We acknowledge the funding by SJM.

所有患者的消融过程的所有典型的并发症如心包积液后，签署知情同意书，血管并发症在​​接入网站，中风/ TIA和食管心房瘘，进行了解释。这应验了当地伦理委员会的要求。没有患者亚组被排除（ 例如，患者的心脏起搏器或ICD）;房颤消融手术一般只禁忌症（ 如禁忌证抗凝，甲亢，瓣膜性房颤等 ）必须得到解决。 1.患者设置<ol><li>入院当天，进行例行的体检，包括静息心电图，血液分析，食管超声和心脏对患者造影CT增强扫描。国际标准化比率（INR）应为2和3之间。 </li><li>如果新型抗凝血剂的使用，无论是跳过1剂（利伐沙班）或2个剂量（达比加群和APIxaban）在手术前。 </li></ol> 2.消融过程<ol><li>将3D EAMS补丁每制造商的说明患者的胸部（正面和背面;左，右），颈部，和腹部。监视用手指夹，以及非侵入性血压氧饱和度。执行腹股沟区域的消毒。 </li><li>辖咪达唑仑（2-3毫克，iv）和芬太尼（0.025毫克，ⅳ）作为术前用药稍微安静的病人和以股血管的穿刺时提供一些止痛药。 </li><li>开始与注射以40ml 1％Mepivacain到左和右腹股沟区域的过程。 </li><li>执行股血管的穿刺。启动穿刺静脉通路1厘米内侧股动脉，1厘米联合和嵴之间的连接下髂前上。执行动脉穿刺1厘米优于静脉接入站点。 <ol><li>在执行两个7F穿刺左股静脉用于放置两个诊断导管:1可操纵decapolar导管冠状窦（CS）和1可操纵decapolar导管用于右心室心尖部。血管的穿刺成功后，推进导丝，取出穿刺针，然后将鞘在每Seldinger技术电线。 </li><li>接着，进行2穿刺右侧:在右股动脉用于侵入性血压测量一个4F穿刺，和一个11F一个在右股静脉对房间隔鞘。插入11F鞘之前，使用荧光透视控制线的血管内的位置，然后将鞘。 </li></ol></li><li>辖肝素（100 IU /公斤，四）抗凝治疗。 </li><li>检查活化凝血时间（ACT），每20分钟;为抗凝目标是250和350秒之间一个ACT。如果有必要，根据ACT测量管理肝素推注。 </li><li>在手术过程中，麦ntain患者中使用咪达唑仑（2-5毫克），芬太尼（0.05-0.1毫克）和丙泊酚深analgosedation（弹丸0.5 mg / kg和0.5毫克/公斤/小时恒定基础量）。 </li><li>获得2实况荧光检查或电影循环使用X射线荧光系统中一个右前斜投影（RAO 15°）和左前斜投影（LAO 50°），每个大约3秒长（ 图3和视频1）7 ，14,15。 注:本项目NFCV这些预先录制的电影循环允许的诊断导管未放置透视导管提示。 </li><li>放置在CS的诊断导管1由第一推进导管末端到上腔静脉（SVC），然后拉回来慢慢和偏转它，使其接近他的束。 <ol><li>偏转导管到其最大容许曲线，并执行顺时针旋转以使末端到CS口。推进导管尽可能深地我n中的CS到达到一个稳定的位置。然后，将使用该系统NFCV标记位置的导管尖端的一个里程碑。 </li><li>使用其他诊断导管放置于上腔静脉（SVC），下腔静脉（IVC）和卵圆窝（ 见图1）的地标。 </li></ol></li><li>执行使用长鞘可操纵8跨房间隔穿刺。 <ol><li>插入导丝长在SVC和验证与透视的位置。推进可操纵鞘通过线路到SVC和右心房（RA）之间的交界处。将长针插入扩张器，拉回护套，直到它"跳"到卵圆窝。 </li><li>通过推进针和注射对比染料（15毫升优维300），以验证所述鞘的在左心房（LA）的正确位置执行穿刺。 </li><li>一旦针尖在洛杉矶，推进扩张器到洛杉矶，从鞘断开并推进鞘在扩张器进入LA。偏转鞘，慢慢除去从护套的针和扩张器。 </li><li>向往加入10ml血液从所述鞘和仔细冲洗肝素生理盐水鞘。冲洗肝素生理盐水鞘不断以2ml / hr的流速。 注:诊断导管用于LA的电解剖重建和肺静脉解剖。冠状静脉窦导管保持在适当位置，并作为参考导管为3D地图系统。 </li></ol></li><li>将长鞘中上肺静脉注射和15造影剂的毫升期间执行2个新的透视或电影循环中RAO 15°（右PV）和LAO 50°（左PV）（优维显300）7,14,15 。 </li><li>与3D的电解剖图的融合进行重建的CT解剖。地图解剖标志在洛杉矶仔细，并使用该共同注册过程。 <ol><li>例如，使用的结左下肺静脉（LIPV）到洛杉矶的身体。至少需要10 - 15分的融合过程，然后仔细检查并与粗纱导管优化共注册过程。完成后，将分割的CT模型被定位在三维空间中的解剖学上正确的位置。 </li></ol></li><li>放置一个温度探头3热电偶反式口头来测量内管腔内食管温度在洛杉矶的水平。 </li><li>通过穿刺鞘插入消融导管。 </li><li>通过使用35瓦（前）和25 W（后）电源设置为17毫升/分钟的灌水量进行绕同侧肺静脉消融。 </li><li>如果内部腔温度超过39℃时，立即停止消融和调整电源设置，降低最小功率为20 W的情况下，温度上升，尽管减少能源设置，可以考虑修改病灶设置要更胃窦如果太克罗本身到食道。 <ol><li>如果温度仍然超过41℃，则消融后执行食管白天排除可能发展到食管心房瘘10粘膜热损伤。 </li></ol></li><li>由螺旋导管的所有bipoles起搏演习在最大功率（一般为10毫安/毫秒）检查肺静脉隔离的使用decapolar圆形导管的完整性。确保经济刺激不会通过在CS导管检查信号捕捉LA。验证有没有LA捕获任何肺静脉。 <ol><li>如果必要的话，检测并在病变组密切"差距":左右移动的圆周病灶消融导管，刺激与来自消融导管尖端的最大输出。如果中庭被捕获，开始消融，直到当地捕获消失16。用这种"节奏和 - 烧蚀"-technique周围的一切肺静脉。 </li></ol></l我&gt; <li>一旦围绕肺静脉隔离线完成后，执行左心房，以确定一个健康心房（紫色示出）或纤维化心房的电压图（示出在蓝色，黄色和灰色）[ 见图1和2] 17。使用临界值0.5 mV的正常组织和0.2毫伏的疤痕组织17。 <ol><li>使用消融导管或诊断导管，并开始在肺静脉前庭。确保有一个与导管末端充分接触并注册本地信号幅度与三维图形系统。对于一个正常大小的LA，取覆盖整个洛杉矶体和PV胃窦（100-150分）点。 </li></ol></li><li>用20秒的冠状静脉窦以300毫秒，250毫秒，200毫秒周期的长度或心房不应时突发起搏进行测试的诱导。如果一个稳定的房性心动过速或心房扑动是诱发，地图和相应的烧蚀。 </li><li>如果ATRIAL颤动诱导，执行电复律（与为200J双相休克）和终止程序。 </li><li>取下护套掌握房间隔和导管。 </li><li>通过注入protaminsulfat拮抗肝素（10,000 IU，IV）和从腹股沟去除笔杆。 </li></ol> 3.后程序管理<ol><li>执行手动股压缩10分钟。除去手动笔杆后，压缩两侧穿刺点。检查是否仍有活动性出血5分钟后。如果没有，继续压缩至少一个额外的5分钟，并放置加压包扎6小时。 </li><li>受到患者6小时卧床休息的病人重新活化前。 </li><li>去除加压包扎和临床检查股血管（触诊和听诊）后，提供的抗凝血药（华法令或新的抗凝血剂），下一个剂量。 </li></ol>

<ol>
	<li>Caponi, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ablation+of+atrial+fibrillation:+Does+the+addition+of+three-dimensional+magnetic+resonance+imaging+of+the+left+atrium+to+electroanatomic+mapping+improve+the+clinical+outcome?),+A+randomized+comparison+of+carto-merge+vs.+Carto-xp+three-dimensional+mapping+ablation+in+patients+with+paroxysmal+and+persistent+atrial+fibrillation.">Ablation of atrial fibrillation: Does the addition of three-dimensional magnetic resonance imaging of the left atrium to electroanatomic mapping improve the clinical outcome?), A randomized comparison of carto-merge vs. Carto-xp three-dimensional mapping ablation in patients with paroxysmal and persistent atrial fibrillation.</a> Europace. 12, 1098-1104 (2010).</li><li>Flugelman, M. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Medical+positioning+system:+A+technical+report.">Medical positioning system: A technical report.</a> EuroIntervention. 4, 158-160 (2008).</li><li>Jeron, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First-in-man+(fim)+experience+with+the+magnetic+medical+positioning+system+(mps)+for+intracoronary+navigation.">First-in-man (fim) experience with the magnetic medical positioning system (mps) for intracoronary navigation.</a> EuroIntervention. 5, 552-557 (2009).</li><li>Sommer, P., Rolf, S., Richter, S., Hindricks, G., Piorkowski, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=non-fluoroscopic+catheter+tracking:+The+mediguide+system.">non-fluoroscopic catheter tracking: The mediguide system.</a> Herzschrittmacherther Elektrophysiol. 23, 289-295 (2012).</li><li>Sommer, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Initial+experience+in+ablation+of+typical+atrial+flutter+using+a+novel+three-dimensional+catheter+tracking+system.">Initial experience in ablation of typical atrial flutter using a novel three-dimensional catheter tracking system.</a> Europace. 15, 578-581 (2013).</li><li>Sommer, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mediguide+in+supraventricular+tachycardia:+Initial+experience+from+a+multicentre+registry.">Mediguide in supraventricular tachycardia: Initial experience from a multicentre registry.</a> Europace. 15, 1292-1297 (2013).</li><li>Rolf, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+ablation+of+atrial+fibrillation+supported+by+novel+nonfluoroscopic+4d+navigation+technology.">Catheter ablation of atrial fibrillation supported by novel nonfluoroscopic 4d navigation technology.</a> Heart Rhythm. 10, 1293-1300 (2013).</li><li>Piorkowski, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Steerable+versus+nonsteerable+sheath+technology+in+atrial+fibrillation+ablation:+A+prospective,+randomized+study.">Steerable versus nonsteerable sheath technology in atrial fibrillation ablation: A prospective, randomized study.</a> Circ Arrhythm Electrophysiol. 4, 157-165 (2011).</li><li>Eitel, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Circumferential+pulmonary+vein+isolation+and+linear+left+atrial+ablation+as+a+single-catheter+technique+to+achieve+bidirectional+conduction+block:+The+pace-and-ablate+approach.">Circumferential pulmonary vein isolation and linear left atrial ablation as a single-catheter technique to achieve bidirectional conduction block: The pace-and-ablate approach.</a> Heart Rhythm. 7, 157-164 (2010).</li><li>Halm, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thermal+esophageal+lesions+after+radiofrequency+catheter+ablation+of+left+atrial+arrhythmias.">Thermal esophageal lesions after radiofrequency catheter ablation of left atrial arrhythmias.</a> Am J Gastroenterol. 105, 551-556 (2010).</li><li>Vallakati, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+nonfluoroscopic+mediguide+tracking+system+on+radiation+exposure+in+radiofrequency+ablation+procedures+(less-rads+registry)-an+initial+experience.">Impact of nonfluoroscopic mediguide tracking system on radiation exposure in radiofrequency ablation procedures (less-rads registry)-an initial experience.</a> J Interv Card Electrophysiol. 38, 95-100 (2013).</li><li>Roguin, A., Goldstein, J., Bar, O., Goldstein, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Brain+and+neck+tumors+among+physicians+performing+interventional+procedures.">Brain and neck tumors among physicians performing interventional procedures.</a> Am J Cardiol. 111 (9), 1368-1372 (2013).</li><li>Richter, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cardiac+resynchronization+therapy+device+implantation+using+a+new+sensor-based+navigation+system:+results+from+the+first+human+use+study.">Cardiac resynchronization therapy device implantation using a new sensor-based navigation system: results from the first human use study.</a> Circ Arrhythm Electrophysiol. 6 (5), 917-923 (2013).</li><li>Sommer, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Non-fluoroscopic+catheter+visualization+in+AF+ablation:+experience+from+375+consecutive+procedures.">Non-fluoroscopic catheter visualization in AF ablation: experience from 375 consecutive procedures.</a> Circ Arrhythm Electrophysiol. 7 (5), 869-874 (2014).</li><li>Sommer, P., Richter, S., Hindricks, G., Rolf, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Non-fluoroscopic+catheter+visualization+using+MediGuide+technology:+experience+from+the+first+600+procedures.">Non-fluoroscopic catheter visualization using MediGuide technology: experience from the first 600 procedures.</a> J Interv Card Electrophysiol. 40 (3), 209-214 (2014).</li><li>Eitel, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Circumferential+pulmonary+vein+isolation+and+linear+left+atrial+ablation+as+a+single-catheter+technique+to+achieve+bidirectional+conduction+block:+the+pace-and-ablate+approach.">Circumferential pulmonary vein isolation and linear left atrial ablation as a single-catheter technique to achieve bidirectional conduction block: the pace-and-ablate approach.</a> Heart Rhythm. 7 (2), 157-164 (2010).</li><li>Rolf, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tailored+Atrial+Substrate+Modification+Based+On+Low-Voltage+Areas+in+Catheter+Ablation+of+Atrial+Fibrillation.">Tailored Atrial Substrate Modification Based On Low-Voltage Areas in Catheter Ablation of Atrial Fibrillation.</a> Circ Arrythm Electrophysiol. 7, 483-489 (2014).</li></ol>

SR，SER和MD温和收讲课费由圣犹达医疗用品公司的PS和GH温和收讲课费，并为顾问澳博。

对于介入心脏病电生理和辐射暴露是因为它的不可预知的副作用低估风险。目前文献揭示了该亚组的临床医生之间的左侧脑肿瘤的发生率较高，这表明左半球到X射线源的接近可能是罪魁祸首12。辐射暴露和瘤的诊断之间的延迟已被报道为20年以上。因此，今天的介入应该使用所有的技术方案，以减少辐射照射到最低限度。 该系统NFCV可以帮助减少透视曝光而不影响程序的时间与14,15这是在过去的3年调整几次才能根据ALARA原则，以尽量减少辐射暴露的工作流。 3D绘图系统，可以帮助改善复杂的三维str的理解uctures，但基本取向为操作员使用常规透视生成。 该间隔穿刺仍是辐射剂量的过程中，因为没有配备传感器的材料与技术NFCV使用这些程序的最大贡献步骤（75-80％）是当前可用。尤其是在雏手中，这代表该程序 - 其他成像方式（如心内或食管超声）最关键的一步有助于安全穿刺和低并发症发生率。 该NFCV不仅用于在消融手术，而且在复杂的植入诸如心脏再同步治疗（CRT）。在这些过程中，系统允许的透视负担由75-80％相对于传统的注入13的减少。最近公布可能表明，30一个学习曲线后 - 40程序1.1分钟，连续50例患者中位透视时间是安全可行的14。这被延伸的数据采集到&gt; 500例（ 见图4）时确认。 <img alt="图4" src="/files/ftp_upload/52606/52606fig4highres.jpg" width="600" /> 图4: <a href="https://www.jove.com/files/ftp_upload/52606/52606fig4highres.jpg" target="_blank">请点击此处查看该图的放大版本。</a> 目前可用的系统的限制是，导管的唯一的提示是可视化。雏运营商将很可能不能够从尖端的取向来内插知道导管轴的位置会。此外，该系统是不能够可视化的​​穿刺鞘爱好。仅导管的一个有限的选择，目前因此仅服务现有的不同程序有限数量使用NFCV技术是合适的。 在不久的将来，更多的设备和工具将可被装备有传感器而被可视化的非荧光镜。该系统基本上在这里工作为不同的程序心血管平台;电生理学是刚刚已被引入所述第一应用。

导管消融术已成为标准治疗在很多心律失常的治疗。而不同的消融策略已经提出并正在施加所有消融过程中其必要性，使用透视的可视化导管共享一个通用性。在使用活的X射线进行消融手术的严重依赖程度有所减轻，在20世纪90年代与3D电解剖标测系统（EAMS），有助于显著减少辐射剂量和时间的到来。利用磁共振成像（MRI）和计算机断层扫描（CT）的心脏成像的集成显示出甚至进一步减少在消融过程1透视曝光。最近，一种新的技术用于导管可视化，称为MediGuide-（MG）的技术，已经引入了可以进一步促进减少在辐射暴露2,3。细节先前已经描述4,5。简要地说，单线圈传感器嵌入DED在导管尖端可以精确地局部化，通过电磁场。关于工具的三维位置和方向信息，然后转移到荧光系统和用于可视化导管末端被投射在2预先记录电影循环虚拟双平面图。先前已经表明，在MG技术的应用可以通过使用诊断导管在心房扑动4和通过在几个室上性心动过速（SVT）6和心房纤颤同时使用诊断和消融导管导致显著减少透视负担（AF ）7例。有可能是担心非荧光导管可视（NFCV）技术的应用可能会增加在没有导管轴的可视化和导管定位是完全基于导管末端的位置的程序的风险。据证实，并发症的发生率等于或甚至更低，以proced数目字进行常规工具14。这可以解释通过常规方法的限制:只能在程序的导管的一定比例将是"可见"。这改变了通过应用NFCV技术，因为导管将在这个虚拟的双平面视图在整个过程中是可见的。 在这个协议中，我们与阵发性，药物难治性的症状严重房颤患者进行房颤消融。这个协议的目标是实现相同的端点作为常规方法， 即，隔离所有肺静脉与成熟的双向块，并减少透视曝光为病人由&gt; 90％相比，通过传统的设置另外使用NFCV技术。

<table><tbody><tr><td>MediGuide System</td><td>SJM</td><td>MG1000</td><td>Non fluoroscopic mapping system</td></tr><tr><td>Patient Reference Sensor (PRS) Patch</td><td>SJM</td><td>H700071</td><td>Reference sensor</td></tr><tr><td>Livewire&amp;trade; Diagnostic Catheter MediGuide Enabled&amp;trade;</td><td>SJM</td><td>D402058</td><td>diagnostic catheter</td></tr><tr><td>Agilis Nxt steerable introducers 71 cm small curle</td><td>SJM</td><td>408309</td><td>steerable sheath</td></tr><tr><td>BRK transseptal needle and stainless steel stylet</td><td>SJM</td><td>408314</td><td>transseptal needle</td></tr><tr><td>EnSite Velocity patch set</td><td>SJM</td><td>100003331</td><td>3D mapping tools</td></tr><tr><td>Safire BLU</td><td>SJM</td><td>A088087</td><td>Ablation catheter</td></tr><tr><td>Sensitherm</td><td>SJM</td><td>26155ST</td><td>thermoprobe</td></tr><tr><td>Siemens Artis</td><td>Siemens</td><td>x</td><td>X Ray biplanar</td></tr><tr><td>Ensite Velocity v. 2.1</td><td>SJM</td><td>x</td><td>3D mapping system</td></tr><tr><td>Ampere generator</td><td>SJM</td><td>H700494</td><td>RF generator</td></tr><tr><td>Ampere Remote control</td><td>SJM</td><td>H700490</td><td>Remote control for generator</td></tr><tr><td>Cool point</td><td>SJM</td><td>IBI-89003</td><td>Irrigation pump</td></tr><tr><td>Cool point tubing set</td><td>SJM</td><td>85785</td><td>Tubing set</td></tr></tbody></table>

non-fluoroscopic catheter tracking for fluoroscopy reduction in interventional electrophysiology

一个技术平台（MediGuide）最近已经推出了非荧光导管跟踪。在一些研究中，我们已经证明，这种非荧光导管可视化系统（NFCV）的应用由90-95％的各种电（EP）的程序降低了透视时间和剂量。这可以是相关性不仅对患者，而且对护士和医生在EP实验室工作。此外，在指示如室上性心动过速的一个子集，NFCV使一个完全非荧光程序，并允许在实验室工作人员不戴铅围裙工作。与这个协议中，我们表明，即使是复杂的程序，如心房纤维性颤动的消融，通常与在常规设置&gt; 30分钟透视时间相关联，可以安全地使用的"90％的透视曝光减少通过额外使用进行的NFCV。

这个过程通常持续2-2.5小时。该患者在深模拟镇静，这意味着它们正在睡觉，接到止痛药，但自主呼吸。如果所有终端，包括双向块在所有的肺静脉，左健心房组织，以及非诱发心房纤颤或心房扑动的都实现了，患者有对自由的12个月后75％的概率从房颤复发。如果左心房与低电压区域（ 见图2）纤维化组织，永久免于心律失常的几率相比减少患者健康左心房组织（ 见图3）。通常情况下，患者可以出院后的程序24小时。在第4-6周消融术后，房性心律失常发作短可能会出现和频繁。 6周后，在消融过程中可能产生的结果是显而易见的。在大多数情况下，所有的医疗抗编曲<html> hythmic处理被中断了烧蚀过程的一天。口服抗凝药是强制性的，需要消融后继续的个体卒中风险，不论至少3个月。 <img alt="图1" src="/files/ftp_upload/52606/52606fig1.jpg" /> 图1:采用NFCV技术房颤消融 。左，中:消融导管（红色尖）在左上肺静脉（LSPV，蓝色标​​记）:使用NFCV技术导管可视化。右图:在3D绘图系统显示相同的设置。消融导管（绿卤）放置在左上肺静脉附近的脊到左心耳。食管温度探头后左心房（绿色导管）。 <a href="https://www.jove.com/files/ftp_upload/52606/52606fig1highres.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <html> ove_content"&gt; <img alt="图2" src="/files/ftp_upload/52606/52606fig2.jpg" /> 图2:"患病"的左心房电压图 。三维重建CT低电压区域的左心房后壁和二尖瓣峡部区域指示先前消融领域。 <a href="https://www.jove.com/files/ftp_upload/52606/52606fig2highres.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <img alt="图3" src="/files/ftp_upload/52606/52606fig3.jpg" /> 图3:"健康"的左心房电压图 。三维重建左心房的CT模型。颜色编码的电压地图显示紫色的健康组织（电图&gt; 0.5毫伏）和灰色的疤痕组织（电图&lt;0.2毫伏）。电图的振幅&gt; 0.2毫伏和&lt;0.5毫伏显示为黄色，红色和蓝色。ighres.jpg"目标="_空白"&gt;点击此处查看该图的放大版本。 视频1:NFCV的原则 。在该过程开始时，2个短电影循环（每3秒）被记录并且被用作动态背景导管可视化。专门设计的带有导管的尖端微型传感器插入病人和受NFCV系统可视化。 <a href="https://www.jove.com/files/ftp_upload/52606/Video1.mp4" target="_blank">请点击此处观看该视频。</a>

Watch this Scientific Journal Video about Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology at JoVE.com

Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

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 ...

non-fluoroscopic-catheter-tracking-for-fluoroscopy-reduction

Research

JoVE Journal

Medicine

13.2K 次观看.  University of Leipzig. 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.

视频: Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

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

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

This report provides a detailed description of a new remote navigation system based on magnetic driven forces, which has been recently introduced as a new robotic tool for human cardiac electrophysiology procedures.

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 ...

科研

医学

Magnetically-Assisted Remote Controlled Microcatheter Tip Deflection under Magnetic Resonance Imaging

X-ray fluoroscopy-guided endovascular procedures have several significant limitations, including difficult catheter navigation and use of ionizing radiation, which can potentially be overcome using a magnetically steerable catheter under MR guidance.
	The main goal of this work is to develop a microcatheter whose tip can be remotely controlled using the magnetic field of the MR scanner. This protocol aims to describe the procedures for applying current to the microcoil-tipped microcatheter to produce consistent and controllable deflections.
	A microcoil was fabricated using laser lathe lithography onto a polyimide-tipped endovascular catheter. In vitro testing was performed in a waterbath and vessel phantom under the guidance of a 1.5-T MR system using steady-state free precession (SSFP) sequencing. Various amounts of current were applied to the coils of the microcatheter to produce measureable tip deflections and navigate in vascular phantoms.
	The development of this device provides a platform for future testing and opportunity to revolutionize the endovascular interventional MRI environment.

Current applied to an endovascular microcatheter with microcoil tip made by laser lathe lithography can achieve controllable deflections under magnetic resonance (MR) guidance, which may improve speed and efficacy of navigation of vasculature during various endovascular procedures.

磁力辅助的远程控制微导管尖端偏转根据磁共振成像

X-ray fluoroscopy-guided  endovascular procedures have several significant limitations, including  difficult catheter navigation and use of ionizing ...

生物工程

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 ...

Three-Dimensional Ultrasonic Needle Tip Tracking with a Fiber-Optic Ultrasound Receiver

Ultrasound is frequently used for guiding minimally invasive procedures, but visualizing medical devices is often challenging with this imaging modality. When visualization is lost, the medical device can cause trauma to critical tissue structures. Here, a method to track the needle tip during ultrasound image-guided procedures is presented. This method involves the use of a fiber-optic ultrasound receiver that is affixed within the cannula of a medical needle to communicate ultrasonically with the external ultrasound probe. This custom probe comprises a central transducer element array and side element arrays. In addition to conventional two-dimensional (2D) B-mode ultrasound imaging provided by the central array, three-dimensional (3D) needle tip tracking is provided by the side arrays. For B-mode ultrasound imaging, a standard transmit-receive sequence with electronic beamforming is performed. For ultrasonic tracking, Golay-coded ultrasound transmissions from the 4 side arrays are received by the hydrophone sensor, and subsequently the received signals are decoded to identify the needle tip&#39;s spatial location with respect to the ultrasound imaging probe. As a preliminary validation of this method, insertions of the needle/hydrophone pair were performed in clinically realistic contexts. This novel ultrasound imaging/tracking method is compatible with current clinical workflow, and it provides reliable device tracking during in-plane and out-of-plane needle insertions.

Accurate and efficient visualization of invasive medical devices is extremely important in many ultrasound-guided minimally invasive procedures. Here, a method for localizing the spatial position of a needle tip relative to the ultrasound imaging probe is presented.

基于光纤超声接收机的三维超声针尖跟踪

Ultrasound is frequently used for guiding minimally invasive procedures, but visualizing medical devices is often challenging with this imaging modality. ...

工程学

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

房颤消融机器人

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) &#8211; the atrial septum&#8217;s thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P &#60;0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a &#8220;cryoballoon only&#8221; technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

The goal of this study is to demonstrate the preferential location of transseptal puncture during a cryoballoon catheter ablation procedure for the treatment of atrial fibrillation.

与前伪劣间隔穿刺网站减少医源性房间隔缺损操作Cryoballoon消融导管时，

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical ...

Ablation of Ischemic Ventricular Tachycardia Using a Multipolar Catheter and 3-dimensional Mapping System for High-density Electro-anatomical Reconstruction

Ventricular tachycardia (VT) in patients with ischemic cardiomyopathy mainly results from endocardial scars after myocardial infarction; those scars represent zones of slow conduction that allow the occurrence and maintenance of reentrant circuits. Catheter ablation enables substrate modification of those low voltage areas and thus can help to alter the scar tissue in such a way that arrhythmias cannot appear anymore. Hospitalizations of concerned patients decrease, quality of life and outcome rise. Consequently, VT ablation represents a growing field in electrophysiology, especially for patients with endocardial scars in ischemic heart disease after myocardial infarction. However, ablation of ventricular tachycardia remains one of the most challenging procedures in the electrophysiology lab. Precise scar definition and localization of abnormal potentials are critical for ablation success. The following manuscript describes the use of a multipolar mapping catheter and 3-dimensional (3D) mapping system to create a high density electro-anatomical map of the left ventricle including a precise scar representation as well as mapping of fractionated and late potentials in order to allow a highly accurate substrate modification.

With the following protocol, we provide an approach to Ventricular Tachycardia (VT) ablation using high density mapping with a multipolar catheter and 3D mapping system enhancing the success of the procedure.

采用多极导管三维测图系统进行缺血性室性心动过速的高密度电解剖重建

Ventricular tachycardia (VT) in patients with ischemic cardiomyopathy mainly results from endocardial scars after myocardial infarction; those scars ...

Improved Registration of 3D CT Angiography with X-ray Fluoroscopy for Image Fusion During Transcatheter Aortic Valve Implantation

The fusion of 3D anatomical models derived from high-fidelity pre-interventional computed tomography angiography (CTA), and x-ray (XR) fluoroscopy to facilitate anatomical guidance is of huge interest for complex cardiac interventions like TAVI procedures with cerebral protection. Co-registration of CTA and XR has been introduced either based on additional intraoperative non-/contrast-enhanced cone-beam computed tomography (CBCT) or two separate aortograms. With the related increase of radiation exposure and/or contrast agent (CA) dose, a potential additional risk for the patient is introduced. Here, we propose a modified co-registration approach making use of arteriograms of the iliofemoral arteries, routinely performed during the femoral puncture and sheath introduction. On-the-fly refinement of the co-registration during the on-going procedure enables accurate co-registration without any additional angiograms, thus reducing CA, XR dose and procedure time, while simultaneously improving operator confidence and procedure safety.

The aim of this study was to improve the co-registration for image fusion (IF) of pre-interventional CT data with real-time x-ray (XR) fluoroscopy during transfemoral transcatheter aortic valve implantation (TAVI).

经导管主动脉瓣植入术中 X 线透视 3D CT 血管造影的改进与影像融合

The fusion of 3D anatomical models derived from high-fidelity pre-interventional computed tomography angiography (CTA), and x-ray (XR) fluoroscopy to ...

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the esophagus from inadvertent thermal injury. Active esophageal cooling is increasingly being used over traditional luminal esophageal temperature (LET) monitoring, and each approach may influence procedure times and the variability around those times. The objective of this study is to measure the effects on procedure time and variability in procedure time of two different esophageal protection strategies utilizing advanced informatics techniques to facilitate data extraction. Trained clinical informaticists first performed a contextual inquiry in the catheterization laboratory to determine laboratory workflows and observe the documentation of procedural data within the electronic health record (EHR). These EHR data structures were then identified in the electronic health record reporting database, facilitating data extraction from the EHR. A manual chart review using a REDCap database created for the study was then performed to identify additional data elements, including the type of esophageal protection used. Procedure duration was then compared using summary statistics and standard measures of dispersion.&#160;A total of 164 patients underwent radiofrequency PVI over the study timeframe; 63 patients (38%) were treated with LET monitoring, and 101 patients (62%) were treated with active esophageal cooling. The mean procedure time was 176 min (SD of 52 min) in the LET monitoring group compared to 156 min (SD of 40 min) in the esophageal cooling group (P = 0.012). Thus, active esophageal cooling during PVI is associated with reduced procedure time and reduced variation in procedure time when compared to traditional LET monitoring.

This study utilized advanced informatics techniques to compare procedure duration in patients undergoing radiofrequency atrial ablation treated with active esophageal cooling to those treated with traditional luminal esophageal temperature monitoring. Contextual inquiry, workflow analysis, and data mapping were utilized. The findings demonstrated reduced procedure time and variability with active cooling.

通过主动食管冷却减少心房颤动射频消融术的手术时间和可变性

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the ...

Reduction of Radiation Exposure during Endovascular Treatment of Peripheral Arterial Disease Combining Fiber Optic RealShape Technology and Intravascular Ultrasound

Vascular surgeons and interventional radiologists face chronic exposure to low-dose radiation during endovascular procedures, which may impact their health in the long term due to their stochastic effects. The presented case shows the feasibility and efficacy of combining Fiber Optic RealShape (FORS) technology and intravascular ultrasound (IVUS) to reduce operator exposure during the endovascular treatment of obstructive peripheral arterial disease (PAD). 
FORS technology enables real-time, three-dimensional visualization of the full shape of guidewires and catheters, embedded with optical fibers that use laser light instead of fluoroscopy. Hereby, radiation exposure is reduced, and spatial perception is improved while navigating during endovascular procedures. IVUS has the capacity to optimally define vessel dimensions. Combining FORS and IVUS in a patient with iliac in-stent restenosis, as shown in this case report, enables passage of the stenosis and pre- and post-percutaneous transluminal angioplasty (PTA) plaque assessment (diameter improvement and morphology), with a minimum dose of radiation and zero contrast agent. The aim of this article is to describe the method of combining FORS and IVUS stepwise, to show the potential of merging both techniques in view of reducing radiation exposure and improving navigation tasks and treatment success during the endovascular procedure for the treatment of PAD.

Described here is a stepwise method of combining Fiber Optic RealShape technology and intravascular ultrasound to show the potential of merging both techniques, in view of the reduction of radiation exposure and improvement of navigation tasks and treatment success during an endovascular procedure for the treatment of peripheral arterial disease.

结合光纤RealShape技术和血管内超声，减少外周动脉疾病血管内治疗期间的辐射暴露

Vascular surgeons and interventional radiologists face chronic exposure to low-dose radiation during endovascular procedures, which may impact their ...