Stereotactic radiofrequency lesion making

The physical principles of radiofrequency (RF) lesion making in stereotactic neurosurgery are summarized. Empirical data are given on the relationship between lesion size and lesioning parameters. Currently accepted ranges of lesioning parameters for selected stereotactic procedures are discussed. Advanced RF lesion electrode designs are described which improve the capabilities to reach and confirm targets.     

Radiofrequency lesion generation and its effect on tissue impedance

The method of radiofrequency heat lesion generation is reviewed with specific reference to the dorsal root entry zone. Experimental data on the impedance of electrolytic media as a function of temperature are reported, and their relation to what should be observed during radiofrequency lesioning in the body is commented upon. The future utility of impedance monitoring is discussed as well as possible implications of bipolar lesion electrode systems.     

Real‐time optical spectroscopic monitoring of nonirrigated lesion progression within atrial and ventricular tissues

Despite considerable advances in guidance of radiofrequency ablation (RFA) therapy for the treatment of cardiac arrhythmias, success rates have been hampered by a lack of tools for precise intraoperative evaluation of lesion extent. Near‐infrared spectroscopic (NIRS) techniques are sensitive to tissue structural and biomolecular properties, characteristics that are directly altered by radiofrequency (RF) treatment. In this work, a combined NIRS‐RFA catheter is developed for real‐time monitoring of tissue reflectance during RF energy delivery. An algorithm is proposed for processing NIR spectra to approximate nonirrigated lesion depth in both atrial and ventricular tissues. The probe optical geometry was designed to bias measurement influence toward absorption enabling enhanced sensitivity to changes in tissue composition. A set of parameters termed “lesion optical indices” are defined encapsulating spectral differences between ablated and unablated tissue. Utilizing these features, a model for real‐time tissue spectra classification and lesion size estimation is presented. Experimental validation conducted within freshly excised porcine cardiac specimens showed strong concordance between algorithm estimates and post‐hoc tissue assessment.      

Principles of electroanatomic mapping

Electrophysiologic testing and radiofrequency ablation have evolved as curative measures for a variety of rhythm disturbances. As experience in this field has grown, ablation is progressively being used to address more complex rhythm disturbances. Paralleling this trend are technological advancements to facilitate these efforts, including electroanatomic mapping (EAM). At present, several different EAM systems utilizing various technologies are available to facilitate mapping and ablation. Use of these systems has been shown to reduce fluoroscopic exposure and radiation dose, with less significant effects on procedural duration and success rates. Among the data provided by EAM are chamber reconstruction, tagging of important anatomic landmarks and ablation lesions, display of diagnostic and mapping catheters without using fluoroscopy, activation mapping, and voltage (or scar) mapping. Several EAM systems have specialized features, such as enhanced ability to map non-sustained or hemodynamically unstable arrhythmias, ability to display diagnostic as well as mapping catheter positions, and wide compatibility with a variety of catheters. Each EAM system has its strengths and weaknesses, and the system chosen must depend upon what data is required for procedural success (activation mapping, substrate mapping, cardiac geometry), the anticipated arrhythmia, the compatibility of the system with adjunctive tools (i.e. diagnostic and ablation catheters), and the operator's familiarity with the selected system. While EAM can offer significant assistance during an EP procedure, their incorrect or inappropriate application can substantially hamper mapping efforts and procedural success, and should not replace careful interpretation of data and strict adherence to electrophysiologic principles.     

Instrumental radiofrequency electromagnetic radiation dosimetry: general principals and modern methodology

The modern experimental radiofrequency electromagnetic field dosimetry approach has been considered. The main principles of specific absorbed rate measurement are analyzed for electromagnetic field biological effect assessment. The general methodology of specific absorbed rate automated dosimetry system applied to establish the compliance of radiation sources with the safety standard requirements (maximum permissible levels and base restrictions) is described.     

An unusual presentation of a malignant jejunal tumor and a different management strategy

BACKGROUND: Malignant small bowel tumors are very rare and leiomyosarcoma accounts for less than 15% of the cases. Management of these tumors is challenging in view of nonspecific symptoms, unusual presentation and high incidence of metastasis. In this case report, an unusual presentation of jejunal sarcoma and management of liver metastasis with radiofrequency ablation (RFA) is discussed. CASE PRESENTATION: A 45-year-old male presented with anemia and features of small bowel obstruction. Operative findings revealed a mass lesion in jejunum with intussusception of proximal loop. Resection of bowel mass was performed. Histopathological findings were suggestive of leiomyosarcoma. After 3-years of follow-up, the patient developed recurrence in infracolic omentum and a liver metastasis. The omental mass was resected and liver lesion was managed with radiofrequency ablation. CONCLUSION: Jejunal leiomyosarcoma is a rare variety of malignant small bowel tumor and a clinical presentation with intussusception is unusual. We suggest that an aggressive management approach using a combination of surgery and a newer technique like RFA can be attempted in patients with limited metastatic spread to liver to prolong the long-term survival in a subset of patients.     

超声造影在肝癌射频消融治疗前后的临床价值研究

目的:探讨实时超声造影(contrast-enhanced ultrasonography,CEUS)在原发性肝癌射频消融(radiofrequency ablation,RFA)微创介入前后治疗临床应用价值的研究。方法:通过分析139例肝癌患者175个病灶在超声引导下射频消融(RFA)治疗,对病灶数量、大小、边界、内部回声、造影剂灌注情况进行对比分析,及治疗后与增强CT结果进行对照。结果:射频消融前,超声造影显示82个病灶表现为动脉早期抱球状、弥漫或轻度增强;治疗1-3个月后超声造影判定89.1%(156/175)的病灶达到完全消融,10.9%(19/175)的病灶消融不完全;增强CT判定84.6%(148/175)的病灶达到完全消融,15.4%(27/175)的病灶消融不完全,治疗后超声造影检查结果与CT增强检查结果一致,两者在病灶残留复发的敏感性、特异性、准确性等方面比较无显著性差异,P>0.01。结论:实时超声造影(CEUS)能准确判断RFA对肿瘤消融的范围及程度,是一种指导治疗,判定治疗后疗效的新方法,在原发性肝癌(RFA)微创介入治疗中具有很高的临床应用价值。     

Figure-8 tachycardia confined to the anterior wall of the left atrium

Incisional atrial tachycardias have been described most frequently in patients with previous corrective surgery for congenital heart defects and mitral valve disease. Less information is available on atrial tachycardias appearing late after isolated aortic valve surgery. We report the case of a patient who developed a left figure-8 tachycardia after undergoing aortic valve replacement. During electrophysiologic study the entire cycle length of the tachycardia was mapped within a low voltage area confined to the left anterior atrial wall. However, during ablation a transmural lesion could not be attained. The mapping and ablation strategy along with the mechanism of the tachycardia are discussed.     

Factors influencing lesion formation during radiofrequency catheter ablation

In radiofrequency (RF) ablation, the heating of cardiac tissue is mainly resistive. RF current heats cardiac tissue and in turn the catheter electrode is being heated. Consequently, the catheter tip temperature is always lower--or ideally equal--than the superficial tissue temperature. The lesion size is influenced by many parameters such as delivered RF power, electrode length, electrode orientation, blood flow and tissue contact. This review describes the influence of these different parameters on lesion formation and provides recommendations for different catheter types on selectable parameters such as target temperatures, power limits and RF durations.     

Multiple arrhythmogenic substrate for tachycardia in a patient with frequent palpitations

We report a 26-year-old woman with frequent episodes of palpitation and dizziness. Resting electrocardiography showed no evidence of ventricular preexcitation. During electrophysiologic study, a concealed right posteroseptal accessory pathway was detected and orthodromic atrioventricular reentrant tachycardia incorporating this pathway as a retrograde limb was reproducibly induced. After successful ablation of right posteroseptal accessory pathway, another tachycardia was induced using a concealed right posterolateral accessory pathway in tachycardia circuit. After loss of retrograde conduction of second accessory pathway with radiofrequency ablation, dual atrioventricular nodal physiology was detected and typical atrioventricular nodal reentrant tachycardia was repeatedly induced. Slow pathway ablation was done successfully. Finally sustained self-terminating atrial tachycardia was induced under isoproterenol infusion but no attempt was made for ablation. During 8-month follow-up, no recurrence of symptoms attributable to tachycardia was observed.     

Percutaneous radiofrequency lesions adjacent to the dorsal root ganglion alleviate spasticity and pain in children with cerebral palsy: pilot study in 17 patients

Background  

Cerebral palsy (CP) may cause severe spasticity, requiring neurosurgical procedures. The most common neurosurgical procedures are continuous infusion of intrathecal baclofen and selective dorsal rhizotomy. Both are invasive and complex procedures. We hypothesized that a percutaneous radiofrequency lesion of the dorsal root ganglion (RF-DRG) could be a simple and safe alternative treatment. We undertook a pilot study to test this hypothesis.     

Inside Cover: Real‐time optical spectroscopic monitoring of nonirrigated lesion progression within atrial and ventricular tissues (J. Biophotonics 4/2019)

There is a clinical need in the treatment of atrial fibrillation by radiofrequency ablation to provide lesion set validation. The integration of optical fibers into radiofrequency ablation catheters can address this issue. Thermally‐induced, dynamic changes in tissue diffuse reflectance are measured through transcatheter near‐infrared spectroscopy. A regression model based on spectral features is proposed and utilized to validate the presence of thermal injury, measure lesion depth, and assess gaps. Further details can be found in the article by Rajinder P. Singh‐Moon, Xinwen Yao, Vivek Iyer, et al. ( e201800144 ).

     

Cryothermal energy ablation of cardiac arrhythmias 2005: state of the art

At the time of antiarrhythmic surgery, cryothermal energy application by a hand-held probe was used to complement dissections and resections and permanently abolish the arrhythmogenic substrate. Over the last decade, significant engineering advances allowed percutaneous cryoablation based on catheters, apparently not very different from standard radiofrequency ablation catheters. Cryothermal energy has peculiar characteristics. In fact, it allows testing in a reversible way the effects of energy application at higher temperature, before producing a permanent lesion at -75 degrees C. Moreover, slow formation of the lesion allows timely discontinuation of the application, as soon as inadvertent modifications of normal atrioventricular conduction are observed during ablation in the proximity of atrioventricular node and His bundle, avoiding its permanent damage. Over the last years, percutaneous cryothermal ablation has been widely used for a variety of cardiac arrhythmias. From the data gathered, it is unlikely that cryoablation will replace standard ablation in unselected cases. Nevertheless, for the above mentioned peculiarities, cryothermal ablation has proved very effective and safe for ablation of arrhythmogenic substrates close to the normal conduction pathways, becoming the first choice method to ablate anteroseptal and midseptal accessory pathways. It can be also the best treatment for ablation of the slow pathway to abolish atrioventricular node reentrant tachycardia in pediatrics or when particular anatomy of the Koch's triangle is observed. Cryothermal ablation of the pulmonary veins for atrial fibrillation, although longer than radiofrequency ablation, is not associated with pulmonary vein stenosis and is expected to be less thrombogenic; new catheter designs for cryothermal ablation of this challenging arrhythmia are to be tested to assess their efficacy and clinical usefulness.     

Double-gap-in-roof reentrant tachycardia following surgical thoracoscopic atrial fibrillation ablation

A case of macro-reentrant tachycardia associated with a box lesion after thoracoscopis left atrial surgical atrial fibrillation (AF) ablation yet to be described. The goal was to clarify the mechanisms and electrophysiological characteristics of this type of tachycardia.A patient was admitted for an EP study following surgical thoracoscopic AF ablation (box lexion formation by right-sided Cobra thoracoscopic ablation). Thoracoscopic ablation was done as the first step of the hybrid ablation approach to the persistent AF; the second step was the EP study. At the EP study, he presented with incessant regular tachycardia (cycle length of 226 ms). An EP study with conventional, 3D activation and entrainment mapping was done to assess the tachycardia mechanism. Two conduction gaps in the superior line (roofline) between the superior pulmonary veins were discovered. The tachycardia was successfully treated with a radiofrequency application near the gap close to the left superior pulmonary vein; however, following tachycardia termination, pulmonary vein isolation was absent. A second radiofrequency application, close to the roof of the right superior pulmonary, vein closed the gap in the box and led to the isolation of all 4 pulmonary veins. No atrial tachycardia recurred during the 6-month follow-up.Conduction gaps in box lesion created by thoracospcopic ablation can present as a novel type of man-made tachycardia after surgical ablation of atrial fibrillation. Activation and entrainment mapping is necessary for an accurate diagnosis.     

鄂尔多斯高原植物群落季节生长格局模拟

影响大尺度空间生态模型模拟结果与资源管理整合的因素主要有两种:一是一些模型生态学意义不明确,二是一些模型所需要的生态输入信息过于复杂。建立一个基于基本的生态学公理且输入较为简单的生态学模型,便于更加有效地服务于资源环境管理。该模型用于模拟发生严重荒漠化的鄂尔多斯高原植物群落的季节及年生长、叶片投影盖度、蒸发系数。模型首先基于降雨、蒸散、渗漏及土壤水分特性与蒸发系数(k)的关系,采用迭代的计算方法,模拟植物群落蒸散与土壤可利用水分达到平衡状态时的k值,进而采用得到广泛验证的经验公式计算植物群落的其它参数。野外N PP观察数据对模型的验证表明:模拟结果与观察值相符较好。模拟结果表明:蒸发系数小于0 .35×10 - 2 ,显示鄂尔多斯高原气候较为干燥;叶片投影盖度低于5 0 % ;除东部的准格尔旗外,植物群落净第一性生产力均低于1t/(hm2·a) ,近90 %的N PP累积集中于5至8月份。根据该文的模拟结果,在进行植被恢复时,恢复植被密度必须低于5 0 % ,放牧密度以0 .8～2 .0个/hm2 羊单位为宜     

CT appearance of experimental thalamic radiofrequency lesion in dog

The location and extent of thalamic lesions following thalamotomy can be identified as a large low density area in the acute stage to a small spot in the chronic stage. Stereotactic experimental radiofrequency lesions were placed in the thalamus of 35 mongrel dogs. CT images and whole brain specimens were obtained on days 0, 3, 7, 10, 14, 21 and 60. The appropriate time to map the lesions in the thalamus was thought to be about day 14, because of the thalamic size ratio and the correction of the ventricular deformity. The histological area of the lesion at day 14 corresponded better to the contrast-enhanced area than to that of the plain CT. These results suggest that the lesion demonstrated by contrast-enhanced CT scans at day 14 gives the best anatomical mapping of the actual histological defect.     

Effect of ventral noradrenergic bundle lesions on concentrations of monoamine neurotransmitters and metabolites in several discrete areas of the rat brain

1. The effects of radiofrequency lesions of the ventral noradrenergic bundle (VNB) on monoamine and metabolite concentrations in several discrete areas of the rat hypothalamus were examined. Monoamines and metabolites were analyzed utilizing high-performance liquid chromatography coupled with electrochemical detection. 2. VNB lesions decreased the concentrations of norepinephrine (NE) and 3-methoxy-4-hydroxyphenylethylene glycol in all areas examined except in the ventromedial nucleus (VMN). Dopamine and 3,4-dihydroxyphenylacetic acid concentrations were selectively decreased in the dorsomedial nucleus (DMN) and also slightly decreased in the medial forebrain bundle following VNB lesions. Serotonin and 5-hydroxyindole-3-acetic acid concentrations were not altered by VNB lesion in any area examined. 3. The results indicate that the NE innervation to the hypothalamus is extensive and that NE in the VMN may not be derived from the VNB. The source of the DA innervation to the DMN may be located in or pass through the area affected by the VNB lesion.     

Advanced fully integrated radiofrequency/optical-coherence-tomography irrigated catheter for atrial fibrillation ablation

The inability of current catheter ablation procedures to accurately monitor lesion formation limits their safety and efficacy. An advanced fully integrated radiofrequency (RF)/optical coherence tomography (OCT) ablation catheter is developed, which enables real-time monitoring during ablation. An OCT fiber array is especially designed, developed and integrated into an off-the-shelf irrigated RF ablation catheter. In-vitro experimental studies performed on poultry and ovine hearts demonstrate the ability of the integrated RF/OCT system to provide information on the quality and orientation of catheter/wall contact. Experimental results show that adipose tissue can be accurately identified from normal myocardial tissue with 94% accuracy and lesion formation is monitored with an overall accuracy of 93%. The ability to predict pop events is also demonstrated, with an accuracy of 86%.     

Applied principles of radiopharmaceutical use in therapy

The initial consideration in use of a radiopharmaceutical in therapy is specificity of localization. A variety of biological principles such as active transport and binding to cellular components have been utilized to achieve this localization. The next concern is to maximize radiation to the lesion while minimizing that to the remainder of the body. This means that there is a major role to be played by emissions with a short path length (such as α particles, weak β particles and Auger electrons). To achieve maximal irradiation of the lesion, dissociation of the radiolabel from the tissue should be minimized; potential approaches for acheiving this are reviewed. Finally, “synergistic effects” between radiation and chemical agents are discussed.     

The Ethical and Legal Framework for the Decision Not to Resuscitate

Practicing physicians are frequently faced with the question of whether or not to institute cardiopulmonary resuscitation in case of cardiac or respiratory arrest in a patient in hospital. Medical training has usually not included any systematic analysis of this issue from either an ethical or a legal standpoint. Many physicians may be unaware that ethical and legal principles, as well as professional guidelines, exist to guide such decision making. In practice, physicians make this decision without the benefit of training in ethical analysis. The problem is especially acute in teaching hospitals when young physicians unacquainted with formal ethics or the law must often make decisions emergently. Studies show some discrepancy between ethical and legal principles and the actual decision making by physicians. For this reason, we recommend an approach that will enable physicians to make and implement decisions not to resuscitate that are consistent with current ethical and legal standards.