Issue link: https://viewer.e-digitaledition.com/i/556451
+++++++++++++++++++++++++++++++++++++ + +++ + +++ +++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: PEDIATRICS ❯ C AT H E T E R A B L AT I O N U S I N G fluoroscopy has become com- monplace over the last two decades as a minimally invasive surgical approach to address arrhythmia. Yet, as technology has advanced, so too have the possibilities of other approaches to catheter ablation, which offer benefits to patients and medical personnel. Three- dimensional (3-D) electrophysiology (EP) mapping is emerging as a potentially safer, cost-effective treatment for arrhythmia, especially in children. With fluoroscopy, a cardiologist uses X-ray beams transmitted to a monitor to provide direction from the point of catheter insertion to the affected heart tissue. The procedure generally takes two to four hours and must be performed in an EP lab or a cath lab. Additionally, medical personnel wear lead-covered shields and eye protection to limit radiation exposure. While the radiation exposure is rela- tively minimal, the effect of fluoroscopy on young patients cannot be fully determined. Ultimately, any radiation exposure carries a lifetime cancer risk. Effects may carry over to offspring as well. Younger children tend to have more complex cases compared to adults, so their radiation exposure may be greater. Another concern among pediatricians is that children requiring catheter ablation may also require other medical procedures or diagnostic testing involving radiation. Over the last decade, cardiologists have been working toward an alterna- tive to fluoroscopy. Three-dimensional electrophysiology mapping has emerged as a viable option. With 3-D mapping, the cardiologist has a real-time view of the catheter as it is threaded through the vein and into the heart. With this continuous view, the procedure time tends to drop. The 3-D mapping approach also has significant implications for medical per- sonnel. Since radiation is not involved, the procedure can take place in an operating room, and staff do not need to wear the same radiation-limiting gear. Since 2012, Akron Children's Hospital has maintained a database involving seven participating children's hospitals nationally and internationally to chart the success rates and procedure dura- tions for cardiac patients. To date, just over 80 percent of patients undergoing catheter ablation are receiving zero fluoroscopy. The average radiation time for all 1,400 database patients was less than two minutes. In the benchmark "Prospective Assessment After Pediatric Catheter Ablation" report from 2004, radiation time was 38.3 minutes, so this demonstrates a >95 percent decrease in radiation exposure compared to the national standard. This technique has implications for medical treatment in developing coun- tries, as well. For example, at Akron Children's sister hospital, St. Damien Pediatric Hospital in Haiti, it could be possible to have a completely portable 3-D mapping device to make radiation-free ablations more convenient and available. While the technology is not there yet, certainly advancements are leading in that direction. Some obstacles toward using 3-D imag- ing include cost and training. Hospitals may be reluctant to purchase the nec- essary equipment when fluoroscopy is already available and the radiation risk appears minimal. Cardiologists and medical staff need to complete training as well to use the 3-D imaging device. Further, certain complex arrhythmias require a detailed view of the anatomy not allowed with 3-D imaging. And the procedure is contraindicated for those with implanted devices such as pacemakers. These instances, however, are the exception. As more cardiologists become familiar with radiation-free ablations and trained in the 3-D mapping procedure, it will likely become the procedure of choice among healthcare providers not just for children but also adults. In 10 years, I believe it will be rare for any radiation to be used. And that shift is good for everyone. Dr. John Clark is a board-certif ied, fellowship-trained pediatric cardiologist. He is the director of the Akron Children's Hospital Pediatric Arrhythmia Center. ■ Benefi of Radiation-Free Catheter Ablation in Children By John Clark, MD 2 0 | Cleveland/Akron/Canton MD NEWS ■ M D N E W S . CO M ■ S E P T E M B E R /O C T O B E R 2 0 1 5