Incidence and causes of inappropriate detection and therapy by implantable defibrillators of cardioversion in patients with ventricular tachyarrhythmia

Background Implantable cardioverter defibrillator （ICD） is the only effective therapy in patients with life threatening ventricular arrhythmias. Inappropriate detection and therapy by ICDs are the most common causes of side effects that affect the quality of life in ICD recipients. This study evaluated the incidence and causes of inappropriate detection and therapy by ICDs in patients in our hospital. Methods From January 2000 to December 2005, fifty patients who received ICD implantation for ventricular arrhythmias for prevention of sudden cardiac death were evaluated in this study. Each ICD was programmed using clinical arrhythmic and cardiac data of the patient before discharge. Patients were followed up by standard schedule after implantation and all data retrieved from each device were collected and saved for further analysis. Results No arrhythmic event was detected in 12/50 （24%） patients during the period of follow-up. Among the remaining patients, 11 （22%） experienced inappropriate detections and therapies during follow-up in this study. ICD detected 383 ventricular tachyarrhythmia （VT） and 108 ventricular fibrillation （VF） episodes and delivered 678 therapies. In VT group, ICD delivered 413 antitachycardiac pacings （ATPs） and 118 shocks, among which 78 ATPs and 9 shocks were initiated by 55/383 （14.3%） inappropriate detections. In VF group ICD delivered 147 shocks, among which 56 shocks were initiated by 28/108 （26.9%） inappropriate detections. Overall, more than 50% of these episodes were caused by atrial fibrillation （AF） with rapid ventricular response, followed by electromagnetic or myopotential interference. In addition, most inappropriate therapies occurred within one year after ICD implantation. Conclusions About one fifth of patients experienced ICD inappropriate detection and therapy after implantation. The main cause was AF with rapid ventricular response, followed by electromagnetic or myopotential interference.     

Effect of atrial pacing therapy with selective pacing algorithms on paroxysmal atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia among the elderly. Its incidence increases dramatically with increasing age and decreasing left ventricular function, peaking in subjects with overt congestive heart failure.1 Because of the unsatisfactory efficacy and possible serious side effects of clinically available anti-AF drugs for AF patients with sick sinus syndrome, pacing techniques have recently been applied in the treatment of AF. The cardiac pacemaker Vitatron Selection 900E has special AF diagnostic and prophylactic therapy algorithms. The objective of this study was to use the diagnostic information concerning the onset mechanisms of AF to program the preventive pacing algorithms for each patient individually and to find out whether a reduction in AF burden could be achieved.     

Clinical application of interventional techniques in the treatment of Budd-Chiari syndrome

Objective To evaluate the clinical value of various kinds of interventional techniques in the treatment of Budd-Chiari syndrome (BCS).Methods Multiple techniques such as recanalization of the inferior vena cava (IVC) under the guidance of marker and multi-angled fluoroscopy, recanalization of the hepatic vein with a transjugular approach, PTA, Z-expandable metallic stent (Z-EMS) implantation and modified TIPSS were used to treat 103 patients with BCS.Hesults Of 103 patients with BCS, 59 patients with obstruction of IVC were treated using recanalization of IVC. Seventeen patients with hepatic vein obstruction had their hepatic veins recanalized. The rest of the patients were given other methods of interventional treatment. Of all the subjects, 101 successfully underwent their procedures, with a success rate of 98.06% ; and only 2 failed to recanalization of the IVC. Fifty-three patients were treated using PTA for the first time, with a success rate of 100%. In the 48 patients undergoing Z-EMS implantation for the first time, the success rate was 95.8%. Five patients were treated with modified TIPSS. After these interventional treatments, the success rate was 100%. Two patients died 16 h and 72 h respectively after operation because of DIC and severe hemoptysis. SevenS-two patients were followed up for 1 -94 months (with a mean of 42. 3 months). The mean follow-up of a BCS patient treated with PTA was 52. 1 months, resulting in a primary patent rate of 59.4% and a restenosis rate of 40. 6%. The mean follow-up of BCS treated with stenting was 33.5 months, with a primary patent rate of 87.5% and a restenosis rate of 12. 5%. Eight patients died 7 -64 months after the interventional procedure.Conclusion Flecanalization of IVC or the hepatic vein transjugularly, PTA, Z-EMS implantation and modified TIPSS can be regarded as safe and effective micro-invasive methods in the treatment of BCS.     

Impact of pathogen burden on in-stent restenosis in patients after coronary stent implantation

Background Although some certain infectious pathogens could be detected in the patients with coronary artery disease, the roles of these infectious factors in the development of coronary artery diseases remain largely unknown. Since the number of infectious pathogens has been argued to be relative to the coronary artery diseases, we therefore examined whether there is a link between the number of infections and the incidence of in- stent restenosis after stent implantation. Methods One hundred and eighty-one patients were enrolled in this study. Infectious pathogens including serum anti-Chlymydia p neumoniae, cytomegalovirus, Helico pylori, human herpes simplex virus-1, human herpes simplex virus-2 antibodies and hepatitis B virus antigen were measured in all patients before coronary stent implantation. Coronary angiography was performed before, immediately after and 6 months after stent implantation. Results Restenosis rate 6 months post stent implantation was similar in patients with low pathogen burden （ 〈3 pathagens, 33.3% ） to those with high pathogen burden （ ≥3 pathogens, 29. 1% ）. Conclusions Previous infections with Chlymydia pneumoniae, cytomegalovirus, Helico pylori, human herpes simplex virus-l, human herpes simplex virus-2 and hepatitis B virus do not contribute to the incidence of restenosis after stent implantation.     

RADIOFREQUENCY CATHETER ABLATION OF PERMANENT ATRIAL FIBRILLATION UNDER GUIDANCE OF CARTO-MERGE TECHNIQUE

Objective To investigate the feasibility and effectiveness of radiofrequency catheter ablation (RFCA) to treat permanent atrial fibrillation (AF) under the guidance of Carto-Merge technique. Methods Fifteen male patients with permanent AF underwent RFCA under the guidance of Carto-Merge technique. The mean age was 54.00±10.44 years, and duration of AF was 23.66±14.93 months. Cardiac magnetic resonance angiography (MRA) was performed to obtain pre-procedural three-dimensional (3D) images on the anatomy of left atrium (LA) and pulmonary veins (PVs) before RFCA procedure. Then the electroanatomical map was integrated with 3D images of MRA to form Carto-Merge map that guided step-by-step ablation strategy of permanent AF. Circumferential PV ablation was performed first until complete PVs electric isolation confirmed by Lasso catheter. If AF was not terminated, lesion lines on roof of LA, mitral isthmus, and tricuspid isthmus were produced. Results The episodes of AF were terminated during RFCA in 2 patients, by direct current cardioversion in the remaining 13 patients. Transient AF occurred in 2 patients after ablation on 1st day and 1st week respectively, AF terminated spontaneously not long after taking metoprolol. One patient developed persistent atrial flutter (AFL) in 2 months after procedure and AFL was eliminated by the second ablation. Persistent AF recurred on 1st day, 1st and 5th week respectively in 3 patients, and did not terminate after 3 months even though amiodarone was given. The remaining 12 patients were all free of AF during 2-11 months of follow-up. The recent success rate for RFCA of permanent AF was 80%. Conclusions Carto-Merge technique can effectively guide RFCA of permanent AF. When combined with single Lasso mapping, it can simplify the mapping, lower expenses, and enhance the success rate of RFCA of permanent AF.     

Deciding optimal pacing site: utility of cardiac magnetic resonance imaging

To the editor:We read with great interest the article by Feng and co-authors1 entitled Pacemaker implantation in a patient with noncompaction and aneurysm of right ventricular combination with postclosure of atrial septal defect,which was published in the current issue of Chinese Medical Journal.Authors presented a case of pacemaker implantation in a patient with right ventricular (RV)noncompaction.They mentioned that the echocardiogram is the key method for myocardial noncompaction diagnosis and they offered the optimal pacing site of ventricular electrode should be the intermediate septum of RV due to echocardiographic visualization.This case gives detailed information and highlights the management of pacemaker implantation in a patient with noncompaction.Some comments may be of interest.     

A more than 2-year follow-up of incomplete apposition after drug-eluting stent implantation

Background Incomplete stent apposition （ISA） has been demonstrated to be more common after drug-eluting stent （DES） implantation than after bare metal stent （BMS） implantation, Clinical outcomes of ISA remain controversial and the predictive accuracy of previous studies was limited by the short follow-up period of only 12-18 months. In the present study, we present the outcomes of a more than 2-year follow-up in patients with ISA after DES implantation, Methods From the clinical and core intravascular ultrasound （IVUS） database of the hospital, we identified 76 patients who had undergone DES implantation in de novo lesions between January 2004 and June 2005 and had received IVUS examination at a scheduled 6-month follow-up. A total of 13 （17.1%） patients had documented I SA at the follow-up by IVUS. Clinical follow-up was available up to 41 months after DES implantation and up to 33 months after identification of ISA, Results Over a mean follow-up of （34：~5） months （range 24-41 months）, 3 of the 13 patients （23.1%） suffered from ST elevated myocardial infarction with one death. Angiography confirmed the very late stent thrombosis （ST） in the area with ISA, All the 3 patients were implanted with sirolimus elulJng stents in left anterior descending artery （LAD） and the very late ST occurred at 29, 31 and 32 months after DES implantation, and separately at 20, 23 and 23 months after the identification of ISA, All of the 3 patients had antiplatelet therapy continued before suffering from ST, and had been apparentJy stable on antiplatelet monotherapy with aspirin for a long peried following dual antiplatelet therapy with aspirin and clopidogrel for more than 12 months. Conclusion ISA of DES may be associated with a high incidence of very late stent thrombosis, even in clinically stable patients with dual antiplatelet therapy of at least 12 months after the procedure.     

Efficacy and feasibility of radiofrequency ablation for decompensated cirrhotic patients with hepatocellular carcinoma

Background Most HCC patients with decompensation of liver function lost the chance of surgical and/or interventional treatment. The aim of this study was to evaluate feasibility and outcome of radiofrequency ablation （RFA） in treating hepatocellular carcinoma （HCC） patients with poor liver function （Child-Pugh class C）, who are not suitable for surgery or hepatic artery chemo-embolization.Methods Thirteen HCC patients （the number of tumors was 17） with liver function of Child-Pugh C （scores： 10.2±0.4）were included in the study. Among the patients, 8 were male and 5 were female with the average age of （61.6±10.9）years old. The average size of HCC was （3.8±1.0） cm. Two patients were recurrent HCC and 30.8% of the patients had multiple tumors （2-3 tumors）. All the patients were treated with RFA.Results There were 22 RFA sessions （1-4 sessions per patient） in all, average ablations per tumor at first session was 3.1. One week after RFA, the liver enzymes elevated in 9 patients （69.2%）, in 7 of them, the liver enzyme returned to pre-RFA level in 1-3 months. One month after RFA, the Child-Pugh grading was 10.3±0.8 （Child-Pugh C）, while that of pre-RFA was 10.2±0.4 （Child-Pugh C）, with no significant difference. Computer tomography （CT） one month after RFA showed that the tumor necrosis rate was 88.2% （15/17）. Five patients had 2-4 repeated RFA due to HCC recurrence.During the follow-up of 2-69 months in this group, survival rate of one year was 53.8%, two years was 30.8%, and three year was 15.4%. The incidence of RFA-related complications was 13.6% （3/22 sessions）, including 1 case of GI hemorrhage and 1 sub-capsular hemorrhage of the liver. One patient with HCC over 5 cm who had fever and liver abscess after RFA, and was dead 2 months later due to liver function failure.Conclusions Minimal invasive RFA provides possible treatment modality for HCC patients with poor liver function, who are not candidates for surgical and/or interventional therapy. For large HCC, due to the required extended treatment region, special attention should be paid to the possibility of acute liver failure.     

Endoscopic polypectomy for pacemaker patients.

Endoscopic polypectomy using high frequency voltage is contraindicated in patients with cardiac pacemakers. Recently, highly advanced pacemakers have enabled us to perform endoscopic polypectomy on these patients by taking appropriate cautions. We successfully removed 10 colonic polyps and one gastric polyp in patients with pacemakers by endoscopic polypectomy. No complication and dysfunction of the pacemaker occurred before, during or after the polypectomy.     

Successful treatment with biventricular pacing in a patient with hypertrophic obstructive cardiomyopathy

We report the effects of biventricular pacing in a patient with hypertrophic obstructive cardiomyopathy (HOCM) refractory to medical therapy. A 58-year-old man with HOCM had suffered from dyspnea, chest pain and palpitation for 5 years. Cardiac catheterization showed a left ventricular outflow tract (LVOT) gradient of 80 mmHg. He refused septal myomectomy and the septal ablation was not available. Based on intraoperative pressure measurements, he was implanted with biventricular pacing and LVOT gradient decreased to 10 mmHg. During the follow-up period of 6 months, the patient’s symptoms were markedly improved. Biventricular pacing may be an alternative therapy for patients with HOCM.

     

Results of transvenous lead extraction of coronary sinus leads in patients with cardiac resynchronization therapy

Background The need for transvenous lead extraction procedures of coronary sinus （CS） leads is increasing due to rising numbers of implanted cardiac resynchronization therapy devices during the past decade. Methods From January 2009 to June 2013, 27 CS leads were scheduled for extraction in 27 patients （mean age （63.1±14.6） years）. Indications for lead extraction were infection in 13 and lead dysfunction in 14 cases. Isolated extraction of CS leads was performed in eight, extraction of multiple leads in 19 cases. Among leads with an implant time of 〉12 months （n=19） mean implant duration （MID） was （46.4±15.2） （12-76） months. Groups were formed depending on infectious or non-infectious indications （INF vs. Non-INF）, and the use or non-use of extraction tools （ET1 vs. ET0）. Results Among patients with an implant duration of 〉12 months, complete procedural success was 94.7% and clinical success 100%. Operative mortality was zero. In the INF versus NON-INF groups complete procedural success （100% vs. 91.7%, P=0.43）, mean number of required extraction tools （0.7 （0-2） vs. 0.9 （0-3）, P=0.65） and MID （49.1±15.0 vs. 44.7±15.8, P=0.83） did not differ significantly. Comparing the groups ET1 and ET0 showed no significant differences in complications （n=l vs. n=l, P=-0.81） and MID （47.0±17.5 vs. 45.5±12.6, P=0.71）. Conclusions In specialized centers transvenous lead extraction of coronary sinus leads with a mean implant duration of almost four years can be performed safely and effectively. Neither non-infectious indications nor the use of extraction tools negatively affected the outcome of the procedure.     

Utility of echocardiographic tissue synchronization imaging to redirect left ventricular epicardial lead placement for cardiac resynchronization therapy

Background Cardiac resynchronization therapy （CRT） with biventricular pacing has demonstrated cardiac function improvement for treating congestive heart failure （HF）. It has been documented that the placement of the left ventricular lead at the longest contraction delay segment has the optimal CRT benefit, This study described follow-up to surgical techniques for CRT as a viable alternative for patients with heart failure. Methods Between April 2007 and June 2012, a total of 14 consecutive heart failure patients with New York Heart Association （NYHA） Class Ill-IV underwent left ventricular epicardial lead placements via surgical approach. There were eight males and six females, aged 36 to 79 years （（59.6±9.2） years）. The mean left ventricular ejection fraction （LVEF） was （33.6±7.4）%. All patients were treated with left ventricular systolic dyssynchrony and underwent left ventricular epicardial lead placements via a surgical approach. Tissue Doppler imaging （TDI） and intraoperative transesophageal echocardiography were used to assess changes in left heart function and dyssynchronic parameters. Also, echo was used to select the best site for left ventricular epicardial lead placement. Results Left ventricular epicardial leads were successfully implanted in the posterior or lateral epicardial wall without serious complications in all patients. All patients had reduction in NYHA score from Ⅲ-Ⅳ preoperatively to Ⅱ-Ⅲ postoperatively. The left ventricular end-diastolic diameter （LVEDD） decreased from （67.9±12.7） mm to （61.2±7.1） mm （P〈0.05）, and LVEF increased from （33.6±7.4）% to （42.2±8.8）% （P〈0.05）. Left ventricular intraventricular dyssynchrony index decreased from （148.4±31.6） ms to （57.3±23.8） ms （P〈0.05）. Conclusions Minimally invasive surgical placement of the left ventricular epicardial lead is feasible, safe, and efficient. TDI can guide the epicardial lead placement to the ideal tar qet location.     

Presence of notched QRS on paced electrocardiographs as a predictor of poor response to cardiac resynchronization therapy

Background Cardiac resynchronization therapy （CRT） on patients with advanced and refractory heart failure has made remarkable progress.Clinically,notched QRS （nQRS） is commonly seen on electrocardiographs （ECGs） with bundle branch block morphology and on paced ECGs after implantation of a CRT device,which may reflect the heterogeneity of ventricular myocardial depolarization and electrical activity.The aim of this study was to determine whether patients with more nQRS myocardial segments on paced ECGs had a worse response to CRT than patients with fewer nQRS myocardial segments.Methods We prospectively enrolled 56 patients of CRT with chronic heart failure from People＇s Hospital affiliated to Peking University from January 2007 to October 2013.Based on nQRS segments on ECGs before CRT,we allocated them to two groups：fewer nQRS （〈2） myocardial segments （lateral,inferior,anterior segments） group （F-nQRS,G1,n=23） and more nQRS （≥2） myocardial segments group （M-nQRS,G2,n=33）.Then according to nQRS segments on ECGs after CRT,we divided them into two groups similarly：fewer nQRS （〈2） myocardial segments group （G3,n=24） and more nQRS （≥2） myocardial segments group （G4,n=32）.This study was approved by the ethics committee of People＇s Hospital.Results At 6 months in the baseline-ECG group,there was a greater absolute increase in left ventricular ejection fraction （LVEF） in G2 than in G1 （（11.5±8.9）% vs.（5.5±10.4）%,P=0.023）,with the incidence of nonresponse lower in G2than in G1 （9.1% vs.39.1%,P=0.018）.In the paced-ECG group,the absolute increase in LVEF was less in G4 than in G3 （（6.4±8.8）% vs.（12.5±10.4）%,P=0.024） and the incidence of nonresponse was higher in G4 than in G3 （31.3% vs.8.3%,P=0.039）.Multivariate analysis showed that fewer nQRS （〈2） myocardial segments on paced ECGs （odds ratio 13.920） was a predictor of positive response to CRT.Conclusion nQRS ≥2 myocardial segments （lateral,inferior,anterio     

Association of renal function with cardiac reverse remodeling and long-term outcome in heart failure patients following cardiac resynchronization therapy

Background Renal insufficiency （RI） is significantly associated with clinical prognosis in patients with heart failure （HF）,but direct evidences on the relation between renal function and clinical outcome in patients receiving cardiac resynchronization therapy （CRT） are limited.The aim of the current study was to systematically evaluate the association of baseline and 6-month renal function with cardiac reverse remodeling and long-term outcome after CRT.Methods We retrospectively evaluated 190 consecutive patients who underwent CRT at Fuwai Hospital from January 2008 to April 2013.Renal function tests,echocardiographic measurement,and clinical parameters at baseline and after 6 months of CRT were performed.Primary endpoint events included all-cause mortality,cardiac transplantation,and unplanned hospitalizations for HF.Results At baseline,compared with normal renal function or mild RI （estimated glomerular filtration rate （eGFR） 〉-60 ml·min-1·1.73 m-2）,moderate-to-severe RI （eGFR 〈60 ml·min-1·1.73 m-2） exerted a negative influence on cardiac reverse remodeling parameters.At 6-month follow-up,114 （60.0%） patients were classified as responders and showed significant renal function improvement,whereas renal function deteriorated in non-responders and subsequently 41 （25.6%） patients developed worsening renal function （WRF）.During the mean follow-up of （24.3±17.1） months,both patients with baseline eGFR 〈60 ml·min^-1·1.73 m^-2 and those with WRF experienced worse event-free survival （P 〈0.01,respectively）.Conclusions：This analysis identified that baseline eGFR as well as WRF after CRT were found to be independent determinants of the combined endpoints of all-cause mortality and HF-related hospitalizations in CRT recipients.     

Effect of ventricular leads position on the clinic outcome of cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is an effective treatment for heart failure patients with severely obvious left ventricular ejection fraction (LVEF) and evidence of cardiac dyssynchrony.1-3 With conventional biventricular stimulation,notable left ventricular (LV) reverse remodeling,the most reliable predictor of long-term survival in CRT patients,is achieved in only 60％-70％ of the patients.4,5 Lack of LV dyssynchrony,non-optimal position of the LV pacing lead,high-myocardial scar burden,and sub-optimal device programming have been related to non-response to CRT.6-8 Particularly,the optimal placement of LV lead in a tributary of the coronary sinus is one of the most challenging technique of CRT device implantation.This article will discuss the effect of ventricular leads on the clinic outcome after CRT and how to locate the optimal ventricular leads to maximize the haemodynamic benefits of CRT and provide superior longterm outcome.     

HGF percutaneous endocardial injection induces cardiomyocyte proliferation and rescues cardiac function in pigs

Objective：To investigate the effect of cardiomyocyte proliferation induced by human hepatocyte growth factor（HGF）in pigs with chronic myocardial infarction（CMI）.Methods：A steerable,deflectable 7F catheter incorporating a 27-guage needle was advanced percutaneously to the left ventricular myocardium of 18 pigs with CMI.Pigs were randomized（1：1：1）to receive adenoviral vector HGF（total dose,1×10^10 genome copies）,which was administered as five injections into the infarcted myocardium（total,1.0 mL）,or saline,or Ad-null（control groups）.Injections were guided by Ensite NavX left ventricular electroanatomical mapping.HGF and cyclin proteins were detected by western blot and immunoprecipitation analysis.Histological and immunohistochemical analysis determined proliferating cardiomyocytes.Myocardial perfusion and cardiac function were estimated by Gated-Single Photon Emission Computed Tomography（G-SPECT）.Results：Western blot analyses showed that HGF were predominantly expressed in the infarct core and border in the myocardium of the infarcted heart.G-SPECT analysis indicated that the HGF group had better cardiac function and myocardial perfusion four weeks after the injection of Ad-HGF than before the injection of Ad-HGF.After treatment there were more proliferating cardiomyocytes in the HGF group compared to either of the control groups.Furthermore,the HGF group myocardial samples expressed higher levels of p-Akt,cyclin A,cyclin E,cyclin D1,cdk2,cdk4 than those in the control groups.Conclusion：The over-expression of HGF activates pro-survival pathways,induces cardiomyocyte proliferation,and improves the perfusion and function of the porcine CMI heart.     

Clinical results of tricuspid valve replacement — a 21-case report

Objective： To summarize the clinical experiences of 21 patients treated with tricuspid valve replacement （TVR） and investigate the surgical indications and methods. Methods： Data from 21 patients who underwent TVR from December 2002 to March 2009 were retrospectively collected and analyzed. The mean age was 48.86± 15.37 years （range： 20-72 years）. The underlying disease of the patients was classified as rheumatic （n = 10）, congenital （n = 8）, endocarditis （n = 2） or chest trauma （n = 1）. Previous cardiac surgery had been performed in 12 patients （57.14%）. Results： In-hospital death occurred in two patients （9.52%）. Postoperative morbidities included cardiac failure （n = 2）, bleeding related re-operation （n = 1）, and plural effusion （n = 2）. Conclusion： The early outcomes of TVR were acceptable. At the present time TVR can be performed through optimal perioperative management.     

Atrial fibrillation

Atrial fibrillation is the most common arrhythmia affecting patients today. Disease prevalence is increasing at an alarming rate worldwide, and is associated with often catastrophic and costly consequences, including heart failure, syncope, dementia, and stroke. Therapies including anticoagulants, anti-arrhythmic medications, devices, and non-pharmacologic procedures in the last 30 years have improved patients＂ functionality with the disease. Nonetheless, it remains imperative that further research into AF epidemiology, genetics, detection, and treatments continues to push forward rapidly as the worldwide population ages dramatically over the next 20 years.     

Asymptomatic Paget’s disease of bone presenting with complete atrioventricular block

Paget＇s disease of bone is a deforming bone disease （osteitis deformans） characterized by increased bone remodeling, bone hypertrophy, and abnormal bone structure, leading to bone expansion, deformities, easy fractures, and occasionally, neoplastic transformation. It is the second most common bone disorder after osteoporosis. The disease is relatively rare in Asia but is common in Europe and North America, affecting approximately 2% of the population over 50 years,     

Successful treatment of acute hemorrhagic cardiac temponade in a patient with hepatocellular carcinoma during percutaneous radiofrequency ablation

Radiofrequency ablation （RFA）, especially percutaneous RFA （PRFA）, is a novel technique for the treatment of hepatocellular carcinoma （HCC） that is becoming increasingly more popular because of its feasibility, effectiveness, repeatability, and safety.1 The complications of PRFA mainly include pneumothorax, hemopneumothorax, visceral organ perforation, liver abscess, bile duct injury,