EP Lab Digest - December 2007 - (Page 8)

8 COVER IMPROVED ANATOMICAL ORIENTATION Continued from page 6 have based our major fixation for the CT image on the pulmonary vein location, and then fine-tuned the registration process with a few additional left atrial landmark points. Using the Verismo software allows for an accurate three-dimensional reconstruction of the CT image for a wide range of quality of the initial CT data. Even in single cases scanned without usage of contrast medium, we were still able to reconstruct the left atrium. It is important to remember that while the anatomical accuracy and detail of a CT image are valuable, the ability to make fine adjustments is critical for effective catheter navigation. Registration is not always 100% accurate. Dynamic Registration allows us to adjust the registration and accommodate the natural variations that occur between the time of CT scanning and the procedure. STORY DECEMBER 2007 A B C Figure 6. (A) PA view of final registration result with PV anatomies hidden and distal areas of CT PVs removed. Note the esophageal temperature probe; (B) LL view; (C) RAO view. Application of Therapy Confirmation of Endpoint and At the Heart Center, we primarily take an anatomical approach to ablation. Patients presenting with paroxysmal AF receive circumferential left atrial ablation lines, and those with persistent AF receive an additional box lesion and a mitral isthmus line Caution: Indications For Use Contraindications Active Fix (Linox S and SD) Passive Fix (Linox T and TD) Warnings and Precautions MRI (Magnetic Resonance Imaging) Deﬁbrillation Threshold Maximum Fixation Tool Rotations (Linox S and Linox SD only) © by BIOTRONIK GmbH & Co. All rights reserved. (Figure 7). Patients presenting with AF at the beginning of the procedure receive an electrical cardioversion, and ablation is performed during sinus rhythm (SR). Prior to ablation, we insert a catheter into the esophagus.We utilize an Esotherm catheter with three Figure 8. Temperature probe readtemperature probes ings from all three electrodes are (Fiab, Florence, Italy), monitored closely throughout the which allows us to ablation procedure. visualize the esophageal location (through EnSite geometry recon- temperature along the posstruction or direct catheter visualization) terior left atrial wall (Figure and to simultaneously record esophageal 8). We measure the esophageal temperature throughout the case, and Figure 7. Creation of the ablation lines guided by have found it to be very EnSite Fusion. Electrical Isolation sensitive. Our practice is to reduce energy output to 25 watts when (advanced or retracted for optimal wall conablating in close vicinity to the esophagus, tact).We have found this to enhance stabiliResuscitation Availability and we are quite cautious with continuous ty of the catheter when creating lesions, and monitoring of the esophageal temperature to enable improved catheter access to chalin these areas. In fact, we have seen remark- lenging areas of the left atrium. For instance, Helix Mechanical Function Test able temperature rises even with 20 to 25 maintaining good position on the ridge watts, which necessitated further energy between the left upper pulmonary vein and the left atrial appendage can be quite diffireduction. (Linox S and Linox SD only) As we create circumferential lesions cult, but we have been able to place the Repositioning or Explanting around the left and right PVs, the abla- catheter there with good stability and repro(Linox S and Linox SD only) tion sites are tagged with 3D lesion ducibility using the steerable sheath. Anchoring Sleeve While the patient is in sinus rhythm, we markers, which represent the true position of the catheter tip in three-dimensional place circumferential left atrial ablation lines space (no “projection to surface” or around the left- and right-sided PVs. “lesion at mouse”) and confirm registra- Following isolation of the whole PV Potential Adverse Events tion accuracy in case of true surface antrum, we confirm line continuity by contact to the CT image. In areas with applying maximum output stimulation minor discrepancies between catheter through the ablation catheter while maplocation and CT surface, we can quick- ping along the inner aspect of the circumly adjust the CT registration during the ferential ablation line and checking to see if procedure. The position of nearly all 3D this captures the LA (seen on the CS signal). lesion markers on the CT surface at the If the LA is captured, this technique also end of the procedure reflects the high clearly shows where the gap in the line degree of accuracy of the registration exists, whether it is near the superior, posteprocess and the subsequent accurate rior, inferior or anterior sections of the BIOTRONIK GmbH & Co. BIOTRONIK, Inc. Woermannkehre 1 6024 Jean Road lesion. When gaps are found, we re-ablate anatomical orientation (Figures 9A–E). Lake Oswego Tel (+49 30) 6 89 05 -600 We utilize the Agilis steerable sheath for until we lose capture. One of the benefits of Fax (+49 30) 6 85 28 04 Tel (+1 5 03) 6 35 35 94 www.biotronik.com Fax (+1 5 03) 6 35 99 36 most movement within the atrium; the abla- this approach is that we are able to complete tion catheter is only handled passively See IMPROVED ANATOMICAL ORIENTATION page 10 http://www.biotronik.com http://www.biotronik.com

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EP Lab Digest - December 2007 Improved Anatomical Orientation During AF Catheter Ablation: Experience from Leipzig Heart Center One EP Lab’s Solution to the Administration of Deep Sedation Contents Letter from the Editor Spotlight Interview: Northeast Georgia Medical Center Emerging Technologies for the Electrophysiology Lab The Western Atrial Fibrillation Symposium About the PRECEDE-HF Trial: Interview with William T. Abraham, MD, FACP, FACC, FAHA Overview on Shire and the Discontinuation of Ethmozine®: After the Heart Rhythm Society Intervenes, the Company Changes its Decision Minimizing the Risk of Infection at Children’s Sibley Heart Center: Interview with Nicole Jarrell, RNC, MSN, and J. Renee Watson, RN, CIC Is There a Link Between Gasoline Vapors and Brugada Syndrome? Interview with Darko Kranjcec, MD and Hugues Abriel, MD, PhD New Feature! Pacemaker/ICD Puzzle Email Discussion Group Events Calendar Industry News and Products

EP Lab Digest - December 2007

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