Endoscopic ultrasound-guided radiofrequency ablation: An effective and safe alternative for the treatment of benign insulinoma

BackgroundInsulinomas are usually benign, small-sized, well-encapsulated and often solitary pancreatic tumors. Currently, enucleation is the treatment of choice for sporadic solitary insulinoma if diameter is less than 2 cm and the structural integrity of the pancreatic duct can be maintained. However, the procedure has a risk of postoperative complications, and especially of pancreatic fistula. There is growing interest in endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) as an effective and less invasive alternative treatment for benign sporadic insulinoma.MethodWe retrospectively analyzed the efficacy and safety of EUS-RFA in four patients with benign localized insulinoma treated in our tertiary care center between June 2018 and November 2019. EUS-RFA was performed with a EUS-guided RFA 19-gauge needle electrode (Starmed; Taewoong Medical, Seoul, South Korea) that released energy at 50W up to 100 Ohms impedance.ResultsThe series comprised three women and one man, with a median age of 58 years (range 52–82 years). Mean tumor size was 12 mm. Although three of the four patients would have been eligible for surgery, EUS-RFA was proposed to them. Symptomatic and biological improvement occurred immediately, generally straight after the procedure, in all patients, and no serious complications were observed. During the mean follow-up period of 22 months, no symptom recurrence was observed.ConclusionsThis preliminary report in 4 patients showed that EUS-RFA was an effective and relatively safe alternative treatment, devoid of major complications, for benign sporadic insulinoma. Larger-scale prospective multicenter studies are, however, needed to confirm the long-term effectiveness and safety of this novel technique.     

Simultaneous Endocardial and Epicardial Delineation of 3D Reentrant Ventricular Tachycardia

BackgroundMechanisms of scar-related ventricular tachycardia (VT) are largely based on computational and animal models that portray a 2-dimensional view.ObjectivesThe authors sought to delineate the human VT circuit with a 3-dimensional perspective from recordings obtained by simultaneous endocardial and epicardial mapping.MethodsHigh-resolution mapping was performed during 97 procedures in 89 patients with structural heart disease. Circuits were characterized by systematic isochronal analysis to estimate the dimensions of the isthmus and extent of the exit region recorded on both myocardial surfaces.ResultsA total of 151 VT morphologies were mapped, of which 83 underwent simultaneous endocardial and epicardial mapping; 17% of circuits activated in a 2-dimensional plane, restricted to 1 myocardial surface. Three-dimensional activation patterns with nonuniform transmural propagation were observed in 61% of circuits with only 4% showing transmurally uniform activation, and 18% exhibiting focal activation patterns consistent with mid-myocardial reentry. The dimensions of the central isthmus were 17 mm (12 to 28 mm) × 10 mm (9 to 19 mm) with 55% exhibiting a minimal dimension of <1.5 cm. QRS activation was transmural in 63% and located 43 mm (34 to 52 mm) from the central isthmus. On the basis of 6 proposed definitions for epicardial VT, the prevalence of an epicardial circuit ranged from 21% to 80% in ischemic cardiomyopathy and 28% to 77% in nonischemic cardiomyopathy.ConclusionsA 2D perspective oversimplifies the electrophysiological circuit responsible for reentrant human VT and simultaneous endocardial and epicardial mapping facilitates inferences about mid-myocardial activation. Intricate activation patterns are frequently observed on both myocardial surfaces, and the epicardium is functionally involved in the majority of circuits. Human reentry may exist within isthmus dimensions smaller than 1 cm, whereas QRS activation is often transmural and remote from the critical isthmus target. A 3-dimensional perspective of the VT circuit may enhance the precision of ablative therapy and may support a greater role for adjunctive strategies and technology to address arrhythmogenic tissue harbored in the mid-myocardium and subepicardium.     

射频消融治疗肝癌晚期复发的危险因素、模式和生存分析

目的本研究旨在确定肝细胞肝癌(HCC)射频消融术(RFA)术后晚期复发的危险因素、模式和生存率,并建立诺谟图预测无复发生存率(RFS)。方法这项回顾性研究纳入了符合米兰标准的HCC患者398例,在2011年1月~2016年12月行射频消融治疗。采用单因素和多因素分析对临床的变量进行分析。结果中位随访时间58.7个月(24.1~96.0个月),98名患者出现晚期复发。14例患者(14.29%)有局部肿瘤进展(LTP),43例(43.88%)单纯肝内远处复发(IDR),15例(15.31%)单独肝外复发(ER),3例(3.06%)同时存在LTP和IDR,同时存在LTP和ER的6例(6.12%),同时存在IDR和ER的患者17例(17.35%)。无晚期复发患者的总生存率(OS)优于晚期复发患者(P<0.001)。男性、多发性肿瘤、肝硬化是晚期复发的独立危险因素。根据风险因素构建一个准确的诺谟图预测RFS发生。结论男性、多发性肿瘤、肝硬化是HCC射频消融后晚期复发的独立危险因素。晚期复发可能主要是发生在肝硬化背景下的新发HCC。     

Catheter ablation superiority over the pharmacological treatments in atrial fibrillation: a dedicated review

Atrial fibrillation globally affects roughly 33.5 million people, making it the most common heart rhythm disorder. It is a crucial arrhythmia, as it is linked with a variety of negative outcomes such as strokes, heart failure and cardiovascular mortality. Atrial fibrillation can reduce quality of life because of the potential symptoms, for instance exercise intolerance, fatigue, and palpitation. There are different types of treatments aiming to prevent atrial fibrillation and improve quality of life. Currently, the primary treatment for atrial fibrillation is pharmacology therapy, however, these still show limited effectiveness, which has led to research on other alternative strategies. Catheter ablation is considered the second line treatment for atrial fibrillation when the standard treatment has failed. Moreover, catheter ablation continues to show significant results when compared to standard therapy. Hence, this review will argue that catheter ablation can show superiority over current pharmacological treatments in different aspects. It will discuss the most influential aspects of the treatment of atrial fibrillation, which are recurrence and burden of atrial fibrillation, quality of life, atrial fibrillation in the setting of heart failure and mortality and whether catheter ablation can be the first line treatment for patients with atrial fibrillation.     

Relationship of Antenna Work and Ablation Cavity Volume Following Percutaneous Microwave Ablation of Hepatic Tumors

PurposeTo formulate a statistical model relating ablation time, power, and work with posttreatment cavity volume following percutaneous microwave ablation of hepatic tumors in vivo.Materials and MethodsA retrospective review (October 2015 to October 2018) yielded 122 hepatic tumors treated with microwave ablation. Ablation cavity dimensions were measured at 1-month follow-up examination and calculated using an ellipsoid volume formula. The antenna manufacturer (Neuwave Medical, Madison, Wisconsin) provided the activation time and energy used to calculate the antenna work. Generalized estimating equations with ordinary least-squares regression models were obtained to relate tumor volume with cumulative antenna work. Coefficient of determination (R²) and mean square error were used as statistical measures of model prediction performance.ResultsThere is a logarithmic relationship between postablation cavity volume (cm³) and cumulative work (kJ), represented by the formula: log₁₀ cm³ = ?0.4583 + 0.9887 × cumulative work (log10 kJ) (R² = 0.41, mean square error, 0.102). Ablation volumes were predicted as a function of antenna work, calculated using an antilog transformation. When a single antenna was used, ablation cavity volume was predicted using a generalized estimating equation ordinary least-squares regression model of power and time: log₁₀cm³= ?0.0546 + 0.0485 × total time (min) + 0.0107 × power (W) (R² = 0.30; mean square error, 0.106). Using this model, a nomogram was developed to predict the postablation cavity volume based on total activation time and target power.ConclusionThere is a logarithmic relationship between the ablation work and posttreatment ablation cavity volume, which can be expressed in a nomogram when using a single probe.     

Mechanochemical Endovenous Ablation of Varicose Veins in Pediatric Patients with Klippel-Trénaunay Syndrome: Feasibility,Safety, and Initial Results

PurposeTo evaluate feasibility, safety, and results of endovenous mechanochemical ablation (MOCA) for treatment of persistent embryonic and dysplastic veins in pediatric patients with Klippel-Trénaunay syndrome (KTS).Materials and MethodsThirteen MOCA procedures were performed in 11 patients (age range, 4–16 years) with KTS and symptomatic persistent embryonic or dysplastic veins during a 24-month period. All patients were evaluated with color Doppler (CD) ultrasound (US), contrast-enhanced MR imaging, and venography to assess the anatomy of the target vessels and patency of the deep venous system. All procedures were performed under general anesthesia with a ClariVein catheter and liquid sodium tetradecyl sulfate as the sclerosing agent. US and fluoroscopic guidance were used in all cases. Technical success rate, primary occlusion rate, adverse effects, and recanalization rates were evaluated. Clinical and radiological (CD US) controls were performed 1 day, 7 days, 1 month, and 6 months after the procedure and once a year thereafter, with a mean follow-up of 16 months (range, 6–25 months).ResultsTechnical success and primary occlusion were achieved in all patients with no adverse events. During the follow-up period, CD US demonstrated partial recanalization and symptom recurrence in 2 patients (18%), 14 and 18 months after the initial procedure. These 2 patients had a second ablation procedure with no recanalization or symptom recurrence during the subsequent follow-up period.ConclusionsMOCA is feasible and appears to be a safe and effective technique for treatment of varicose veins in pediatric patients with KTS.