ECG parameters such as heart rate, P wave duration, PR interval, QRS interval, or QT duration at rest, during and after training. Furthermore, heart rate variability (HRV) parameters and occurrence of arrhythmias are evaluated. In brief, this manuscript describes a step-by-step approach to experimentally explore exercise induced effects on cardiac electrophysiology, including potential proarrhythmogenic remodeling in mouse models.

Electrocardiogram (ECG) is the key variable to understanding cardiac electrophysiology. Physical exercise has beneficial effects but may also be harmful in the context of cardiovascular diseases. This manuscript provides a method of recording real-time ECG during exercise, which can serve to investigate its effects on cardiac electrophysiology in mice.

小鼠跑步机训练期间的实时心电图监测

Regular physical exercise is a major contributor to cardiovascular health, influencing various metabolic as well as electrophysiological processes. ...