Abbott EP Product Portfolio Equipment

RAO

Right Anterior Oblique

• Spine is on the left

• CS catheter pointed away

• long axis view of HRA, HIS, RVA

• Posterior to Anterior

LAO

• Left Anterior Oblique

• HIS points directly at us

• Spine is on the right

• CS catheter forms a smile

AP

• Anteriorposterior

• RA forms a left cardiac border

• spine is in the middle

• LVOT forms right cardiac border

Fluoroscopy (FLURO)

• RAO, LAO, AP

• radiation flows from the X ray tube to the image intensifier

• structures that resist the flow of radiation (higher density) have increased opacity

• bones are whiter than soft tissue

• ALARA (As low as reasonably achievable)

Intracardiac Ultrasound (ICE)

• Probe maneuvered within the heart to:

• guide catheters and visualize blood flow

• assist in transseptal complication

Benefits: no radiation required

limitations:

• clarity is dependent on transducer type and distance of structure to probe

• requires groin access

ICE Home View

ICE Transseptal view

Echocardiography (ECHO)

How it works:

• transducer: houses piezoelectric crystals

• crystals vibrate when stimulated by an electrical current

• crystal produce mechanical ultrasound waves (high frequency sound pressure waves)

• ultrasound waves echo back to crystals

• crystals convert waves - electrical current with varying brightness based on density

Examples:

ICE

TEE

Computed Tomography (CT)

• cross sectional slices are digitally stacked together to form a 3D image of the patient’s heart

• benefits: provides detailed patient anatomy prior to the case/ catheter placement

• limitations: relies on radiation and contrast

• static image of a dynamic structure

• uses gating to image at one portion of the cardiac cycle

• slice thickness and spacing determine image resolution

Scanning Planes

Coronal: divides structure from front to back

Transverse: divides the structure into upper and lower portions perpendicular to the long axis

Sagittal: divides structure vertically through the long axis creating right and left

SR (Swartz series right sided)

• fixed sheath

• Swartz right sided

• typical RA AFL

• Accessory pathways and focal tachycardias located along the TVA

Series: (the number determines the curve so 4 has the largest curve)

• SR0

• SR1

• SR2

• SR3

• SR4

RAMP (right sided)

• fixed sheaths

• Right Atrial multi-purpose

• CTI dependent flutter

• orients catheter tip perpendicular against the tissue

Series

• RAMP

• RAMP1

SAFL (right sided)

• fixed sheath

• S-shaped/ atrial flutter

• provides excellent stability on the CTI

• Orients catheter tip flat against the tissue

• S- shape shaft stabilizes sheath in IVC

SEPT (right sided)

• septal

• helps place ablation catheter on the septal CTI

• Orients catheter tip flat against the tissue

• S-shape shaft stabilizes sheath in the IVC

CSTA (right sided)

• crista terminalis

• useful for mapping and ablation in the high right atrium

• guides to the crista terminalis and RA free wall

SL (left sided)

• Swartz Left sided

• designed to contour the left atrium

• braided (for stability across septum and atraumatic tip)

• 81 cm SL accommodates 89cm length Abbott BRK transseptal needles

Series:

• SL0

• SL1

• SL2

• SL3

• SL4

LAMP (Left sided)

• left atrial multi-purpose

• multiple reach angles provide options for gaining access to the pulmonary veins and mitral isthmus areas

• braided (for stability across septum and atraumatic tip)

series

• LAMP 135

• LAMP 90

• LAMP 45

Agilis NxT Steerable Introducer

• 8.5 F

• Inner Diameter - 8.5F

• Outer Diameter - 11.5F

Qualities:

• auto lock steering

• offset venting holes

• atraumatic tip

Agilis Curl Options

curl options:

• small: 61cm

• medium: 71cm

• large: 82cm

Deflection:

• bi-directional: 180 and 90 degree deflection

• no alignment knotch on handle

Why use Agilis Nxt 8.5F?

Efficacy:

• higher acute ablation success rates

• higher rate of complete pulmonary vein isolations

• fewer acute PV reconnections

• higher rate of bidirectional MI block and decreased need for CS ablation

Contact force:

• higher average contact force in AF ablation

• shorter AF procedures with CF catheters in severe LA enlargements

• fewer acute left PV segment reconnections

Time:

• shorter procedure time in AF and flutter ablations

• shorter fluoro time

• shorter RF energy time

Reoccurrence:

• fewer chronic PV reconnections

• lower rate of AF re ablation

• lower rate of cardioversion after AF ablations

Competitor for Agilis?

Carto Vizigo:

• 8.5F/ 11.5F outer diameter

• 71cm useable length

• braided sheath

• small, medium, and large curve

• rotating collar handle, deflects the tip clockwise 180 and counterclockwise 180

• advantages: has electrodes on the outside of the sheath to allow for visualization on the Carto System

Agilis NxT steerable introducer Dual Reach 13F

• inner diameter: 13F

• outer diameter: 17.5F

• atraumatic tip: reducing the stepdown when crossing the septum

• 6 offset venting holes: 4 distal and 2 that are more proximal

• material transition: 6 inches from deflectable shaft to create a more pliable tip

• bidirectional rotating collar

• 3-war stopcock: for air or blood aspiration, fluid infusion, blood sampling

• braided shaft

Curl options for Agilis Steerable Dual Reach

small: 18.4

medium: 24.8

large: 45.1mm

total length: 91cm

useable length: 71cm

fill volume: 15cc

Who is the competitor for the Agilis Dual Reach 13F

Boston Scientific Faradrive

• paired with farapulse and versacross

• inner 13F, outer 16.8F

• useable length: 74cm

• overall length: 91cm

• radio opaque tip marker

• bidirectional steering

Transseptal Needles

BRK and BRK-1

• usable length options: 71cm, 89cm, 98cm

BRK XS and BRK-1 (extra sharp)

• usable length options: 71cm, 89cm, 98cm

Competitor to BRK transseptal needles?

Boston Scientific VersaCross

• access product includes:

• VersaCross RF wire ( J-tip or Pigtail)

• RF connector cable

• Versacross transseptal sheath (8,5F)

• Dilator

• 0.035 guidewire

• clinical advantage: less manual force needed

Ensite X surface electrode kit

• 6 locating electrodes and 4 patient reference sensor patches

• 1 system reference electrode

• 1 right leg ECG electrode

System Reference Electrode

what does it do?

• serves as our systems electrical reference for impedance and ECG measurements

Placement

• the electrode is places on the patient’s abdomen

• should be the first and last electrode to be connected/ disconnected

• this is sometimes put on the patients back because of the belly button interference (no air should be under the patch)

Right leg ECG Electrode

what does it do?

• serves as the right left 12 lead ECG electrode during a procedure

• cancels out powerline noise that may be picked up by the system reference

placement?

• RL ECG placed on the patients right left

• sometimes moved into inner thigh so physician doesnt constantly bump it

What are the locating electrodes?

• 6 electrodes impart low intensity currents generated by the amplifier

• supports the acquisition of impedance signals used for locating EP catheters

• the locating electrodes work in patch pairs

placement:

left (red)

right (orange)

front (black)

neck (back of neck sometimes on traps) (green)

back (brown)

Lleg (blue)

Patient Reference Sensors (PRS) Patches

• patches are used to secure PRS sensors on the patient

• usage: patches are single use and included in the kit

• PRS sensors are reusable and part of the system hardware

Placement

• front: 1 patch holds the anterior PRS (PRS-A) which detects metal distortion

• Back: 3 patches hold posterior PRS sensors (PRS - P2, P3) forming a triangle

• the center of the triangle defines the magnetic coordinate systems zero points

PRS Placement

• green side up

• the anterior patch guidelines:

• must not be inclined more than 45 degrees relative to the patient table

Diagnostic EP Catheters

• solely for diagnostic purpose and are not designed for RF energy delivery

• catheters are named by their number and electrodes

• catheters are measured (F size) by their outer diameter

What are the diagnostic catheter families?

Fixed:

• supreme

• response

Steerable:

• LiveWire

• Inquiry

Circular:

• Inquiry AFocus II double loop

Supreme and Response Catheter Curves

• JSN

• JSN-1

• CRD

• CRD-1

• CRD-2

• CSL

• DAO

• DAO-1

• STR

fixed diagnostic cath

Inquiry AFocus II Double Loop

shaft/handle:

• 7F shaft

• push/pull plunger handle

• unidirectional 180-degree deflection

loop:

• fixed loop catheter

• 20mm, 4F loop

• 20 electrodes with equidistant 4mm electrode spacing

• not indicated for retrograde access or ventricular use

What is the PA interval and how long should it be?

• the PA interval is a measure from onset of the p wave on surface ECG to rapid depolarization of A wave on HIS catheter

• 35-45 msec

• the time it takes for signals to travel from the SA node to AV node

What is the A-H interval and how long should it be?

• measure from A signal to onset of H deflection on HIS catheter

• time for electrical signals to travel through AV node

• 70-80 msec

Normal signal sequence in normal sinus rhythm?

HRA- HIS - CS - H deflection - RVA - HIS V and CSV

• Lead II can be used to locate the “surface p wave”

What is the normal PS interval?

• 120 - 200 msec

• from the start of atrial depolarization to the start of ventricular depolarization

What is the normal QRS interval?

• < 120 msec

• time for ventricular depolarization

What is the normal HV interval?

• 35 - 55 msec

• earliest deflection of HIS to the onset of earliest ventricular signal on any channel

Where is each precordial lead located?

V1 - 4th intercostal space, right of the sternum

V2 - 4th intercostal space, left of the sternum

V3 - midway between V2 and V3

V4 - 5th intercostal space, midclavicular line

V5 - 5th intercostal space, anterior axillary line

V6 - 5th intercostal space, midaxillary space