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>

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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 border="0" cellpadding="0" cellspacing="0">
	<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&#8482; Diagnostic Catheter MediGuide Enabled&#8482;</td>
			<td>SJM</td>
			<td>D402058</td>
			<td>diagnostic catheter</td>
		</tr>
		<tr>
			<td>Agilis Nxt steerable introducers 71cm 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

13.1K 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

Dual-phase Cone-beam Computed Tomography to See, Reach, and Treat Hepatocellular Carcinoma during Drug-eluting Beads Transarterial Chemo-embolization

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 dimensional&#160;(3D) diagnostic imaging in the interventional suite and can enhance minimally-invasive therapy beyond the limitations of 2D angiography alone. The role of CBCT has been recognized in transarterial chemo-embolization (TACE) treatment of hepatocellular carcinoma (HCC). The recent introduction of a CBCT technique: dual-phase CBCT (DP-CBCT) improves intra-arterial HCC treatment with drug-eluting beads (DEB-TACE). DP-CBCT can be used to localize liver tumors with the diagnostic accuracy of multi-phasic multidetector computed tomography (M-MDCT) and contrast enhanced magnetic resonance imaging (CE-MRI) (See the tumor), to guide intra-arterially guidewire and microcatheter to the desired location for selective therapy (Reach the tumor), and to evaluate treatment success during the procedure (Treat the tumor). The purpose of this manuscript is to illustrate how DP-CBCT is used in DEB-TACE to see, reach, and treat HCC.

Dual-phase cone-beam computed tomography (DP-CBCT) is a useful intraprocedural imaging technique for transarterial chemo-embolization treatment with drug-eluting beads of hepatocellular carcinoma. DP-CBCT has been used to perform three major steps in oncologic interventional radiology: tumor localization (see), navigation and intraprocedural catheter guidance (reach), and intraprocedural evaluation of treatment success (treat).

双相位锥束CT看看，到达，并在药物洗脱珠Transarterial化疗栓塞治疗原发性肝癌

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 ...

In vivo 19F MRI for Cell Tracking

In vivo 19F MRI allows quantitative cell tracking without the use of ionizing radiation. It is a noninvasive technique that can be applied to humans. Here, we describe a general protocol for cell labeling, imaging, and image processing. The technique is applicable to various cell types and animal models, although here we focus on a typical mouse model for tracking murine immune cells. The most important issues for cell labeling are described, as these are relevant to all models. Similarly, key imaging parameters are listed, although the details will vary depending on the MRI system and the individual setup. Finally, we include an image processing protocol for quantification. Variations for this, and other parts of the protocol, are assessed in the Discussion section. Based on the detailed procedure described here, the user will need to adapt the protocol for each specific cell type, cell label, animal model, and imaging setup. Note that the protocol can also be adapted for human use, as long as clinical restrictions are met.

In vivo 19F MRI for Cell Tracking

We describe a general protocol for in vivo cell tracking using MRI in a mouse model with ex vivo labeled cells. A typical protocol for cell labeling, image acquisition processing and quantification is included.

在体内 19女性 MRI对细胞跟踪

In vivo 19F MRI allows quantitative cell tracking without the use of ionizing radiation. It is a noninvasive technique that can be applied to humans. ...

The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire

The supraclavicular fossa ultrasound view can be useful for central venous catheter (CVC) placement. Venipuncture of the internal jugular veins (IJV) or subclavian veins is performed with a micro-convex ultrasound probe, using a neonatal abdominal preset with a probe frequency of 10 Mhz at a depth of 10-12 cm. Following insertion of the guidewire into the vein, the probe is shifted to the right supraclavicular fossa to obtain a view of the superior vena cava (SVC), right pulmonary artery and ascending aorta. Under real-time ultrasound view, the guidewire and its J-tip is visualized and pushed forward to the lower SVC. Insertion depth is read from guidewire marks using central venous catheter. CVC is then inserted following skin and venous dilation. The supraclavicular fossa view is most suitable for right IJV CVC insertion. If other insertion sites are chosen the right supraclavicular fossa should be within the sterile field. Scanning of the IJVs, brachiocephalic veins and SVC can reveal significant thrombosis before venipuncture. Misplaced CVCs can be corrected with a change over guidewire technique under real-time ultrasound guidance. In conjunction with a diagnostic lung ultrasound scan, this technique has a potential to replace chest radiograph for confirmation of CVC tip position and exclusion of pneumothorax. Moreover, this view is of advantage in patients with a non-p-wave cardiac rhythm were an intra-cardiac electrocardiography (ECG) is not feasible for CVC tip position confirmation. Limitations of the method are lack of availability of a micro-convex probe and the need for training.

The overall goal is to enable clinicians to insert a central venous catheter under real-time ultrasound guidance via the right supraclavicular fossa view of the lower part of the superior vena cava. This view is useful for different catheter insertion sites, thrombosis detection before insertion and ultrasound guided correction of misplaced catheters.

锁骨上窝超声显示为中心静脉导管放置和导管改过来导丝

The supraclavicular fossa ultrasound view can be useful for central venous catheter (CVC) placement. Venipuncture of the internal jugular veins (IJV) or ...

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 ...

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 ...

Development and Evaluation of 3D-Printed Cardiovascular Phantoms for Interventional Planning and Training

Catheter-based interventions are standard treatment options for cardiovascular pathologies. Therefore, patient-specific models could help training physicians&#39; wire-skills as well as improving planning of interventional procedures. The aim of this study was to develop a manufacturing process of patient-specific 3D-printed models for cardiovascular interventions.
To create a 3D-printed elastic phantom, different 3D-printing materials were compared to porcine biological tissues (i.e., aortic tissue) in terms of mechanical characteristics. A fitting material was selected based on comparative tensile tests and specific material thicknesses were defined. Anonymized contrast-enhanced CT-datasets were collected retrospectively. Patient-specific volumetric models were extracted from these datasets and subsequently 3D-printed. A pulsatile flow loop was constructed to simulate the intraluminal blood flow during interventions. Models&#39; suitability for clinical imaging was assessed by x-ray imaging, CT, 4D-MRI and (Doppler) ultrasonography. Contrast medium was used to enhance visibility in x-ray-based imaging. Different catheterization techniques were applied to evaluate the 3D-printed phantoms in physicians&#39; training as well as for pre-interventional therapy planning.
Printed models showed a high printing resolution (~30 &#181;m) and mechanical properties of the chosen material were comparable to physiological biomechanics. Physical and digital models showed high anatomical accuracy when compared to the underlying radiological dataset. Printed models were suitable for ultrasonic imaging as well as standard x-rays. Doppler ultrasonography and 4D-MRI displayed flow patterns and landmark characteristics (i.e., turbulence, wall shear stress) matching native data. In a catheter-based laboratory setting, patient-specific phantoms were easy to catheterize. Therapy planning and training of interventional procedures on challenging anatomies (e.g., congenital heart disease (CHD)) was possible.
Flexible patient-specific cardiovascular phantoms were 3D-printed, and the application of common clinical imaging techniques was possible. This new process is ideal as a training tool for catheter-based (electrophysiological) interventions and can be used in patient-specific therapy planning.

Here we present development of a mock circulation setup for multimodal therapy evaluation, pre-interventional planning, and physician-training on cardiovascular anatomies. With the application of patient-specific tomographic scans, this setup is ideal for therapeutic approaches, training, and education in individualized medicine.

干预规划和培训的3D打印心血管幻影的开发与评估

Catheter-based interventions are standard treatment options for cardiovascular pathologies. Therefore, patient-specific models could help training ...

Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function

Approximately 40% of patients undergoing invasive coronary angiography for investigation of angina are found to have no obstructive coronary artery disease (ANOCA). Abnormal coronary function underlies coronary vasomotion syndromes including coronary endothelial dysfunction, microvascular angina, vasospastic angina, post-PCI angina and myocardial infarction with no obstructive coronary arteries (MINOCA). Each of these endotypes are distinct subgroups, characterized by specific disease mechanisms. Diagnostic criteria and linked therapy for these conditions are now established by expert consensus and clinical guidelines.
Coronary function tests are performed as an adjunctive interventional diagnostic procedure (IDP) in appropriately selected patients during coronary angiography. This aids differentiation of patients according to endotype. The IDP includes two distinct components: a diagnostic guidewire test and a pharmacological coronary reactivity test. The tests last approximately 5 minutes for the former and 10-15 minutes for the latter. Patient safety and staff education are key.
The diagnostic guidewire test measures parameters of coronary flow limitation (fractional flow reserve [FFR], coronary flow reserve [CFR], microvascular resistance [index of microvascular resistance (IMR)], basal resistance index, and vasodilator function [CFR, resistive reserve ratio (RRR)]).
The pharmacological coronary reactivity test measures the vasodilator potential and propensity to vasospasm of both the main coronary arteries and the micro-vessels. It involves intra-coronary infusion of acetylcholine and glyceryl trinitrate (GTN). Acetylcholine is not licensed for parenteral use and is therefore prescribed on a named-patient basis. Vasodilatation is the normal, expected response to infusion of physiological concentrations of acetylcholine. Vascular spasm represents an abnormal response, which supports the diagnosis of vasospastic angina.
The purpose of this practical guide is to provide information on the preparation and administration of the IDP in clinical practice. It discusses some key preparation and safety considerations, as well as tips for procedural success. The IDP supports stratified medicine for a personalized approach to health and wellbeing.

The purpose of this practical guide is to provide information on the preparation and administration of an interventional diagnostic procedure in clinical practice. It discusses some key preparation and safety considerations, as well as tips for procedural success.

介入诊断程序：冠状动脉血管功能评估实用指南

Approximately 40% of patients undergoing invasive coronary angiography for investigation of angina are found to have no obstructive coronary artery ...

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 ...

Drug Treatment by Central Venous Catheter in a Mouse Model of Angiotensin II Induced Abdominal Aortic Aneurysm and Monitoring by 3D Ultrasound

Since pharmaceutical treatment options are lacking in the clinical management of abdominal aortic aneurysm (AAA), animal models, in particular mouse models, are applied to advance the understanding of the disease pathogenesis and to identify potential therapeutic targets. Testing novel drug candidates to block AAA growth in these models generally requires repeated drug administration during the time course of the experiment. Here, we describe a compiled protocol for AAA induction, insertion of an intravenous catheter to facilitate prolonged therapy, and serial AAA monitoring by 3D ultrasound. Aneurysms are induced in apolipoprotein E (ApoE) deficient mice by angiotensin II release over 28 days from osmotic mini-pumps implanted subcutaneously into the mouse back. Subsequently, the surgical procedure for external jugular vein catheterization is conducted to allow for daily intravenous drug treatment or repeated blood sampling via a subcutaneous vascular access button. Despite the two dorsal implants, the monitoring of AAA development is readily facilitated by sequential semi-automated 3D ultrasound analysis, which yields comprehensive information on the expansion of aortic diameter and volume and on aneurysm morphology, as illustrated by experimental examples.

This protocol describes the consecutive implantation of an osmotic pump to induce abdominal aortic aneurysm by angiotensin II release in apolipoprotein E (ApoE) deficient mice and of a vascular access port with a jugular vein catheter for repeated drug treatment. Monitoring of aneurysm development by 3D ultrasound is effectively conducted despite dorsal implants.

血管紧张素II诱导的腹主动脉瘤小鼠模型中中心静脉导管的药物治疗及3D超声监测

Since pharmaceutical treatment options are lacking in the clinical management of abdominal aortic aneurysm (AAA), animal models, in particular mouse ...