We discontinued all antiarrhythmic drugs for, at least, 5 half‐lives, and no patient received oral amiodarone before ablation. Moreover, antiarrhythmic drugs were not resumed after ablation. We used the NavX System (St. Jude Medical Inc., St. Paul, MN) for ablation. The esophageal temperature monitoring system (SensiTherm, St. Jude Medical, Inc.) was used to provide intra‐esophageal temperature feedback. Sheath introducers were inserted through the right femoral vein under sedation. We performed the trans‐septal procedure and advanced three 8‐F SL0 sheaths (St. Jude Medical, Inc.) or two 8‐F SL0 sheaths and a steerable sheath (Agilis, St. Jude Medical, Inc.) into the left atrium. After the trans‐septal puncture, a single bolus of 5000 U of heparin was administered. A continuous infusion with heparinized saline was performed to maintain an activated clotting time of 300‐350 seconds. Pulmonary vein isolation was performed with 3D mapping and guidance using two 7‐F decapolar circular catheters (Lasso and Libero), which were positioned at the ipsilateral pulmonary vein ostia. The procedure was completed with cavotricuspid isthmus ablation. Each radiofrequency application was performed for 30‐50 s, the temperature was limited to 42°C and power to 30 W. We used the maximum power of 25 W while delivering energy to sites near the esophagus.
Navx system
Manufactured by Abbott
Sourced in United States
The NavX system is a medical device designed for navigation and mapping of cardiac structures. It provides real-time three-dimensional visualization and tracking of catheters and other instruments during cardiac procedures.
Automatically generated - may contain errors
Lab products found in correlation
8 f sl0 sheaths, by Abbott (2 mentions)
Sensitherm, by Abbott (1 mentions)
Agilis, by Abbott (1 mentions)
Image pro software 6, by Media Cybernetics (1 mentions)
Celsius, by Johnson & Johnson (1 mentions)
Coolflex, by Abbott (1 mentions)
Stockert generator, by Johnson & Johnson (1 mentions)
Arctic front advance, by Medtronic (1 mentions)
13 protocols using navx system
1
Pulmonary Vein Isolation with Esophageal Monitoring
2
Mapping Atrial Fibrillation Substrate
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Intracardiac electrograms were recorded using a Prucka CardioLab™ Electrophysiology system (General Electric Health Care System Inc., Milwaukee, WI, USA). Double trans-septal punctures were performed and multi-view pulmonary venograms were obtained. After obtaining trans-septal access, systemic anticoagulation was achieved with intravenous heparin to maintain an activated clotting time of 350-400 sec. We generated 3D-spiral CT merged 3D electroanatomical mapping (NavX system, St. Jude Medical Inc., Minneapolis, MN, USA). We generated a LA 3D voltage map by obtaining contact bipolar electrograms from 350-500 points of the LA endocardium during high right atrial pacing (pacing cycle length: 500 ms) using a multi-polar ring catheter (Lasso, Johnson & Johnson Inc., Diamond Bar, CA, USA). The bipolar electrograms were filtered from 32 to 300 Hz. Color-coded voltage maps were generated by recording bipolar electrograms and measuring peak-to-peak voltage. The percentage of color-coded areas of voltage maps was analyzed by customized software (Image Pro software 6.0, Media Cybernetics Inc., Silver Spring, MD, USA), referenced to the color scale bars, and utilized for the calculation of the mean and regional endocardial voltages.11 (link)
3
Modeling Atrial Electrophysiology and Acetylcholine
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A realistic model of the LA was constructed from human computed tomography images by using the NavX system (St. Jude Medical Inc., Minnetonka, MN, USA). A triangular mesh comprising approximately 450,000 triangles was generated in the atrial model. The human atrial action potential model used in the two-dimensional (2D) model was used for the model of ionic currents. The reaction-diffusion equation for cardiac wave propagation was solved numerically to obtain time-dependent action potential maps [16 (link)]. The effect of ACh was incorporated by modeling the GPs and the nerves based on the “octopus hypothesis” [6 (link)]. In the octopus hypothesis, the nerves are radially distributed from the GP (Fig 1 ). Consequently, the concentration of ACh is higher adjacent to the GP area [6 (link)]. The locations of 4 GPs (left inferior, right anterior, right inferior, and left superior GPs) were determined based on the electrophysiological mapping data of Katritsis et al. [17 ]. ACh was modeled to be present at the GPs and nerves. In the PV areas, the ionic currents were adjusted as described by Cha et al. [10 (link)], in order to model the different ionic currents between the PV and LA.
4
Catheter Ablation for Drug-Refractory AF
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This study included 20 consecutive patients undergoing initial catheter ablation for drug-refractory AF: 9 for paroxysmal AF (spontaneous termination within 7 days), and 11 for persistent AF (AF lasting more than 7 days). The study protocol was approved by the Institutional Review Board of Nihon University Itabashi Hospital (December 7, 2012, RK-121109-5), and all patients provided written informed consent for participation in the study, which was conducted under ethics committee approval. All antiarrhythmic drugs were discontinued for at least 5 half-lives before ablation, and all patients underwent multidetector-row computed tomography for construction of 3-dimensional maps of the left atrium (LA) (NavX system; St. Jude Medical, Inc., St. Paul, MN, USA).
5
Catheter Ablation of Atrial Fibrillation
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A NavX system (St. Jude Medical Inc., St. Paul, MN) was used for catheter ablation. A 5‐french deflectable catheter was inserted into the coronary sinus (CS) via the right femoral vein. The trans‐septal procedure was performed using fluoroscopic landmarks, and three 8‐F SL0 sheaths (St. Jude Medical, Inc.) were advanced into the LA. After the trans‐septal procedure, a single bolus of 5000U of heparin was administered. A continuous infusion with heparinized saline was delivered to maintain an activated clotting time of 300 to 350s. The 3D biatrial geometry was created on the NavX system, and sequential contact mapping was performed using a 7‐F decapolar circular catheter (Lasso, Biosense‐Webster, Inc., Diamond Bar, CA). The LA was divided into nine areas (pulmonary veins [PVs], roof, left atrial appendage [LAA], LA septum, lateral, anterior, bottom, posterior, and CS) and RA into seven (lateral, anterior, posterior, cavotricuspid isthmus, superior vena cava, inferior vena cava, and RA septum) for a location analysis of the AF substrate.5 The points in each region were similar in number and nearly equally distributed.
6
Catheter Ablation for Persistent Atrial Fibrillation
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During the procedure, intracardiac electrograms were recorded using a Prucka CardioLab electrophysiology system (General Electric Health Care System Inc). Ablation was guided by 3-dimensional electroanatomical mapping (NavX system; St. Jude Medical Inc). An open irrigation 3.5-mm-tip deflectable catheter (Celsius, Johnson & Johnson Inc; Cool Flex, St. Jude Medical Inc; 30 to 35 W; 47°C) was used for RFCA (Stockert generator; Biosense Webster Inc). All patients initially underwent circumferential pulmonary vein (PV) isolation and cavotricuspid isthmus ablation. For patients with persistent AF, we added a roof line, posterior inferior line, and anterior line19 (link) as a standard lesion set. At the operator’s discretion, additional ablations were delivered to the superior vena cava, non-PV foci, or regions of complex fractionated electrograms. We confirmed the PV isolation by both entrance and exit block and rechecked it under an isoproterenol infusion before finishing the procedure. In addition, we attempted to reinduce AF by isoproterenol infusion with rapid atrial pacing before finishing the procedure. The end point of our procedure was defined as no immediate recurrence of AF after cardioversion while receiving an isoproterenol infusion (5 to 10 μg/min). If there was immediate recurrence of AF after cardioversion, we then ablated these non-PV foci.
7
Ablation Procedure for Atrial Arrhythmias
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Antiarrhythmic drugs were discontinued at least five half‐lives before the procedure. Amiodarone was discontinued at least 1 month before the ablation procedure. Transesophageal echocardiography was performed within 24 hours before the procedure to exclude the presence of atrial thrombi. The ablation procedure was performed under sedation with intravenous propofol with continuous monitoring of blood pressure and oxygen saturation. The high right atrium, low right atrium, and coronary sinus were mapped with a decapolar catheter (Bard Electrophysiology Inc) and steerable duo‐decapolar catheter (St. Jude Medical Inc) inserted through the left femoral vein. A quadripolar catheter was also placed in the superior vena cava. Intracardiac electrograms were recorded using an electrophysiology system (Prucka CardioLabTM ; General Electric Health Care System Inc). After a double transseptal puncture, anticoagulation was started with unfractionated heparin, maintaining an activated clotting time between 300 and 350 seconds. We used three‐dimensional (3D) mapping guided geometry (NavX System; St. Jude Medical Inc) for electroanatomic mapping in all patients.
8
Ablation Protocol for Atrial Fibrillation
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Our ablation protocol has been previously described. 4 Antiarrhythmic drugs were discontinued at least 5 half-lives and amiodarone at least 3 months before ablation. The NavX system (St. Jude Medical, Inc., Saint Paul, MN) or CARTO systems (Biosense Webster Inc., Diamond Bar, CA) were used for 3-dimensional mapping in all cases. Before January 2006, we used a closed-tip catheter; and after January 2006, an openirrigated tip catheter. After July 2006, all irrigated-tip catheter ablation procedures were performed using 50 W for short durations (generally o10 seconds) at each site, 18, 19 (link) including the posterior wall. All patients underwent circumferential pulmonary vein isolation and linear ablation of the LA roof. Patients with right or LA isthmus flutter underwent linear ablation of the cavotricuspid and/or mitral isthmus. Patients with persistent AF had low posterior LA lines and LA complex fractionated electrograms ablated. Some patients with longstanding persistent AF underwent additional ablation within the coronary sinus (at 30-35 W), ablation of complex right atrial fractionated electrograms, and/or superior vena cava isolation. Isoproterenol was given, and nonpulmonary vein triggers were mapped and ablated. Repeat ablation procedures were not performed until at least 3 months after initial ablation.
9
Bipolar EGM Mapping for Atrial Ablation
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Bipolar EGMs were automatically collected during sinus rhythm. EGM analysis was performed off‐line on the NAVX system (ABBOTT, Minnesota, USA) using electronic calipers at a speed of 100 mm/s. For our study, only the initial map and relative EGMs were considered for analysis prior to any radiofrequency (RF) ablation. Voltage maps of both atria were built according to threshold values of > 0.5 mV for healthy tissue. Low voltage tissue was defined as voltage lower than 0.05 mV. Border zones were defined as voltages in between the above‐mentioned thresholds.
10
Simulation of Atrial Electrical Wave Propagation
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Computed tomography images of the human left atrium were segmented to generate a 3-dimensional (3D) model of the left atrium using the NavX system (Abbott, Lake Bluff, IL, USA). A triangular mesh was generated on the atrial model for the calculation of the electrical potentials. The electrical wave propagation in the atrium was simulated by numerically solving the following reaction-diffusion equation [17 (link)]:
where Vm is the membrane potential, β is the membrane surface-to-volume ratio, Cm is the membrane capacitance per unit area, D is the conductivity tensor, and Iion and Is are, respectively, the ionic and stimulation currents. A mathematical model of the human atrial Iion, as developed by Courtemanche et al. [18 (link)], was adopted to determine the ionic currents at each computational node. For the Is, a current of -2900pA was applied for 1.5ms at each pacing time at a site corresponding to the location of Bachmann’s bundle.
where Vm is the membrane potential, β is the membrane surface-to-volume ratio, Cm is the membrane capacitance per unit area, D is the conductivity tensor, and Iion and Is are, respectively, the ionic and stimulation currents. A mathematical model of the human atrial Iion, as developed by Courtemanche et al. [18 (link)], was adopted to determine the ionic currents at each computational node. For the Is, a current of -2900pA was applied for 1.5ms at each pacing time at a site corresponding to the location of Bachmann’s bundle.
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