Robotic Magnetic Navigation for Atrial Fibrillation Ablation
Carlo Pappone, MD, PhD*,
Gabriele Vicedomini, MD,
Francesco Manguso, MD, PhD,
Filippo Gugliotta, BE,
Patrizio Mazzone, MD,
Simone Gulletta, MD,
Nicoleta Sora, MD,
Simone Sala, MD,
Alessandra Marzi, MD,
Giuseppe Augello, MD,
Laura Livolsi, MD,
Andreina Santagostino, MD and
Vincenzo Santinelli, MD
Department of Electrophysiology, San Raffaele Scientific Institute, Milan, Italy
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Figure 1 Fluoroscopic views in anteroposterior projection showing the NaviStar-RMT catheter incorporating a small permanent magnet in the tip and two other magnets in the distal portion of the device. The soft distal catheter body allows the tip to be deflected in any direction (A to C) and steered by the magnetic navigation system to reach the targeted right-superior pulmonary vein (D). Two standard quadripolar catheters are placed into the coronary sinus and right ventricle.
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Figure 2 Sequential fluoroscopic views showing successful attempts (A to C) to navigate a magnetic catheter through the previous trans-septal puncture (D) by using stored magnetic field vector in left atrium.
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Figure 3 (A to D) The video workstation-based User Interface (Navigant, Stereotaxis Inc.) shows four paired Navigant images (upper two, two-dimensional sync C-arm on the left and three-dimensional NaviSphere on the right, which represent navigation of the magnetic catheter to (A) left superior pulmonary vein; (B) left inferior pulmonary vein; (C) right superior pulmonary vein; (D) right inferior pulmonary vein. The magnetic field vector is in yellow. The images displayed also show the magnetic catheter aligning parallel to the chosen magnetic field vector to reach each pulmonary vein. Fluoroscopic views (29° right or left anterior oblique projections including three catheter shadows) were previously stored still images. Real-time catheter location is displayed as the white-blue quadripolar catheter tip. Note: The red points on fluoroscopic images were desired locations transferred from CARTO RMT.
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Figure 4 Three fluoroscopic images (A to C) of sequential magnetic catheter navigation at three different locations of mitral valve annulus for mapping. The figure shows how we can deflect the catheter and maintain a good contact remotely. The electrograms inset (A to C) in the second column shows the typical appearance of the corresponding mitral annular electrogram recorded from the magnetic ablation catheter aligned with the magnetic field vector (white line catheter). Consistent atrial and ventricular electrogram recordings demonstrate a stable catheter contact at the three predefined mitral annular locations.
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Figure 5 (A) Posteroanterior view showing color-coded preablation electroanatomical voltage map of the left atrium and pulmonary veins using a CARTO RMT integration system. (B) Post-ablation electroanatomical map with encircled lesions around all targeted pulmonary veins and the mitral isthmus line. Note atrial electrograms before (A, arrow) and after ablation (B). No potentials were recorded inside encircled lesions (arrow). The mitral isthmus ablation line is evident. (C) A mesh anatomical map is shown. (D) Red points depicted on fluoroscopic views indicate ablation points sent from the CARTO RMT integration system. Blue line shown on both fluoroscopic images represents the base for target control navigation on Navigant.
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Figure 6 Graph showing the learning curve of remote magnetic navigation for atrial fibrillation ablation. Sequence of the first 40 procedures performed at Hospital San Raffaele. Note that the ablation time curve stabilizes after the first 12 cases. In the first and third patient, radiofrequency ablation was completed manually.
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