Abstract
Electrophysiological stimulation and ablation is currently performed with manually deflectable catheters of different lengths and curves. Disadvantages of conventional therapy are catheter stiffness, limited local stability, risk of dislocation or perforation, and reduced tissue contact in regions with difficult access. Fluoroscopy to control catheter movement and position may require substantial radiation times.
Magnetic navigation was first applied for right heart catherization in congenital heart disease in 1991; the first electrophysiological application took place in 2003. Today, an ablation electrode with small magnets is aligned in the patient’s heart by two external magnets positioned at both sides of the thorax. Antegrade and retrograde movement of the distal catheter tip are performed via an external device on the patient's thigh. Three-dimensional MRI scans acquired before intervention can be merged with electroanatomical reconstruction, leading to further reductions of radiation burden. During treatment of supraventricular tachyarrhythmias high local precision of magnetically guided catheters, good local stability, and a substantially reduced radiation time have been reported. First applications in ventricular tachyarrhythmias and complex congenital cardiac defects indicate a comparable effect. Limitations of this therapy are the application in left atrial procedures (open irrigated ablation catheters not yet available), difficult transaortic retrograde approach (high lead flexibility), and the considerable costs.
Magnet-assisted navigation is feasible during percutaneous coronary interventions of tortuous coronary arteries and in positioning guidewires in coronary sinus side branches for resynchronisation therapy. Future applications will be complex left atrial procedures, magnetically guided cardiac stem cell therapy, local drug application, and extracardiac vessel therapy.
Zusammenfassung
In der elektrophysiologischen Diagnostik und Therapie werden Stimulations- und/oder Ablationskatheter mit unterschiedlichen Vorkrümmungen und Längen durch den Arzt mittels integrierter Zugseilsysteme über einen Handgriff bewegt. Nachteile dieser Technologie sind erhöhte Kathetersteifigkeit, eingeschränkte Stabilität im kontrahierenden Herz mit Dislokationsgefahr, selten Perforationsgefahr und ein teilweise schlechter Gewebekontakt in anatomisch ungünstig zu erreichenden Regionen des Herzens. Die erforderliche Röntgendurchleuchtung zur Kontrolle der Katheterlage führt zu einer relevanten Strahlenbelastung für Patient und Untersucher.
Die magnetische Navigation wurde erstmals 1991 bei einem Neugeborenen mit einem komplexen kongenitalen Vitium in der invasiven Diagnostik eingesetzt und 2003 zum ersten Mal während der elektrophysiologischen Untersuchung und Ablationstherapie angewandt. Heutzutage wird durch zwei externe, lateral des Thorax positionierte Magnete ein Ablationskatheter mit magnetischer Spitze im Herzen des Patienten ausgerichtet und über eine externe Führungsschiene vor- und zurückbewegt. Durch die zusätzliche Kombination mit dreidimensionaler präinterventioneller MRT-Bildgebung in Verbindung mit elektroanatomischer Rekonstruktion können die Durchleuchtungszeiten weiter reduziert werden. Bei der Behandlung von supraventrikulären Tachykardien zeigt sich eine hohe Bewegungspräzision und Stabilität mit einer deutlichen Reduktion der Strahlenbelastung. Erste Anwendungen in der Radiofrequenzablation ventrikulärer Tachykardien deuten auf eine ähnliche Effektivität hin, ebenso erste Applikationen bei komplexen kongenitalen Vitien. Limitationen stellen derzeit der eingeschränkte Einsatz bei linksatrialen Prozeduren infolge nicht verfügbarer offen gekühlter Kathetersysteme, ein aufgrund der erhöhten Katheterflexibilität erschwerter retrograd transaortaler Zugangsweg und letzlich der erhebliche Kostenaufwand dar. Neben dem Einsatz in der interventionellen Therapie komplexer Koronarstenosen und der Implantation linksventrikulärer Elektroden zur Resynchronisationstherapie sind künftige Anwendungsgebiete komplexe linksatriale Prozeduren, die Stammzelltherapie und Anwendung in anderen extrakardialen Gefäßregionen.
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Schimpf, R., Reents, T., Hessling, G. et al. Magnetische Navigation in der elektrophysiologischen Diagnostik und Therapie. Herzschr. Elektrophys. 18, 157–165 (2007). https://doi.org/10.1007/s00399-007-0575-8
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DOI: https://doi.org/10.1007/s00399-007-0575-8