What are the guidelines for using transcatheter electrosurgery in interventional cardiology procedures?

Guidelines for Transcatheter Electrosurgery in Interventional Cardiology Procedures

Transcatheter electrosurgery should be performed by a multidisciplinary heart team with specialized training in interventional cardiology procedures, using appropriate imaging guidance and following a carefully planned procedural approach to ensure patient safety and optimal outcomes.

Multidisciplinary Team Requirements

Transcatheter electrosurgery procedures require a comprehensive multidisciplinary team (MDT) approach, consisting of:

• Interventional cardiologist and/or cardiothoracic surgeon with specialized training
• Echocardiography specialist (cardiologist or anesthesiologist trained in interventional TEE and 3D TEE)
• Cardiac anesthesiologist
• Specialized nursing and technical staff
• Heart failure specialist (when applicable)

The MDT should meet regularly to discuss patient selection, procedural planning, and post-procedure care 1. All team members should be involved in pre-procedure planning to discuss:

• Specific procedural steps
• Required tools and equipment
• Potential complications
• Contingency plans for unexpected events

Procedural Applications and Techniques

Transcatheter electrosurgery encompasses several techniques that use radiofrequency energy to:

1. Tissue traversal: Using insulated guidewires with exposed tips to concentrate current for crossing tissue planes 2, 3

   • Applications include:
     • Transseptal access
     • Transcaval aortic access
     • Recanalization of arterial and venous occlusions

2. Tissue cutting/laceration: Using kinked guidewires ("Flying V" configuration) or single-loop snares energized during traction 4, 3

   • Applications include:
     • BASILICA (Bioprosthetic or Native Aortic Scallop Intentional Laceration)
     • LAMPOON (Laceration of the Anterior Mitral leaflet to Prevent Outflow Obstruction)
     • ELASTA-Clip procedures

Imaging Requirements

Proper imaging is critical for transcatheter electrosurgery procedures:

• Transesophageal echocardiography (TEE) should be used for patients undergoing transcatheter intracardiac procedures 1
• 3D TEE is particularly valuable for complex procedures like mitral valve interventions 1
• Intracardiac echocardiography (ICE) may be used as an alternative when TEE is not feasible 1
• Fluoroscopic guidance is used in conjunction with echocardiography

The ASA and Society of Cardiovascular Anesthesiologists strongly recommend TEE during catheter-based valve replacement and repair procedures 1.

Training and Competency Requirements

Operators performing transcatheter electrosurgery should have:

• Completion of an ACGME-accredited interventional cardiology fellowship
• Experience with at least 300 diagnostic coronary procedures prior to interventional training 1
• Specific training in structural heart interventions
• For procedures like PFO/ASD closure, a minimum of 10 procedures during training is recommended 1

Due to the complexity and specialized nature of these procedures, they should be concentrated among a limited number of operators to ensure adequate expertise 1.

Procedural Planning and Execution

1. Patient selection:

   • Comprehensive evaluation by the MDT
   • Assessment of anatomical suitability
   • Evaluation of comorbidities and surgical risk

2. Pre-procedure planning:

   • Detailed review of imaging
   • Selection of appropriate devices and equipment
   • Discussion of potential complications and contingency plans

3. Procedure execution:

   • Use of appropriate anesthesia (typically general anesthesia)
   • Continuous echocardiographic monitoring
   • Careful delivery of radiofrequency energy
   • For tissue traversal, ensure proper insulation of guidewires except at the tip
   • For tissue cutting, use proper "Flying V" configuration or snare technique
   • Consider flooding the field with non-ionic dextrose to eliminate alternative current paths 3

Post-Procedure Care

• Patients should be monitored in an appropriate setting based on risk profile and procedure complexity 1
• High-risk patients or those with hemodynamic/rhythm instability should receive care in a cardiac intensive care setting
• Continued involvement of MDT members throughout recovery is essential
• Follow-up echocardiography should be performed to assess results and monitor for complications

Common Pitfalls and Complications

• Tissue damage beyond the intended target
• Vascular complications
• Cardiac perforation
• Thromboembolic events
• Collateral damage to adjacent structures

To minimize these risks:

• Ensure proper patient selection
• Use appropriate imaging guidance
• Maintain precise control of radiofrequency energy delivery
• Have contingency plans for managing complications
• Ensure immediate availability of surgical backup

Conclusion

Transcatheter electrosurgery represents an evolving field in interventional cardiology that enables novel therapeutic approaches for structural heart disease. Following these guidelines with a well-trained multidisciplinary team and appropriate patient selection can help ensure optimal outcomes while minimizing risks.