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Abstract Background Cardiac tamponade (CT) can be a complication following invasive cardiac procedures. We assessed CT following common cardiac electrophysiology (EP) procedures to facilitate risk prediction of associated morbidity and in‐hospital mortality. Methods Patients who underwent various EP procedures in the cardiac catheterization lab (ablations and device implantations) were identified using the International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification (ICD‐9‐CM and ICD‐10‐CM, respectively) from the Nationwide Inpatient Sample (NIS) database. Patient demographics, presence of comorbidities, CT‐related events, and in‐hospital death were also abstracted from the NIS database. Results The frequency of CT‐related events in patients with EP intervention from 2010 to 2017 ranged from 3.4% to 7.0%. In‐hospital mortality related to CT‐related events was found to be 2.2%. Increasing age was the only predictor of higher mortality in atrial fibrillation (AF) ablation and cardiac resynchronization therapy (CRT) groups (OR [95% CI]: AF ablation = 11.15 [1.70–73.34], p = .01; CRT = 1.41 [1.05–1.90], p = .02). Conclusions In the real‐world setting, CT‐related events in EP procedures were found to be 3.4%–7.0% with in‐hospital mortality of 2.2%. Older patients undergoing AF ablation were found to have higher mortality.

Background: Cardiac tamponade (CT) can be a complication following invasive cardiac procedures. We assessed CT following common cardiac electrophysiology (EP) procedures to facilitate risk prediction of associated morbidity and in‐hospital mortality. Methods: Patients who underwent various EP procedures in the cardiac catheterization lab (ablations and device implantations) were identified using the International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification (ICD‐9‐CM and ICD‐10‐CM, respectively) from the Nationwide Inpatient Sample (NIS) database. Patient demographics, presence of comorbidities, CT‐related events, and in‐hospital death were also abstracted from the NIS database. Results: The frequency of CT‐related events in patients with EP intervention from 2010 to 2017 ranged from 3.4% to 7.0%. In‐hospital mortality related to CT‐related events was found to be 2.2%. Increasing age was the only predictor of higher mortality in atrial fibrillation (AF) ablation and cardiac resynchronization therapy (CRT) groups (OR [95% CI]: AF ablation = 11.15 [1.70–73.34], p =.01; CRT = 1.41 [1.05–1.90], p =.02). Conclusions: In the real‐world setting, CT‐related events in EP procedures were found to be 3.4%–7.0% with in‐hospital mortality of 2.2%. Older patients undergoing AF ablation were found to have higher mortality. [ABSTRACT FROM AUTHOR]

Pericardial tamponade is the most common major complication during invasive electrophysiology (EP) procedures, particularly in atrial flutter and atrial fibrillation ablations. According to a multicenter analysis, the incidence of tamponade in atrial fibrillation ablation is 0.67%, while in atrial flutter ablation it is 0.27%, and the highest incidence is during ventricular tachycardia ablations, with an incidence of 2.2%. Tamponade requires urgent care, including pericardiocentesis, and can be fatal if not promptly recognized and treated. Mortality associated with ablations is 0.17%, with tamponade contributing to 9.7% of all deaths following these procedures.¹ The most common procedure in most centers for treating tamponade begins with fluoroscopy-guided pericardiocentesis, typically through an anterior subxiphoid approach. After puncture, a pigtail catheter is inserted for continuous drainage of pericardial fluid. Protamine is routinely administered in most centers either immediately after diagnosis or after complete aspiration of blood from the pericardium. Auto-transfusion of aspirated blood is also standard in more than 70% of centers, while the decision for surgical intervention is made if bleeding is not controlled within 60 to 80 minutes.¹ Nurses play a key role in recognizing early symptoms of tamponade, quickly activating emergency protocols, and assisting during pericardiocentesis. Their responsibilities include monitoring vital signs, administering protamine to neutralize heparin, and performing auto-transfusion of aspirated blood, thereby contributing to the stabilization of the patient.² Establishing an effective, agreed-upon emergency protocol for cases such as tamponade is crucial for reducing risk and improving treatment outcomes, especially in hospitals with limited resources or without constant availability of cardiac surgery.¹ [ABSTRACT FROM AUTHOR]

Purpose of Review: The advanced use of intracardiac echocardiography (ICE) is both a significant leap forward and an underutilized and unrealized innovation for electrophysiological (EP) procedures [1]. ICE can inform operators of complex anatomic heterogeneity as well as close anatomic relationships beyond fluoroscopy and even electroanatomic mapping. We will review the myriad advantages of advanced ICE application to EP ablation procedures. Recent Findings: While 3D mapping has significantly advanced diagnosis and treatment efficiency for ablation procedures quite rapidly, widespread adoption of advanced ICE techniques beyond a supplemental technology has not been as swift. The advanced application of ICE has the ability to vastly improve the safety of EP procedures while reducing or eliminating required fluoroscopic guidance in many aspects [2]. Summary: The advanced application of ICE offers many opportunities to improve procedural efficacy and safety. Further research should focus on quantifying these benefits and understanding how best to disseminate these techniques for broader electrophysiological practice. [ABSTRACT FROM AUTHOR]

Abstract Aim Three‐dimensional (3D) nonfluoroscopic mapping systems (NMSs) are generally used during the catheter ablation (CA) of complex arrhythmias. We evaluated the efficacy, safety, and economic advantages of using NMSs during His‐Bundle CA (HB‐CA). Methods A total of 124 consecutive patients underwent HB‐CA between 2012 and 2019 in our EP Laboratory. We compared two groups: 63 patients who underwent HB‐CA with fluoroscopy alone from 2012 to 2015 (Group I) and 61 patients who underwent HB‐CA with the aid of NMSs from 2016 to 2019 (Group II). Two cost‐effectiveness analyses were carried out: the alpha value (AV) (ie, a monetary reference value of the units of exposure avoided, expressed as $/man Sievert) and the value of a statistical life (VSL) (ie, the amount of money that a community would be willing to pay to reduce the risk of a person's death owing to exposure to radiation, it is not the cost value of a person's life). The cost reduction estimated by means of both these methods was compared with the real additional cost of using NMSs. Results The use of NMS resulted in reduced fluoroscopy time in Group II {median 1.35 min} in comparison with Group I {median 4.8 min (P

Introduction: The coronavirus disease (COVID-19) pandemic has generated serious repercussions on the health system, reducing the number of all cardiology procedures worldwide. Objectives: Describe the impact of the COVID-19 pandemic on the procedures performed by the electrophysiology department in a national referral center. Methods: We made a retrospective review of our data base and we compared procedures made in the past 3 years since 2017-2019 with the procedures made in the 2020. We divided the procedures into two large groups: Cardiac Implantable Electronic Devices (CIED) related procedures and electrophysiological procedures (EP) which included conventional and complex ablations. Results: There was a significant reduction in all the procedures, the average of procedures performed in the last 3 previous years was 467, while in 2020, we performed only 319 (p = 0.01); this represents a reduction of 33.4% in the total number of procedures. There was no statistical difference regarding the CIED related procedures, the average of procedures in the past 3 previous years was 174, and in 2020 we performed 190 procedures (p = 0.46). Regarding the EP, the average of the past 3 previous years was 293, while in 2020, we performed only 129 procedures (p < 0.01). The reduction in the EP was 55.97%. The most affected months were April, May, and June. Conclusions: The COVID-19 pandemic considerably affected the number of the procedures in our center, reducing it by 33.4%. The reduction of procedures fundamentally affected the ablations, with a reduction of 55.97%. The number of CIED related procedures was not affected. [ABSTRACT FROM AUTHOR]

Noninvasive cardiac imaging is crucial for the characterization of patients who are candidates for cardiac ablations, for both procedure planning and long-term management. Multimodality cardiac imaging can provide not only anatomical parameters but even more importantly functional information that may allow a better risk stratification of cardiac patients. Moreover, fusion of anatomical and functional data derived from noninvasive cardiac imaging with the results of endocavitary mapping may possibly allow a better identification of the ablation substrate and also avoid peri-procedural complications. As a result, imaging-guided electrophysiological procedures are associated with an improved outcome than traditional ablation procedures, with a consistently lower recurrence rate.

Aim: Three‐dimensional (3D) nonfluoroscopic mapping systems (NMSs) are generally used during the catheter ablation (CA) of complex arrhythmias. We evaluated the efficacy, safety, and economic advantages of using NMSs during His‐Bundle CA (HB‐CA). Methods: A total of 124 consecutive patients underwent HB‐CA between 2012 and 2019 in our EP Laboratory. We compared two groups: 63 patients who underwent HB‐CA with fluoroscopy alone from 2012 to 2015 (Group I) and 61 patients who underwent HB‐CA with the aid of NMSs from 2016 to 2019 (Group II). Two cost‐effectiveness analyses were carried out: the alpha value (AV) (ie, a monetary reference value of the units of exposure avoided, expressed as $/man Sievert) and the value of a statistical life (VSL) (ie, the amount of money that a community would be willing to pay to reduce the risk of a person's death owing to exposure to radiation, it is not the cost value of a person's life). The cost reduction estimated by means of both these methods was compared with the real additional cost of using NMSs. Results: The use of NMS resulted in reduced fluoroscopy time in Group II {median 1.35 min} in comparison with Group I {median 4.8 min (P <.05)}. The effective dose reduction (ΔE) was 1.16 milli‐Sievert. Conclusion: The use of NMS significantly reduces fluoroscopy time. However, the actual reduction is modest and in our EP Laboratory this reduction is not cost‐effective. Indeed, when the ΔE is referred to country and agency tables for absolute values of AV or VLS, it is not economically advantageous in almost all cases. [ABSTRACT FROM AUTHOR]

The aim of this study is to evaluate the cost-effectiveness of an extended use of 3D non-fluoroscopic mapping systems (NMSs) during paediatric catheter ablation (CA) in an adult EP Lab. This study includes 58 consecutive patients (aged between 8 and 18) who underwent CA from March 2005 to February 2015. We compare the fluoroscopy data of two groups: group I, patients who underwent CA from 2005 to 2008 using only fluoroscopy, and group II, patients who underwent CA from 2008 to 2015 performed also using NMSs. Two cost-effectiveness analyses were carried out: the first method was based on the alpha value (AV), and the second one was based on the value of a statistical life (VSL). For both methods, a children’s correction factor was also considered. The reduction cost estimated from all these methods was compared to the real additional cost of using NMSs. The use of an NMS during a CA procedure has led to an effective dose reduction (ΔE) of 2.8 milli-Sievert. All presented methods are based on parameters with a wide range of values. The use of an NMS, applying directly AV values or VSL values, is not cost-effective for most countries. Only considering the children’s correction factor, the CA procedure using an NMS seems to be cost-effective. The cost-effectiveness of a systematic use of NMSs during CA procedures in children and teenagers remains a challenging task. A positive result depends on which value of AV or VSL is considered and if the children’s correction factor is applied or not. [ABSTRACT FROM AUTHOR]

Background: Vascular complications are frequently reported after electrophysiological (EP) procedures. Ultrasound (US) guidance during femoral vein cannulation has shown to reduce vascular damage related to unsuccessful attempts. The aim of our study is to define, under ultrasound guidance, anatomical and technical predictors of successful femoral vein cannulation in a cohort of patients undergoing EP procedures. Material and Methods: From December 2015 to January 2018, 192 patients (mean age 63,1±15,9 years, M:F=118:74) undergoing EP procedures were enrolled in the study. US-guided approach to femoral vessels cannulation was used in all subjects by four untrained operators. Femoral vein and artery depths and diameters were measured in all patients. Unsuccessful attempts (UA) and time to successful cannulation (TSC) were also calculated. Results: Vein and artery depths correlated with body weight (r=0.38 and 0.39, p=0.00), body mass index (r=0.53 and 0.50, p=0.00), and body surface area (r=0.25 and 0.28, p=0.00). Interestingly, the number of UA positively correlated with vein depth (r=0.23, p=0.01 for the right side and r=0.33, p=0.00 for the left side). Linear regression analysis showed that both vein depth (ß=0.42, p=0.001) andoperator training (ß= -0.75,p=0.00) were independently associated with UA. Conclusions: Anthropometric features, namely BMI and BSA, may provide information about femoral vein/artery anatomy in patients undergoing EP procedures. Patients with high BMI have deeper and larger veins, however only vein depth is a determinant of successful cannulation. Numbers of UA and TSC significantly decrease with operators training. [ABSTRACT FROM AUTHOR]

Heparin is used to decrease the risk of thromboembolic complications during electrophysiology studies (EPS); however, there is wide practice variation and minimal evidence to guide heparin dosing, particularly in pediatric patients. This study retrospectively analyzed heparin dosing and response, measured via activated clotting time (ACT), in patients undergoing EPS and used these data (pre-protocol cohort, n = 40), as well as guidance from available literature to implement a standardized heparin protocol (phase 1, n = 43). We utilized quality improvement methodology to refine this protocol (phase 2, n = 40) to improve therapeutic heparin response. Prior to the protocol, patients achieved therapeutic ACT levels (250-350 s) only 35% of the time which improved to 60% during phase 1 (p < 0.05) and to 73% during phase 2 (p < 0.001 compared to pre-protocol). There were no thromboses or significant adverse events in any group. These results demonstrate the effectiveness of a standardized heparin protocol in achieving effective antithrombotic therapy during left-sided pediatric EPS. [ABSTRACT FROM AUTHOR]

Standard imaging during electrophysiological procedures (EPs) uses fluoroscopy. The aim of this study was to evaluate the feasibility, efficacy, safety and effect of an extended use of non-fluoroscopic mapping systems (NMSs) for imaging during paediatric EPs in an adult EP laboratory focusing on the amount of X-ray exposure. This study is a retrospective analysis that includes consecutive young patients (83 pts, aged between 8 and 18) who underwent EPs from March 2005 to February 2015. We compare the fluoroscopy data of two groups of pts: Group I, pts who underwent EPs from 2005 to 2008 using only fluoroscopy and Group II, pts who underwent EPs from 2008 to 2015 performed also using NMSs. The use of an NMS resulted in reduced fluoroscopy time in Group II {median value 0.1 min (95 % CI [0.00-1.07])} compared to Group I {median value 3.55 min (95 % CI [1.93-7.83]) (MW test, P < 0.05)}. There was a complementary reduction in the total X-ray exposure from 2.53 Gy cm (95 % CI [1.51-4.66]) in Group I to 0.05 Gy cm in Group II (95 % CI [0.00-1.22]) (MW test, P < 0.05). Regarding ablation procedures, the median effective dose decreased from 3.04 mSv (95 % CI [1.22-6.89]) to 0.25 mSv (95 % CI [0.00-0.60]) (MW test, P < 0.05). The use of an NMS dramatically reduces fluoroscopy time and total X-ray exposure during EPs in children and teenagers in an adult EP laboratory. In our experience, this reduction is mainly related to the systematic day-to-day use of NMSs. [ABSTRACT FROM AUTHOR]

Purpose To compare the spatial accuracy of three typical active tracking sequences using a new, unique phantom design. Materials and Methods Three different tracking sequences (Single Echo, Dual Echo and Hadamard Multiplexed) were compared with each other in a phantom study with respect to their positional accuracy. A custom-built phantom was constructed to conduct the experiments with precise framework conditions which facilitated sufficient measurement accuracy. An electrophysiology catheter incorporating four micro-coils was used as an interventional device. Tracking profiles were acquired in all three spatial dimensions and validated against the distances that were measured by a Vernier caliper in combination with a three-dimensional reference scan. Results The Bland-Altman plots demonstrated that all three sequences show < 1.5 mm positional error. The measurement accuracy of Single Echo and Double Echo are prone to off-resonances, whereas Hadamard Encoding is immune to it. Conclusion The developed phantom enabled the performance of objective measurements of the accuracy of different active tracking sequences. The proposed setup allows for objectively contrasting different methods for interventional procedures. J. Magn. Reson. Imaging 2014;40:490-495. © 2013 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]