Ablating Afib 4000 miles away!

May 19, 2006

*Boston, MA* - One of the concepts behind robotic and magnetic navigation

in electrophysiologic procedures is to allow tired EPs under the heavy

strain of lead to get off their feet and work remotely. That concept was

taken to extremes this week at the *Heart Rhythm Society* (HRS) *2006

Scientific Sessions* as *Dr Carlo Pappone *(San Raffaele University

Hospital, Milan, Italy), working the controls in Boston, MA, performed a

live AF ablation on a patient almost 4000 miles away in Milan, Italy.

" Very few physicians are able to treat patients with atrial fibrillation

because the learning curve for this procedure is very long, " Pappone told *

heart**wire*. " As magnetic navigation technology becomes more readily

available and cheaper to install and use, it will increase the number of

physicians able to ablate atrial fibrillation. To shorten the learning

curve, we need to create a strategy to support the new centers to get them

trained more quickly and to provide them with experienced centers as backup.

A satellite setup like this would permit a new center to be guided by very

expert centers. The patient can benefit from doctors with the most

experience in this field. "

*Ablating atrial fibrillation 4000 miles away*

Not surprisingly, the live case demonstration had a large " wow " factor

attached to it, with many meeting attendees impressed by the technology. In

addition to the distance, ablation of AF is typically not a very easy

ablation procedure, but Pappone was able to complete the case in under an

hour, a time that is extremely difficult for most operators to accomplish

manually.

Speaking with *heart**wire*, Pappone said the male patient was 34 years old

and had a history of juvenile AF. He had previously failed antiarrhythmic

drug therapy with flecainide, sotalol, and propafenone alone or in

combination and was in persistent AF—experiencing daily symptomatic

episodes—since June 2005. Heart function and structure were normal.

A senior clinician and staff, present in the Milan lab and ready to

intervene should complications arise, inserted the catheter into the groin.

From there, Pappone took over the controls in Boston and via a secure

satellite link was able to manipulate the catheter with the magnetic

navigation system (Stereotaxis, St Louis, MO) to perform the ablation.

Pappone completed the ablation in 50 minutes, and the whole procedure was

performed without complications.

There was a slight lag—the time between moving the controls in Boston and

the eventual movement of the catheter in Milan—of approximately 1/10 of a

second, but this did not interfere with the ability to perform the

procedure. Asked why he wanted to participate in such a unique live case,

Pappone said it was important to show that it could be done. He envisions

the remote aspect of the system being used to teach other

electrophysiologists in different cities, countries, and continents, working

with them to treat, guide, or provide support in their earliest AF-ablation

cases.

To prepare for the case, Pappone said he conducted practice sessions at a

training facility, remotely using the system approximately 100 m away from

the cath lab.

*Cost still an issue*

While many meeting attendees were impressed by the technology, some wondered

whether using the system remotely, from the US or Europe and connected to a

distant smaller center, is feasible in the real world. The biggest obstacle,

naturally, is that the regional hospital would require the magnetic guidance

system to be in place. With the system costing approximately $2 million,

this is not always in the budget. Still, Pappone is an optimist and

envisions more and more hospitals and private practices gaining access to

the technology.

" I think the cost is mainly due to the installation and the need to create a

special room for the magnets and to shield the wall of this room, " he said.

" In the near future, in the next six to 12 months, the system is going to

get smaller and will be easier to install. You're not going to need such an

extensive installation. With that, the cost is likely to come down, probably

to where it is one third of what it is today, and that will allow more

hospitals to get the system in place. "

Commenting on the live case for *heart**wire*, *Dr Anne Curtis* (University

of South Florida, Tampa), the outgoing president of the HRS, said that the

distance between the patient and Pappone was attention-grabbing. She said it

is possible for such systems to be used as a teaching tool with less

experienced centers, especially if it allowed them access to high-volume

operators and their expertise, but that there are barriers. " Right now, cath

labs are expensive enough, and this greatly increases the cost, " she said.

In a separate symposium, *Dr Walid Saliba* (Cleveland Clinic) took the

podium to answer the million-dollar question concerning robotic and magnetic

navigation: is it worth the money? According to Saliba, making his

conclusions at the beginning of his presentation rather than at the end, the

answer is obvious.

" If you have the money, go for it, " said Saliba.

During the well-attended session, Saliba said new technology ultimately

comes down to whether the new systems are safe and as efficacious as

existing methods and whether or not they offer an advantage over manual

navigation. He noted that with AF ablation, clinicians often struggle with

keeping the catheters in position as well as accessing difficult-to-reach

locations. Both robotic and magnetic navigation offer advantages here, as

the catheters can be deflected easily and held in place better than by

manual navigation, he said. In addition, the data are continuing to support

the use of robotic and magnetic navigation for successfully treating various

arrhythmias, often with less fluoroscopy time, he said.

May 19, 2006

Great...

One more thing that can be " best shored "