Robotics and Ablation The Erasmus MC experience

1. Robotics and AblationThe Erasmus MC experience Tamas Szili-Török MD, PhD Erasmus MC - Rotterdam

3. Sensei MNS-Stereotaxis

4. Robotics Karel Capek- 1920: R.U.R (Rossum Universal Robots) Labor- Robota (work) Asimov: robotics- the scientific field studying robots

5. ROBOTICS: Definition of the “robot”: A robot is a virtual or mechanical arteficial agent, which is able to do tasks on its own.

6. Sensei MNS-Stereotaxis

7. Imrpovement of electrophysiology procedures Efficacy Efficiency Reproducibility Safety

8. Ways to achieve standardization of EP procedures • Simplification • Automation • Integration

10. What is magnetic navigation? • Magnetic Navigation is an interaction between: • External magnetic field of a specified direction and magnitude • Tiny magnet in the tip of the endovascular device End result is ALIGNMENT of the tip magnet with the field direction There is NO significant magnetic pull, push, attract, or repel effect on the endovascular device

11. What is magnetic navigation? • Two remotely controlled magnets move changing the orientation of the magnetic field in any direction. • A small magnet located in the tip of the catheter orients itself to the remotely determined magnetic field.

12. Set up of magnetic navigation equipment

13. Magnetic Navigation System Theoretical advantages: • Atraumatic, flexible catheter design • Unrestricted catheter navigation • Reproducibility using stored magnetic vectors • Enhanced stability • Less fluoroscopy exposure both for the patient and for the operator

14. Optimizing RF power delivery • Appropriate therapy + tip delivery= clinical success

15. Patients • 610 patients underwent EP and ablation using either MNS or MAN • MNS group: 292 pts • MAN group: 318 pts

16. Subgroup analysis Based on the diagnosed arrhythmia: AFib, AFl/AT, AVJ, AVNRT, CMT and VT The VT subgroup was further divided to structural heart disease associated (VT-SHD) or non-structural heart disease associated (VT-NSHD) VTs

17. Patient Demographics

18. Data collection and analysis • Acute success rate • Recurrence during FU (3 month following the procedure, and every 3 month thereafter except for AVNRT, AFl, AVJ and CMT) • Fluoroscopy and procedure times • Complications

19. Complications • Major: • stroke • death • pericardial effusion or tamponade • major bleeding • permanent AV block • Minor: • minor bleeding • temporary AV block

20. Results – Patient Demographics

21. MNS MAN p < 0,05 Acute Success Rate Recurrence Rate Results Acute Success and Recurrence

22. Results – Acute Succes Rate

23. Fluoroscopy and procedure times

24. Results – Recurrence Rate

25. Results - Complications

26. Ablation of atrial flutter 61 patients were divided to 3 groups 24 patients were treated with 8 mm tip catheter using manual navigation technique (MAN) 18 patients were treated with 8 mm tip catheter using MNS (MNS-8mm) 19 patients were treated with irrigated tip catheter using MNS (MNS-irr)

27. Endpoints Primary: success within 15 applications Secondary: procedure time, fluoroscopy time

28. Results: MVGT- MNS registry 61 pts included MNS 37 pts Manual Navig. 8 mm tip 24 pts MNS - irr 19 pts MNS - 8 mm 18 pts Success within 15 application 18 pts Success within 15 application 20 pts Max of 15 RF application failure 1+6+4 = 11 pts Success within 15 application 12 pts Open irrigation tip catheter

29. Acute Success Rates Bidirection isthmus block was achieved within 15 applications: MAN: 20/24=83% MNS – 8mm: 12/18=67% MNS – irrigation tip: 18/19=95% Isthmus block could be reached in all cases after switching to manual-guided irrigation tip catheters. p<0.05

30. Complications II. (group MNS) Probably no any reason to use 8 mm MNS catheter

31. Ablation of ventricular tachycardias SHD: structural heart disease

32. Results: Patient data

33. Results: Acute success rate SHD: structural heart disease

34. Procedural data

35. Recommendations • Left atrium: 3,5 mm tip electrode, open irrigation, posterior wall: 30 W, max power: 45 W (only at the ridge between LSPV and appendage, in case of more segmental RF applications: reduce to 20-25 W, irr: 17 ml • Left ventricle: min. 50 W for the ventricle. Irrigation starts at 20 ml, if power goes to 55 W irr: 30 ml/min • In standard WPW procedures, 4 mm tip standard electrode, 55 W power, 60 °C • In CTI dependant flutter: maximum voltage guided technique, 3.5 mm tip irrigation catheter, min 55 W power level- but high irrigation level starting at 30 ml (steam pop). preferably ½ 6 (more septal) • In AVNRT, 4 mm tip standard catheter, power titration from 10 W up to 40-50 W, 50 °C • RV: Irrigation tip, starting with relatively low irr. level (10 ml), power 45 W

36. Optimizing RF energy delivery

37. The effect on ablation results of improved catheter and mapping technology Triedman et al, JACC, 2002 37

38. Thiagalingam et al. JCE, 2009 38

39. Consequences of high catheter contact force Tilz et al, JCE, 2010

40. Okumura, JCE, 2008

41. Magnetic catheters provide constant contact

42. Magnetic catheters provide constant contact 50 Watts, 60 seconds 25 Watts, 60 seconds Cross-sections show full thickness lesions in 5mm thick tissue Epicardial view of endocardially-delivered lesions in a canine model

43. History • 1991 Anterior and apical MI, conservative therapy • 1992 CABG (venous grafts LAD, MO, RDP) • 2000 Monomorphic VT, VT ablation (other center) and amiodarone therapy. • 2002 Multiple hospitalization, heart failure due to ischemic origin DCM • 2003 Polymorph VTs, CAG: no stenosis of the grafts, EF 25%, DDD ICD impl.

44. History • 2006 Repositioning of the ICD due to decubitus • 2007 Multiple ICD shocks for VF. • 2008 Polymorph VTs, ICD shocks. EF 26%.CAG: Occluded native coronaries (RCA, LAD, LCX). Intact venous grafts. VT-ablation (postero-lateral and apical applications). • 2008 Recurrant slow-VTs. Amiodarone+lidocaine (oral mexiletine started) • 2009 Recurrant VTs, multiple shocks, long-term hospitalization. Heart-transplant waiting list. • 2010.02. Recurrant VTs again

45. Magnetic navigation guided ablation

46. Magnetic catheter inserted retrogradely in the LV

47. Manually controlled catheter from the groin vein

48. Manually controlled catheter from the right jugular vein

49. Echocardiogram at 3 months follow up

50. After orthotopic heart tarnsplantion