Author + information
- Received October 10, 2010
- Revision received March 7, 2011
- Accepted March 17, 2011
- Published online July 1, 2011.
- François Regoli, MD, PhD⁎,
- Francesco F. Faletra, MD⁎,
- Gaetano Nucifora, MD⁎,
- Elena Pasotti, MD⁎,
- Tiziano Moccetti, MD⁎,
- Catherine Klersy, MD† and
- Angelo Auricchio, MD, PhD⁎,⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Angelo Auricchio, Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
Objectives The aim of this study was to evaluate the feasibility and acute efficacy of real-time 3-dimensional transesophageal echocardiography (RT3DTEE)–guided ablation of the cavotricuspid isthmus (CVTI).
Background The use of RT3DTEE to guide a transcatheter radiofrequency ablation procedure has never been systematically investigated.
Methods Seventy consecutive patients with CVTI-dependent atrial flutter underwent CVTI ablation. Procedural monitoring using RT3DTEE was assigned to patients who requested general anesthesia for the procedure (n = 21 [30%]). In the other 49 patients (the control group), the procedures were monitored using the standard fluoroscopic approach. Procedural time was considered as skin-to-skin electrophysiological procedure duration, not including anesthesia preparation; adequate radiofrequency ablation applications (with fixed temperature and power settings) were considered as lesions lasting ≥ 60 s.
Results RT3DTEE allowed visualization of the CVTI and identified related structures in most patients (20 of 21); anatomic features such as long CVTI (n = 11), prominent Eustachian ridge (n = 9), prominent Eustachian valve (n = 6), septal recess (n = 8), and pectinate muscles (n = 10) were frequent. Also, RT3DTEE allowed continuous visualization of ablation catheter movement and contact. Compared with the control group, RT3DTEE was equally effective in achieving CVTI bidirectional block (100% in both groups), and no complications occurred. RT3DTEE shortened procedural time (median 73.0 min, interquartile range [IQR] 60.0 to 90.0 min, vs. median 115.0 min, IQR 85.0 to 133.0 min, p < 0.001), reduced radiation exposure (median fluoroscopy time 4.2 min, IQR 3.1 to 8.4 min, vs. median 19.3 min, IQR 12.9 to 36.4 min, p < 0.001; median fluoroscopy dose 575.4 cGy · cm2, IQR 428.5 to 1,299.4 cGy · cm2, vs. median 3,520.7 cGy · cm2, IQR 1,700.0 to 6,709.0 cGy · cm2, p < 0.001), and reduced the number of radiofrequency applications to achieve bidirectional block (median 7, IQR 6 to 10, vs. median 12, IQR 10 to 22, p = 0.007). A strong learning curve was detected by comparing procedural data between the first and last patients treated using RT3DTEE.
Conclusions RT3DTEE-guided ablation of CVTI was feasible, allowing real-time detailed morphological CVTI characterization as well as continuous visualization of the ablation catheter during radiofrequency ablation. This approach entailed marked reductions in procedural time, radiation exposure, and the number of radiofrequency applications.
- atrial flutter ablation
- cavotricuspid anatomy
- electrophysiologic imaging
- 3-dimensional echocardiography
Dr. Faletra has received speaking fees from Philips Medical Systems. Dr. Auricchio is a consultant for Sorin Group, Medtronic, Biotronik, EBR System, Merck, Biosense Webster, BDS Cordis, Philips, Impulse Dynamics, and has received speaker fees from Sorin Group, Medtronic, Biotronik, St. Jude Medical, and Abbott. All other authors have reported that they have no relationships to disclose.
- Received October 10, 2010.
- Revision received March 7, 2011.
- Accepted March 17, 2011.
- American College of Cardiology Foundation