Remote magnetic navigation for ablation of typical atrial flutter: Long-term results | Revista Portuguesa de Cardiologia (English edition)

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"leonor.parreira@gmail.com" 1 => "lparreira@netvisao.pt" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Diogo" "apellidos" => "Cavaco" ] 2 => array:2 [ "nombre" => "Pedro" "apellidos" => "Carmo" ] 3 => array:2 [ "nombre" => "Katya" "apellidos" => "Reis-Santos" ] 4 => array:2 [ "nombre" => "Rita" "apellidos" => "Quaresma" ] 5 => array:2 [ "nombre" => "Tiago" "apellidos" => "Teixeira" ] 6 => array:2 [ "nombre" => "Marta" "apellidos" => "Marques" ] 7 => array:2 [ "nombre" => "Pedro" "apellidos" => "Adragão" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Centro do Ritmo Cardíaco, Hospital da Luz, Lisboa, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ablação do istmo cavo-tricúspide com sistema de navegação magnética por controlo remoto no tratamento do flutter auricular típico – resultados a longo prazo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1840 "Ancho" => 3257 "Tamanyo" => 362387 ] ] "descripcion" => array:1 [ "en" => "Reference fluoroscopic images on the Navigant workstation in right and left anterior oblique views showing the real-time position of the ablation catheter, without further fluoroscopy, in the cavotricuspid isthmus at the 5 o’clock position, the automatic vector of the magnetic navigation system (yellow arrow) and the His bundle (yellow point). OAD: right anterior oblique; OAE: left anterior oblique." ] ] ] "textoCompleto" => "IntroductionAtrial flutter (AFL) is an abnormal cardiac rhythm characterized by rapid regular atrial depolarizations with a rate of approximately 300/min and regular ventricular rate. Typical AFL is the most common macroreentrant atrial tachycardia.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Catheter ablation of the cavotricuspid isthmus (CTI) is the treatment of choice for this arrhythmia due to its high success rate and low rate of complications compared to drug therapy, which is relatively ineffective.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The Niobe magnetic navigation system (MNS) (Stereotaxis) was developed for remote control of ablation procedures, aimed at improving steering of the catheters and reducing fluoroscopy time. The system has been shown to be effective and safe in ablation of different types of supraventricular and ventricular arrhythmias, and is superior to conventional ablation for ventricular tachycardia.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> In a randomized trial of ablation of supraventricular tachycardias with the Niobe system compared to manual navigation, the MNS was associated with reduced fluoroscopy time and number of radiofrequency (RF) applications.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> However, initial studies of AFL ablation reported lower success rates than with manual steering,<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a> which may be due to the limited contact force possible with flexible catheters.The aim of this study was to assess the feasibility and safety of the MNS for ablation of AFL and its long-term success and to compare the results obtained with an 8-mm tip catheter versus an irrigated catheter.MethodsStudy populationBetween January 2008 and October 2012, 38 consecutive patients underwent electrophysiological study and catheter ablation of typical AFL with the Niobe MNS at our institution. AFL was documented by 12-lead ECG and the patients were symptomatic despite medication. No patient was contraindicated for magnetic navigation, and all gave their written informed consent.Electrophysiological studyPatients were assessed after six hours’ fasting and antiarrhythmic medication was suspended for five half-lives; amiodarone was suspended at least one month before the procedure. Patients with persistent AFL who were not under oral anticoagulation underwent transesophageal echocardiography to exclude the presence of left atrial thrombi.Surface electrocardiograms and intracavitary electrograms were recorded on an AXIOM Sensis system (Siemens Healthcare). Programmed stimulation was performed using a UHS 3000 heart stimulator (Biotronik). The catheters were inserted via the femoral vein and positioned under fluoroscopic guidance, a quadripolar catheter (Navistar, Biosense Webster) in the His bundle and an octapolar catheter (Dynamic XT, Bard) in the coronary sinus (CS).When ablation was carried out in AFL rhythm, entrainment pacing was used to demonstrate the presence of isthmus-dependent atrial flutter. Patients in sinus rhythm underwent CS pacing to measure conduction time across the CTI before ablation.Magnetic navigationAll procedures were carried out using the Niobe II system. The MNS has been previously described<a class="elsevierStyleCrossRef" href="#bib0045">9</a>; it basically consists of two computer-controlled magnets positioned on either side of the fluoroscopy table, which create a magnetic field (0.1 T). The position of the magnets is controlled from a console, the Navigant workstation, which orientates the magnetic field according to vectors selected by the operator. The ablation catheter has three magnets at its distal end, which orientate it parallel to the magnetic field. Changes in the orientation of the magnetic field deflect the catheter tip, which is advanced or withdrawn remotely by a motor at the proximal end of the catheter (Cardiodrive, Stereotaxis). Magnetic field vectors can be stored, enabling subsequent automatic navigation to previous sites.Mapping and ablationThe MNS is integrated with a CARTO XP RMT (Biosense Webster) electroanatomical mapping system and provides real-time information on the position and orientation of the mapping catheter tip. This information is overlaid on the fluoroscopic images on the Navigant workstation, providing real-time monitoring of the catheter position without the need for further fluoroscopy (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The location of the His bundle is marked on the screen of the CARTO workstation.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>A Navistar RMT (Biosense Webster) catheter with an 8-mm tip was used for the first 17 procedures and a Navistar RMT Thermocool (Biosense Webster) irrigated-tip catheter for the subsequent 21 procedures. The ablation catheter was introduced via the femoral vein and advanced manually to the right atrium without the need for long sheaths, then remotely to the tricuspid annulus at the 6 o’clock position in left anterior oblique view and subsequently to the right ventricle, after which it was gradually withdrawn until an atrial potential was detected on the distal bipole of the ablation catheter. RF energy was then applied at this point and the ablation catheter was progressively withdrawn under remote control to the inferior vena cava (IVC).The MNS vector was directed downward in the initial portion of the CTI and more anteriorly in the final portion, closer to the IVC (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). Using an EP Shuttle RF generator (Stockert), RF was applied between the distal electrode of the ablation catheter and a cutaneous patch electrode, with a power limit of 70 W and maximum temperature of 55°C in the case of the 8-mm catheter, and a power limit of 50 W and maximum temperature of 45°C with the irrigated catheter. The duration of RF application depended on the disappearance of the atrial potential on the distal electrogram, but was never less than 30 s. Light sedation with midazolam (bolus) or remifentanil (perfusion) was administered during RF application when necessary. Procedure and fluoroscopy times were recorded, procedure time being defined as the interval between venous puncture and removal of the introducer. Acute success was defined as demonstration of bidirectional block in the CTI and non-inducibility of AFL after 30 min. Bidirectional block was demonstrated by documentation of downward activation in the right atrial lateral wall during CS pacing and downward activation in the septum during low-lateral right atrial pacing, as well as a conduction delay across the isthmus. As previously described,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> the minimum conduction delay across the isthmus during CS pacing that demonstrates conduction block in the CTI was taken to be 110 ms (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>If the initial ablation line did not result in CTI block, the line was mapped to detect possible gaps, and if CTI conduction persisted after any gaps were eliminated, additional lines were created in more lateral or septal positions. If bidirectional CTI block could not be achieved, the procedure was considered unsuccessful. All patients remained under surveillance in hospital for 24 hours after the procedure.The results obtained with an 8-mm tip catheter were compared with those using an irrigated catheter.Follow-upFollow-up consultations included clinical assessment between the first and third month after the procedure and then every six months. Holter 24-hour monitoring was performed between the third and sixth month and then at least once a year. Clinical success was defined as absence of palpitations and/or absence of AFL on ECG.Statistical analysisData are presented as means ± standard deviation for continuous variables and as frequencies for categorical variables. Categorical variables were analyzed with the chi-square test and continuous variables with the Student's t test.ResultsPopulationThirty-eight consecutive patients, mean age 61±15 years, 28 male, underwent ablation of typical AFL. Twenty-six had persistent AFL. Nineteen had hypertension, four had coronary disease and had undergone coronary artery bypass grafting, two had non-ischemic dilated cardiomyopathy, one had Ebstein's anomaly and 12 had no structural heart disease. The baseline characteristics of the two groups (those treated by 8-mm tip catheter and by irrigated catheter) are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. There were no significant differences between the groups.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Mapping and ablationAblation was carried out in AFL rhythm in 31 patients and in sinus rhythm in seven. The procedure was successful in 37 patients (97%). FLA was terminated during the procedure in 30 cases.Procedure time was 167±59 min and fluoroscopy time was 7.8±5.3 min. The mean number of RF applications was 22±15, with a mean application time of 24±13 min.The ablation procedure characteristics in the study population are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The success rate was similar in both groups, 94% in the 8-mm tip catheter group and 100% in the irrigated catheter group, as was procedure time, but fluoroscopy time was significantly shorter in the irrigated catheter group (13.4±3.7 vs. 6±4.4 min; p<0.01). The number of RF applications and total RF application time did not differ significantly between the groups.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Follow-upThere were no procedure-related complications.During a follow-up of 32±19 months (6–60) two patients had relapse of AFL, one in each group (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). One patient refused reablation and in the other the procedure was repeated with an irrigated catheter, which was successful. Six patients developed atrial fibrillation (AF) during follow-up that was treated by ablation. After pulmonary vein isolation, conduction across the CTI was assessed and continuing bidirectional block was confirmed in all patients.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>There were no deaths during follow-up.DiscussionThe main finding of this study was that the Niobe II MNS is safe and effective for treatment of AFL, with similar success rates to conventional ablation.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> We also found that 8-mm tip and irrigated catheters are equally effective, which is in agreement with previous studies comparing these two types of catheter for AFL ablation.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a>Linear CTI ablation, first described by Cosio et al.,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> is the first-line strategy for treatment of typical AFL. The first procedures used a 4-mm tip catheter, but success rates were as low as 67% in some series.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Efforts to improve these figures included the development of 8-mm tip catheters and then irrigated-tip catheters designed to increase the size of lesions, improving success rates, which in some cases have reached 99%.<a class="elsevierStyleCrossRefs" href="#bib0060">12,14,16,17</a> The high success rates of AFL ablation, together with the poor results of drug therapy,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> have led to catheter CTI ablation becoming a common procedure.Previous studies comparing conventional AFL ablation with remote navigation-controlled systems showed that the latter produced worse results (91% vs. 84%).<a class="elsevierStyleCrossRef" href="#bib0035">7</a>In our study, the success rates with the MNS of 94% using an 8-mm tip catheter and 100% with an irrigated catheter are higher than those described with conventional systems.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Previous studies have also shown that procedure time and RF time tend to be longer with the MNS but fluoroscopy time is significantly shorter.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Mean fluoroscopy time in our series (7.8±5.3 min) was also significantly shorter than reported for conventional ablation.<a class="elsevierStyleCrossRefs" href="#bib0060">12,14,16,17</a> The longer fluoroscopy time seen in the 8-mm tip catheter group may be due to the greater difficulty in adjusting the larger tip to the anatomy of the CTI, but may also be the result of the learning curve associated with the MNS, since the first cases using the remote system were treated with an 8-mm tip catheter. Randomized trials comparing the two catheter types have shown similar success and complication rates as well as procedure and fluoroscopy times.<a class="elsevierStyleCrossRefs" href="#bib0060">12,15</a>Our long-term success rate (5% relapse at 32±19 months) was better than that described for conventional ablation, well below the 10.9% at 13.8±0.3 months of Perez et al.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> and the 20% at 21±11 months reported by Blomstrom-Lundqvist et al.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Although we did not assess coagulum formation on the catheter tip in our study, most studies show a tendency for higher prevalence of this complication with 8-mm tip catheters than with irrigated catheters (between 6% and 15%).<a class="elsevierStyleCrossRefs" href="#bib0040">8,12</a> For this reason, notwithstanding the good results obtained with the 8-mm tip catheter, the irrigated catheter has been our choice for AFL ablation since it became available for the MNS.The occurrence of AF following ablation of AFL, although not strictly speaking a relapse of the initial arrhythmia, is a cause of morbidity and hospitalization. The incidence of AF after AFL ablation depends on whether it had occurred before the procedure and on the duration of follow-up, and ranges between 8 and 52%.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> In our patient population the incidence of AF was 16% in a mean follow-up of 32±19 months; the figure was higher in the 8-mm tip catheter group, but without statistical significance, and may be due to the longer follow-up in this group.LimitationsThe present study was not randomized and included a small number of patients, and no comparison was made with conventional ablation in terms of procedure or fluoroscopy times or efficacy. The comparison between the two different catheter types was performed retrospectively.ConclusionsOur study demonstrates that the remote control Niobe II system is safe and effective for AFL ablation, with a high rate of acute success and a low rate of relapse. Irrigated catheters and 8-mm tip catheters were equally effective and safe for the ablation of typical AFL using the MNS.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres407251" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction and Aim" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec383492" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres407252" "titulo" => array:5 [ 0 => "Resumo" 1 => "Introdução e objetivos" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusões" ] ] 3 => array:2 [ "identificador" => "xpalclavsec383491" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Electrophysiological study" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Magnetic navigation" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Mapping and ablation" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Follow-up" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Population" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Mapping and ablation" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Follow-up" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Limitations" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusions" ] 10 => array:3 [ "identificador" => "sec0080" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0095" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0100" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-10-14" "fechaAceptado" => "2014-05-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec383492" "palabras" => array:4 [ 0 => "Typical atrial flutter" 1 => "Radiofrequency ablation" 2 => "Remote magnetic navigation" 3 => "Stereotaxis" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec383491" "palabras" => array:4 [ 0 => "Flutter auricular típico" 1 => "Ablação por radiofrequência" 2 => "Navegação magnética" 3 => "Estereotaxia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Introduction and AimRemote magnetic navigation has proved to be effective in the ablation of most supraventricular and ventricular arrhythmias. Initial studies reported worse results with this system compared to conventional ablation for atrial flutter. The aim of this study was to assess the acute and long-term success of atrial flutter ablation with remote magnetic navigation and to retrospectively compare the results obtained with an 8-mm tip catheter versus an irrigated catheter. MethodsWe studied 38 consecutive patients, mean age 61±15 years, 28 male, who underwent ablation of typical atrial flutter with the Niobe II remote magnetic navigation system (Stereotaxis). Ablation was performed with an 8-mm tip catheter in 17 patients and with an irrigated-tip catheter in 21 patients. Acute success was defined as the presence of bidirectional isthmus block, and long-term success as absence of symptoms and atrial flutter during Holter monitoring. ResultsBidirectional isthmus block was achieved in 37 patients (97%), and the success rate was similar in both groups. Total procedure time was not significantly different between the groups but fluoroscopy time was shorter in the irrigated tip group (13.4±3.7 min vs. 6±4.4 min; p<0.01). The number of applications and total radiofrequency time did not differ. There were no complications. During a follow-up of 32±19 months there were two relapses, one in each group. ConclusionsThe Niobe II remote control system for ablation of typical atrial flutter is safe and effective in both the short and long term. The 8-mm and irrigated-tip catheters showed similar safety and efficacy." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "Introdução e objetivosA ablação com sistema de navegação magnética tem demonstrado ser eficaz em vários tipos de procedimentos de ablação. Estudos iniciais apontam para uma menor eficácia deste método na ablação do istmo cavo-tricúspide. O objetivo deste estudo foi avaliar a eficácia imediata e a longo prazo deste método e comparar retrospetivamente os resultados obtidos com o cateter de 8mm com os obtidos com o cateter irrigado. MétodosEstudaram-se 38 doentes consecutivos, idade média 61±15 anos, 28 homens, referenciados para ablação de flutter típico com sistema de navegação magnética Niobe II (Stereotaxis) com um período de seguimento superior a seis meses. A ablação foi efetuada com cateter de 8mm em 17 doentes e com cateter irrigado em 21 doentes. O sucesso imediato foi definido como presença de bloqueio ístmico bidirecional e o sucesso a longo prazo definido com ausência de sintomas e de flutter auricular no registo de Holter. ResultadosO bloqueio ístmico bidirecional foi obtido em 37 doentes (97%). A taxa de sucesso foi semelhante nos dois grupos. O tempo de procedimento não diferiu entre os dois grupos, mas o tempo de fluoroscopia foi significativamente inferior no grupo com cateter irrigado (13,4±3,7min versus 6±4,4min; p<0,01). O número de aplicações e o tempo de radiofrequência foram semelhantes nos dois grupos. Não foram registadas complicações. Após um período de seguimento médio de 32±19 meses ocorreram duas recidivas, uma em cada grupo. ConclusõesO sistema de navegação magnética Niobe II mostrou-se eficaz e seguro na ablação de flutter típico permitindo uma taxa de sucesso elevada com uma eficácia mantida a longo prazo. O cateter de 8mm e o cateter irrigado mostraram-se igualmente eficazes e seguros." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Parreira L, Cavaco D, Carmo P, et al. Ablação do istmo cavo-tricúspide com sistema de navegação magnética por controlo remoto no tratamento do flutter auricular típico – resultados a longo prazo. Rev Port Cardiol. 2014;33:773–779." ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "List of abbreviations" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:7 [ 0 => array:2 [ "termino" => "AF" "descripcion" => "atrial fibrillation" ] 1 => array:2 [ "termino" => "AFL" "descripcion" => "atrial flutter" ] 2 => array:2 [ "termino" => "CS" "descripcion" => "coronary sinus" ] 3 => array:2 [ "termino" => "CTI" "descripcion" => "cavotricuspid isthmus" ] 4 => array:2 [ "termino" => "IVC" "descripcion" => "inferior vena cava" ] 5 => array:2 [ "termino" => "MNS" "descripcion" => "magnetic navigation system" ] 6 => array:2 [ "termino" => "RF" "descripcion" => "radiofrequency" ] ] ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1840 "Ancho" => 3257 "Tamanyo" => 362387 ] ] "descripcion" => array:1 [ "en" => "Reference fluoroscopic images on the Navigant workstation in right and left anterior oblique views showing the real-time position of the ablation catheter, without further fluoroscopy, in the cavotricuspid isthmus at the 5 o’clock position, the automatic vector of the magnetic navigation system (yellow arrow) and the His bundle (yellow point). OAD: right anterior oblique; OAE: left anterior oblique." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1847 "Ancho" => 3257 "Tamanyo" => 403650 ] ] "descripcion" => array:1 [ "en" => "Radiofrequency applications (red circles) on the CARTO mapping system. On the right, fluoroscopic image showing the ablation catheter and the magnetic navigation vector. OAD: right anterior oblique; OAE: left anterior oblique." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2090 "Ancho" => 3257 "Tamanyo" => 485982 ] ] "descripcion" => array:1 [ "en" => "Pacing by the mid-proximal bipole in the coronary sinus with the mapping catheter on the lateral side of the ablation line, showing a conduction delay of 192 ms in the cavotricuspid isthmus." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "AFL: atrial flutter; LVH: left ventricular hypertrophy; RA: right atrial." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">8-mm tip catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Irrigated catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58±18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent AFL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RA dilatation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Isolated AFL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medication</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral anticoagulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amiodarone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Propafenone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flecainide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Beta-blockers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab634572.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the study population." ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "AFL: atrial flutter; RF: radiofrequency energy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">8-mm tip catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Irrigated catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AFL during ablation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Procedure time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">189±61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">151±71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fluoroscopy time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.4±3.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6±4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No. of RF applications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22±15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21±14,8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RF application time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25±15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Success \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16/17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21/21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab634570.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Ablation procedure characteristics." ] ] 5 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "AFL: atrial flutter." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">8-mm tip catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Irrigated catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow-up (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.5±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrence of AFL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incidence of AFL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (24%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (10%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab634571.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Follow-up." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases. A Statement from a Joint Expert Group from the Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "N. Saoudi" 1 => "F. Cosıo" 2 => "A. Waldo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/euhj.2001.2658" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2001" "volumen" => "22" "paginaInicial" => "1162" "paginaFinal" => "1182" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11440490" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Blomstrom-Lundqvist" 1 => "M.M. Scheinman" 2 => "E.M. Aliot" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.CIR.0000091380.04100.84" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2003" "volumen" => "108" "paginaInicial" => "1871" "paginaFinal" => "1909" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14557344" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catheter ablation utilizing remote magnetic navigation: a review of applications and outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Bradfield" 1 => "R. Tung" 2 => "R. Mandapati" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8159.2012.03382.x" "Revista" => array:6 [ "tituloSerie" => "Pacing Clin Electrophysiol" "fecha" => "2012" "volumen" => "35" "paginaInicial" => "1021" "paginaFinal" => "1034" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22510160" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ablação de arrítmias da câmara de saída do ventrículo direito e esquerdo com sistema de navegação magnética por controlo remoto" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L. Parreira" 1 => "D. Cavaco" 2 => "K. Reis-Santos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2012.12.012" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2013" "volumen" => "32" "paginaInicial" => "489" "paginaFinal" => "495" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23790283" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Remote magnetic versus manual catheter navigation for ablation of supraventricular tachycardias: a randomized, multicenter trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.A. Wood" 1 => "M. Orlov" 2 => "K. Ramaswamy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8159.2008.01183.x" "Revista" => array:6 [ "tituloSerie" => "Pacing Clin Electrophysiol" "fecha" => "2008" "volumen" => "31" "paginaInicial" => "1313" "paginaFinal" => "1321" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18811813" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Initial clinical experience with a remote magnetic catheter navigation system for ablation of cavotricuspid isthmus-dependent right atrial flutter" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Arya" 1 => "H. Kottkamp" 2 => "C. 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Original Article

Remote magnetic navigation for ablation of typical atrial flutter: Long-term results

Ablação do istmo cavo-tricúspide com sistema de navegação magnética por controlo remoto no tratamento do flutter auricular típico – resultados a longo prazo

Leonor Parreira

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leonor.parreira@gmail.com
lparreira@netvisao.pt

Corresponding author.

, Diogo Cavaco, Pedro Carmo, Katya Reis-Santos, Rita Quaresma, Tiago Teixeira, Marta Marques, Pedro Adragão

Centro do Ritmo Cardíaco, Hospital da Luz, Lisboa, Portugal

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      "titulo" => "Cardiovascular profile in myotonic dystrophy type 1&#58; Analysis of a case series in a specialized center"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Reference fluoroscopic images on the Navigant workstation in right and left anterior oblique views showing the real-time position of the ablation catheter&#44; without further fluoroscopy&#44; in the cavotricuspid isthmus at the 5 o&#8217;clock position&#44; the automatic vector of the magnetic navigation system &#40;yellow arrow&#41; and the His bundle &#40;yellow point&#41;&#46; OAD&#58; right anterior oblique&#59; OAE&#58; left anterior oblique&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0040" class="elsevierStylePara elsevierViewall">Atrial flutter &#40;AFL&#41; is an abnormal cardiac rhythm characterized by rapid regular atrial depolarizations with a rate of approximately 300&#47;min and regular ventricular rate&#46; Typical AFL is the most common macroreentrant atrial tachycardia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Catheter ablation of the cavotricuspid isthmus &#40;CTI&#41; is the treatment of choice for this arrhythmia due to its high success rate and low rate of complications compared to drug therapy&#44; which is relatively ineffective&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The Niobe magnetic navigation system &#40;MNS&#41; &#40;Stereotaxis&#41; was developed for remote control of ablation procedures&#44; aimed at improving steering of the catheters and reducing fluoroscopy time&#46; The system has been shown to be effective and safe in ablation of different types of supraventricular and ventricular arrhythmias&#44; and is superior to conventional ablation for ventricular tachycardia&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> In a randomized trial of ablation of supraventricular tachycardias with the Niobe system compared to manual navigation&#44; the MNS was associated with reduced fluoroscopy time and number of radiofrequency &#40;RF&#41; applications&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; initial studies of AFL ablation reported lower success rates than with manual steering&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> which may be due to the limited contact force possible with flexible catheters&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The aim of this study was to assess the feasibility and safety of the MNS for ablation of AFL and its long-term success and to compare the results obtained with an 8-mm tip catheter versus an irrigated catheter&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population</span><p id="par0055" class="elsevierStylePara elsevierViewall">Between January 2008 and October 2012&#44; 38 consecutive patients underwent electrophysiological study and catheter ablation of typical AFL with the Niobe MNS at our institution&#46; AFL was documented by 12-lead ECG and the patients were symptomatic despite medication&#46; No patient was contraindicated for magnetic navigation&#44; and all gave their written informed consent&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Electrophysiological study</span><p id="par0060" class="elsevierStylePara elsevierViewall">Patients were assessed after six hours&#8217; fasting and antiarrhythmic medication was suspended for five half-lives&#59; amiodarone was suspended at least one month before the procedure&#46; Patients with persistent AFL who were not under oral anticoagulation underwent transesophageal echocardiography to exclude the presence of left atrial thrombi&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Surface electrocardiograms and intracavitary electrograms were recorded on an AXIOM Sensis system &#40;Siemens Healthcare&#41;&#46; Programmed stimulation was performed using a UHS 3000 heart stimulator &#40;Biotronik&#41;&#46; The catheters were inserted via the femoral vein and positioned under fluoroscopic guidance&#44; a quadripolar catheter &#40;Navistar&#44; Biosense Webster&#41; in the His bundle and an octapolar catheter &#40;Dynamic XT&#44; Bard&#41; in the coronary sinus &#40;CS&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">When ablation was carried out in AFL rhythm&#44; entrainment pacing was used to demonstrate the presence of isthmus-dependent atrial flutter&#46; Patients in sinus rhythm underwent CS pacing to measure conduction time across the CTI before ablation&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Magnetic navigation</span><p id="par0075" class="elsevierStylePara elsevierViewall">All procedures were carried out using the Niobe II system&#46; The MNS has been previously described<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; it basically consists of two computer-controlled magnets positioned on either side of the fluoroscopy table&#44; which create a magnetic field &#40;0&#46;1 T&#41;&#46; The position of the magnets is controlled from a console&#44; the Navigant workstation&#44; which orientates the magnetic field according to vectors selected by the operator&#46; The ablation catheter has three magnets at its distal end&#44; which orientate it parallel to the magnetic field&#46; Changes in the orientation of the magnetic field deflect the catheter tip&#44; which is advanced or withdrawn remotely by a motor at the proximal end of the catheter &#40;Cardiodrive&#44; Stereotaxis&#41;&#46; Magnetic field vectors can be stored&#44; enabling subsequent automatic navigation to previous sites&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Mapping and ablation</span><p id="par0080" class="elsevierStylePara elsevierViewall">The MNS is integrated with a CARTO XP RMT &#40;Biosense Webster&#41; electroanatomical mapping system and provides real-time information on the position and orientation of the mapping catheter tip&#46; This information is overlaid on the fluoroscopic images on the Navigant workstation&#44; providing real-time monitoring of the catheter position without the need for further fluoroscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The location of the His bundle is marked on the screen of the CARTO workstation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">A Navistar RMT &#40;Biosense Webster&#41; catheter with an 8-mm tip was used for the first 17 procedures and a Navistar RMT Thermocool &#40;Biosense Webster&#41; irrigated-tip catheter for the subsequent 21 procedures&#46; The ablation catheter was introduced via the femoral vein and advanced manually to the right atrium without the need for long sheaths&#44; then remotely to the tricuspid annulus at the 6 o&#8217;clock position in left anterior oblique view and subsequently to the right ventricle&#44; after which it was gradually withdrawn until an atrial potential was detected on the distal bipole of the ablation catheter&#46; RF energy was then applied at this point and the ablation catheter was progressively withdrawn under remote control to the inferior vena cava &#40;IVC&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The MNS vector was directed downward in the initial portion of the CTI and more anteriorly in the final portion&#44; closer to the IVC &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Using an EP Shuttle RF generator &#40;Stockert&#41;&#44; RF was applied between the distal electrode of the ablation catheter and a cutaneous patch electrode&#44; with a power limit of 70 W and maximum temperature of 55<span class="elsevierStyleHsp" style=""></span>&#176;C in the case of the 8-mm catheter&#44; and a power limit of 50 W and maximum temperature of 45<span class="elsevierStyleHsp" style=""></span>&#176;C with the irrigated catheter&#46; The duration of RF application depended on the disappearance of the atrial potential on the distal electrogram&#44; but was never less than 30 s&#46; Light sedation with midazolam &#40;bolus&#41; or remifentanil &#40;perfusion&#41; was administered during RF application when necessary&#46; Procedure and fluoroscopy times were recorded&#44; procedure time being defined as the interval between venous puncture and removal of the introducer&#46; Acute success was defined as demonstration of bidirectional block in the CTI and non-inducibility of AFL after 30 min&#46; Bidirectional block was demonstrated by documentation of downward activation in the right atrial lateral wall during CS pacing and downward activation in the septum during low-lateral right atrial pacing&#44; as well as a conduction delay across the isthmus&#46; As previously described&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> the minimum conduction delay across the isthmus during CS pacing that demonstrates conduction block in the CTI was taken to be 110 ms &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">If the initial ablation line did not result in CTI block&#44; the line was mapped to detect possible gaps&#44; and if CTI conduction persisted after any gaps were eliminated&#44; additional lines were created in more lateral or septal positions&#46; If bidirectional CTI block could not be achieved&#44; the procedure was considered unsuccessful&#46; All patients remained under surveillance in hospital for 24 hours after the procedure&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The results obtained with an 8-mm tip catheter were compared with those using an irrigated catheter&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Follow-up</span><p id="par0105" class="elsevierStylePara elsevierViewall">Follow-up consultations included clinical assessment between the first and third month after the procedure and then every six months&#46; Holter 24-hour monitoring was performed between the third and sixth month and then at least once a year&#46; Clinical success was defined as absence of palpitations and&#47;or absence of AFL on ECG&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical analysis</span><p id="par0110" class="elsevierStylePara elsevierViewall">Data are presented as means &#177; standard deviation for continuous variables and as frequencies for categorical variables&#46; Categorical variables were analyzed with the chi-square test and continuous variables with the Student&#39;s t test&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Population</span><p id="par0115" class="elsevierStylePara elsevierViewall">Thirty-eight consecutive patients&#44; mean age 61&#177;15 years&#44; 28 male&#44; underwent ablation of typical AFL&#46; Twenty-six had persistent AFL&#46; Nineteen had hypertension&#44; four had coronary disease and had undergone coronary artery bypass grafting&#44; two had non-ischemic dilated cardiomyopathy&#44; one had Ebstein&#39;s anomaly and 12 had no structural heart disease&#46; The baseline characteristics of the two groups &#40;those treated by 8-mm tip catheter and by irrigated catheter&#41; are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; There were no significant differences between the groups&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Mapping and ablation</span><p id="par0120" class="elsevierStylePara elsevierViewall">Ablation was carried out in AFL rhythm in 31 patients and in sinus rhythm in seven&#46; The procedure was successful in 37 patients &#40;97&#37;&#41;&#46; FLA was terminated during the procedure in 30 cases&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Procedure time was 167&#177;59 min and fluoroscopy time was 7&#46;8&#177;5&#46;3 min&#46; The mean number of RF applications was 22&#177;15&#44; with a mean application time of 24&#177;13 min&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The ablation procedure characteristics in the study population are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The success rate was similar in both groups&#44; 94&#37; in the 8-mm tip catheter group and 100&#37; in the irrigated catheter group&#44; as was procedure time&#44; but fluoroscopy time was significantly shorter in the irrigated catheter group &#40;13&#46;4&#177;3&#46;7 vs&#46; 6&#177;4&#46;4 min&#59; p&#60;0&#46;01&#41;&#46; The number of RF applications and total RF application time did not differ significantly between the groups&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Follow-up</span><p id="par0135" class="elsevierStylePara elsevierViewall">There were no procedure-related complications&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">During a follow-up of 32&#177;19 months &#40;6&#8211;60&#41; two patients had relapse of AFL&#44; one in each group &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; One patient refused reablation and in the other the procedure was repeated with an irrigated catheter&#44; which was successful&#46; Six patients developed atrial fibrillation &#40;AF&#41; during follow-up that was treated by ablation&#46; After pulmonary vein isolation&#44; conduction across the CTI was assessed and continuing bidirectional block was confirmed in all patients&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">There were no deaths during follow-up&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">The main finding of this study was that the Niobe II MNS is safe and effective for treatment of AFL&#44; with similar success rates to conventional ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> We also found that 8-mm tip and irrigated catheters are equally effective&#44; which is in agreement with previous studies comparing these two types of catheter for AFL ablation&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Linear CTI ablation&#44; first described by Cosio et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> is the first-line strategy for treatment of typical AFL&#46; The first procedures used a 4-mm tip catheter&#44; but success rates were as low as 67&#37; in some series&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Efforts to improve these figures included the development of 8-mm tip catheters and then irrigated-tip catheters designed to increase the size of lesions&#44; improving success rates&#44; which in some cases have reached 99&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14&#44;16&#44;17</span></a> The high success rates of AFL ablation&#44; together with the poor results of drug therapy&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> have led to catheter CTI ablation becoming a common procedure&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Previous studies comparing conventional AFL ablation with remote navigation-controlled systems showed that the latter produced worse results &#40;91&#37; vs&#46; 84&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In our study&#44; the success rates with the MNS of 94&#37; using an 8-mm tip catheter and 100&#37; with an irrigated catheter are higher than those described with conventional systems&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Previous studies have also shown that procedure time and RF time tend to be longer with the MNS but fluoroscopy time is significantly shorter&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Mean fluoroscopy time in our series &#40;7&#46;8&#177;5&#46;3 min&#41; was also significantly shorter than reported for conventional ablation&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14&#44;16&#44;17</span></a> The longer fluoroscopy time seen in the 8-mm tip catheter group may be due to the greater difficulty in adjusting the larger tip to the anatomy of the CTI&#44; but may also be the result of the learning curve associated with the MNS&#44; since the first cases using the remote system were treated with an 8-mm tip catheter&#46; Randomized trials comparing the two catheter types have shown similar success and complication rates as well as procedure and fluoroscopy times&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Our long-term success rate &#40;5&#37; relapse at 32&#177;19 months&#41; was better than that described for conventional ablation&#44; well below the 10&#46;9&#37; at 13&#46;8&#177;0&#46;3 months of Perez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and the 20&#37; at 21&#177;11 months reported by Blomstrom-Lundqvist et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although we did not assess coagulum formation on the catheter tip in our study&#44; most studies show a tendency for higher prevalence of this complication with 8-mm tip catheters than with irrigated catheters &#40;between 6&#37; and 15&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;12</span></a> For this reason&#44; notwithstanding the good results obtained with the 8-mm tip catheter&#44; the irrigated catheter has been our choice for AFL ablation since it became available for the MNS&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The occurrence of AF following ablation of AFL&#44; although not strictly speaking a relapse of the initial arrhythmia&#44; is a cause of morbidity and hospitalization&#46; The incidence of AF after AFL ablation depends on whether it had occurred before the procedure and on the duration of follow-up&#44; and ranges between 8 and 52&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In our patient population the incidence of AF was 16&#37; in a mean follow-up of 32&#177;19 months&#59; the figure was higher in the 8-mm tip catheter group&#44; but without statistical significance&#44; and may be due to the longer follow-up in this group&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Limitations</span><p id="par0180" class="elsevierStylePara elsevierViewall">The present study was not randomized and included a small number of patients&#44; and no comparison was made with conventional ablation in terms of procedure or fluoroscopy times or efficacy&#46; The comparison between the two different catheter types was performed retrospectively&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">Our study demonstrates that the remote control Niobe II system is safe and effective for AFL ablation&#44; with a high rate of acute success and a low rate of relapse&#46; Irrigated catheters and 8-mm tip catheters were equally effective and safe for the ablation of typical AFL using the MNS&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Ethical disclosures</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Protection of human and animal subjects</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Confidentiality of data</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Right to privacy and informed consent</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:2 [
          "identificador" => "xres407251"
          "titulo" => array:5 [
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            1 => "Introduction and Aim"
            2 => "Methods"
            3 => "Results"
            4 => "Conclusions"
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        1 => array:2 [
          "identificador" => "xpalclavsec383492"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres407252"
          "titulo" => array:5 [
            0 => "Resumo"
            1 => "Introdu&#231;&#227;o e objetivos"
            2 => "M&#233;todos"
            3 => "Resultados"
            4 => "Conclus&#245;es"
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        3 => array:2 [
          "identificador" => "xpalclavsec383491"
          "titulo" => "Palavras-chave"
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          "titulo" => "Introduction"
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          "titulo" => "Methods"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Study population"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Electrophysiological study"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Magnetic navigation"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Mapping and ablation"
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              "titulo" => "Follow-up"
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              "titulo" => "Statistical analysis"
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              "titulo" => "Mapping and ablation"
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              "titulo" => "Follow-up"
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          "titulo" => "Discussion"
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          "titulo" => "Limitations"
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          "titulo" => "Conclusions"
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          "titulo" => "Ethical disclosures"
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              "identificador" => "sec0085"
              "titulo" => "Protection of human and animal subjects"
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            1 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Confidentiality of data"
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              "identificador" => "sec0095"
              "titulo" => "Right to privacy and informed consent"
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          "titulo" => "Conflicts of interest"
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        12 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-10-14"
    "fechaAceptado" => "2014-05-17"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec383492"
          "palabras" => array:4 [
            0 => "Typical atrial flutter"
            1 => "Radiofrequency ablation"
            2 => "Remote magnetic navigation"
            3 => "Stereotaxis"
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        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
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          "palabras" => array:4 [
            0 => "<span class="elsevierStyleItalic">Flutter</span> auricular t&#237;pico"
            1 => "Abla&#231;&#227;o por radiofrequ&#234;ncia"
            2 => "Navega&#231;&#227;o magn&#233;tica"
            3 => "Estereotaxia"
          ]
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      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Remote magnetic navigation has proved to be effective in the ablation of most supraventricular and ventricular arrhythmias&#46; Initial studies reported worse results with this system compared to conventional ablation for atrial flutter&#46; The aim of this study was to assess the acute and long-term success of atrial flutter ablation with remote magnetic navigation and to retrospectively compare the results obtained with an 8-mm tip catheter versus an irrigated catheter&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We studied 38 consecutive patients&#44; mean age 61&#177;15 years&#44; 28 male&#44; who underwent ablation of typical atrial flutter with the Niobe II remote magnetic navigation system &#40;Stereotaxis&#41;&#46; Ablation was performed with an 8-mm tip catheter in 17 patients and with an irrigated-tip catheter in 21 patients&#46; Acute success was defined as the presence of bidirectional isthmus block&#44; and long-term success as absence of symptoms and atrial flutter during Holter monitoring&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Bidirectional isthmus block was achieved in 37 patients &#40;97&#37;&#41;&#44; and the success rate was similar in both groups&#46; Total procedure time was not significantly different between the groups but fluoroscopy time was shorter in the irrigated tip group &#40;13&#46;4&#177;3&#46;7 min vs&#46; 6&#177;4&#46;4 min&#59; p&#60;0&#46;01&#41;&#46; The number of applications and total radiofrequency time did not differ&#46; There were no complications&#46; During a follow-up of 32&#177;19 months there were two relapses&#44; one in each group&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The Niobe II remote control system for ablation of typical atrial flutter is safe and effective in both the short and long term&#46; The 8-mm and irrigated-tip catheters showed similar safety and efficacy&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A abla&#231;&#227;o com sistema de navega&#231;&#227;o magn&#233;tica tem demonstrado ser eficaz em v&#225;rios tipos de procedimentos de abla&#231;&#227;o&#46; Estudos iniciais apontam para uma menor efic&#225;cia deste m&#233;todo na abla&#231;&#227;o do istmo cavo-tric&#250;spide&#46; O objetivo deste estudo foi avaliar a efic&#225;cia imediata e a longo prazo deste m&#233;todo e comparar retrospetivamente os resultados obtidos com o cateter de 8<span class="elsevierStyleHsp" style=""></span>mm com os obtidos com o cateter irrigado&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudaram-se 38 doentes consecutivos&#44; idade m&#233;dia 61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15 anos&#44; 28 homens&#44; referenciados para abla&#231;&#227;o de <span class="elsevierStyleItalic">flutter</span> t&#237;pico com sistema de navega&#231;&#227;o magn&#233;tica Niobe II &#40;Stereotaxis&#41; com um per&#237;odo de seguimento superior a seis meses&#46; A abla&#231;&#227;o foi efetuada com cateter de 8<span class="elsevierStyleHsp" style=""></span>mm em 17 doentes e com cateter irrigado em 21 doentes&#46; O sucesso imediato foi definido como presen&#231;a de bloqueio &#237;stmico bidirecional e o sucesso a longo prazo definido com aus&#234;ncia de sintomas e de <span class="elsevierStyleItalic">flutte</span>r auricular no registo de Holter&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">O bloqueio &#237;stmico bidirecional foi obtido em 37 doentes &#40;97&#37;&#41;&#46; A taxa de sucesso foi semelhante nos dois grupos&#46; O tempo de procedimento n&#227;o diferiu entre os dois grupos&#44; mas o tempo de fluoroscopia foi significativamente inferior no grupo com cateter irrigado &#40;13&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;7<span class="elsevierStyleHsp" style=""></span>min <span class="elsevierStyleItalic">versus</span> 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;4<span class="elsevierStyleHsp" style=""></span>min&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; O n&#250;mero de aplica&#231;&#245;es e o tempo de radiofrequ&#234;ncia foram semelhantes nos dois grupos&#46; N&#227;o foram registadas complica&#231;&#245;es&#46; Ap&#243;s um per&#237;odo de seguimento m&#233;dio de 32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19 meses ocorreram duas recidivas&#44; uma em cada grupo&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O sistema de navega&#231;&#227;o magn&#233;tica Niobe II mostrou-se eficaz e seguro na abla&#231;&#227;o de <span class="elsevierStyleItalic">flutter</span> t&#237;pico permitindo uma taxa de sucesso elevada com uma efic&#225;cia mantida a longo prazo&#46; O cateter de 8<span class="elsevierStyleHsp" style=""></span>mm e o cateter irrigado mostraram-se igualmente eficazes e seguros&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Parreira L&#44; Cavaco D&#44; Carmo P&#44; et al&#46; Abla&#231;&#227;o do istmo cavo-tric&#250;spide com sistema de navega&#231;&#227;o magn&#233;tica por controlo remoto no tratamento do <span class="elsevierStyleItalic">flutter</span> auricular t&#237;pico &#8211; resultados a longo prazo&#46; Rev Port Cardiol&#46; 2014&#59;33&#58;773&#8211;779&#46;</p>"
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      0 => array:3 [
        "identificador" => "nom0005"
        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0065">List of abbreviations</span>"
        "listaDefinicion" => array:1 [
          0 => array:1 [
            "definicion" => array:7 [
              0 => array:2 [
                "termino" => "AF"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">atrial fibrillation</p>"
              ]
              1 => array:2 [
                "termino" => "AFL"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">atrial flutter</p>"
              ]
              2 => array:2 [
                "termino" => "CS"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">coronary sinus</p>"
              ]
              3 => array:2 [
                "termino" => "CTI"
                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">cavotricuspid isthmus</p>"
              ]
              4 => array:2 [
                "termino" => "IVC"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">inferior vena cava</p>"
              ]
              5 => array:2 [
                "termino" => "MNS"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">magnetic navigation system</p>"
              ]
              6 => array:2 [
                "termino" => "RF"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">radiofrequency</p>"
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      0 => array:7 [
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Reference fluoroscopic images on the Navigant workstation in right and left anterior oblique views showing the real-time position of the ablation catheter&#44; without further fluoroscopy&#44; in the cavotricuspid isthmus at the 5 o&#8217;clock position&#44; the automatic vector of the magnetic navigation system &#40;yellow arrow&#41; and the His bundle &#40;yellow point&#41;&#46; OAD&#58; right anterior oblique&#59; OAE&#58; left anterior oblique&#46;</p>"
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1847
            "Ancho" => 3257
            "Tamanyo" => 403650
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Radiofrequency applications &#40;red circles&#41; on the CARTO mapping system&#46; On the right&#44; fluoroscopic image showing the ablation catheter and the magnetic navigation vector&#46; OAD&#58; right anterior oblique&#59; OAE&#58; left anterior oblique&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2090
            "Ancho" => 3257
            "Tamanyo" => 485982
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Pacing by the mid-proximal bipole in the coronary sinus with the mapping catheter on the lateral side of the ablation line&#44; showing a conduction delay of 192 ms in the cavotricuspid isthmus&#46;</p>"
        ]
      ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">AFL&#58; atrial flutter&#59; LVH&#58; left ventricular hypertrophy&#59; RA&#58; right atrial&#46;</p>"
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">76&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">81&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">LVH</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Isolated AFL</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Medication</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oral anticoagulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Amiodarone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Propafenone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Flecainide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Beta-blockers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab634572.png"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the study population&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">AFL&#58; atrial flutter&#59; RF&#58; radiofrequency energy&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">8-mm tip catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Irrigated catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AFL during ablation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Procedure time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">189&#177;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">151&#177;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fluoroscopy time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;4&#177;3&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#177;4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46; of RF applications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#177;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#177;14&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RF application time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#177;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#177;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Success&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#47;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#47;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab634570.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Ablation procedure characteristics&#46;</p>"
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        "identificador" => "tbl0015"
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AFL&#58; atrial flutter&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">8-mm tip catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Irrigated catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Follow-up &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                      "titulo" => "Prospective randomised comparison of irrigated-tip and large-tip catheter ablation of cavotricuspid isthmus-dependent atrial flutter"
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                        0 => array:2 [
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2014.05.006

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	9	5	14
2024 October	43	34	77
2024 September	41	23	64
2024 August	53	27	80
2024 July	42	27	69
2024 June	40	28	68
2024 May	88	17	105
2024 April	78	21	99
2024 March	77	20	97
2024 February	53	18	71
2024 January	33	28	61
2023 December	32	30	62
2023 November	38	25	63
2023 October	31	15	46
2023 September	43	18	61
2023 August	39	18	57
2023 July	37	7	44
2023 June	38	13	51
2023 May	46	22	68
2023 April	29	5	34
2023 March	32	18	50
2023 February	26	23	49
2023 January	38	15	53
2022 December	42	16	58
2022 November	57	18	75
2022 October	38	21	59
2022 September	32	34	66
2022 August	49	24	73
2022 July	42	31	73
2022 June	38	18	56
2022 May	34	33	67
2022 April	37	22	59
2022 March	32	28	60
2022 February	25	23	48
2022 January	32	19	51
2021 December	25	25	50
2021 November	44	36	80
2021 October	29	38	67
2021 September	24	24	48
2021 August	37	20	57
2021 July	27	30	57
2021 June	28	15	43
2021 May	27	30	57
2021 April	39	41	80
2021 March	47	18	65
2021 February	71	17	88
2021 January	36	11	47
2020 December	37	9	46
2020 November	37	13	50
2020 October	24	12	36
2020 September	49	12	61
2020 August	29	4	33
2020 July	62	8	70
2020 June	34	3	37
2020 May	54	6	60
2020 April	37	16	53
2020 March	48	7	55
2020 February	115	24	139
2020 January	48	10	58
2019 December	45	10	55
2019 November	39	10	49
2019 October	46	4	50
2019 September	113	11	124
2019 August	43	6	49
2019 July	39	11	50
2019 June	35	18	53
2019 May	38	11	49
2019 April	36	15	51
2019 March	43	8	51
2019 February	57	17	74
2019 January	54	7	61
2018 December	74	11	85
2018 November	104	10	114
2018 October	154	19	173
2018 September	32	12	44
2018 August	48	16	64
2018 July	44	12	56
2018 June	35	13	48
2018 May	78	10	88
2018 April	60	9	69
2018 March	85	6	91
2018 February	79	11	90
2018 January	37	4	41
2017 December	128	5	133
2017 November	47	11	58
2017 October	52	14	66
2017 September	43	12	55
2017 August	54	14	68
2017 July	47	11	58
2017 June	62	17	79
2017 May	74	12	86
2017 April	32	6	38
2017 March	51	30	81
2017 February	56	10	66
2017 January	37	12	49
2016 December	48	16	64
2016 November	44	11	55
2016 October	49	13	62
2016 September	70	9	79
2016 August	2	11	13
2016 July	14	10	24
2016 June	19	13	32
2016 May	13	8	21
2016 April	30	2	32
2016 March	45	15	60
2016 February	62	34	96
2016 January	46	25	71
2015 December	42	30	72
2015 November	50	27	77
2015 October	44	26	70
2015 September	42	27	69
2015 August	41	24	65
2015 July	34	17	51
2015 June	14	10	24
2015 May	34	28	62
2015 April	41	25	66
2015 March	30	22	52
2015 February	37	24	61
2015 January	95	52	147

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