| With the rapid development electrophysiological examination (Electrophysiology Study, EPS) and radiofrequency ablation (RFCA) for the decades,it has been a common technology for arrthmia diagnosis and treatment. In the oprations, a coronary sinus (CS) electrode is essentially preproposed as a landmark. The Coronary Sinus electrodes is usually catheterised through the subclavian vein access with a fixed curve coronary sinus electrode,but such approach is complained for following deficiencies:1. As lacking of direct location mark for subclavian vein puncture, usually it is empirically located by the clavicle for their spacial relationship. And is prone to pneumothorax and hemopneumothorax, miss inserting into the subclavian artery and other serious complications for its closely near the lung, pleura and the subclavian artery. The the puncture point can not well oppresed, with is troublesome when the sheath is miss inserted into subclavian artery, may lead to massive hemorrhage and death.In addition, the variation of subclavian vein, particularly common in older patients, adds the difficulty of the puncture; 2. The subclavian vein access is with a fixed coronary sinus electrode, the placement can be even difficult when the coronary sinus variates or atrial enlarges. As the anatomically far away for organs, puncture of femoral vein can avoid the pre-mentioned complications. With a steerable catheter.increased electrode control ability comparing the fixed one, the femoral vein access is becoming widely used. This study is to compare the effectivity and security of the two accesses, and to determine the better one.Methods:Study designWe retrospectively analysised six hundred and forty-one consecutive patients undergoing electrophysiological study or radiofrequency catheter ablation in our department from January,2010 to May,2012 underwent CS catheterization with either the femoral vein access (FVA) with a steerable curve deca-polar catheter(n=321) or the subclavian vein access (SVA) with a fixed curve deca-polar catheter (n=320).Veins punctureAfter pre-opration examinations and informed consent was obtained, the procedures were proformed. Subclavian vein puncture:Patients recumbent position without pillow, the puncture site was at lcm below the junction of the inner and middle thirds of the clavicle. The puncture is proformed by the Seldinger method. The needle is kept parallel with chest or have a angle less than 30°and inserted towards the gap between of sternum incisure and the thyroid cartilage with a negative pressure. A 6F sheath was inserted after verify the wire was in the superior vena cava. A fixed electrode was placed into the CS after washing the sheath with saline.Femoral vein puncture:The puncture site was at 2-3 cm below the middle point of the inguinal ligament and 0.5 cm inner to the femoral artery. The needle is kept a angle 30°-45°with the skin. A steerable electrode was placed into the CS after a 6F sheath was inserted. Successful puncture is defined as successfully established the expected venous approach without a related complications; Failed puncture:expected venous approach has not been established or is with a related complications; succeed and failed coronary sinus electrode placement respectively defined as successful and failed to place electrodes into the CS after a venous approach has already been established; overall success rate:succeed both in vein puncture and electrode placement without complications. The puncture success rate, coronary sinus electrode placement success rate, time expenditure, and complication rates were compare the two groups.Analysis:All analysis was performed with the use of SPSS software version 13.0. Continuous variables are expressed as mean+1 standard deviation and were compared with Student t test. Categorical variables were compared with Chi-square or Fisher’s exact probability test. Groups were compared with t-test or approximate t-test.p<0.05 was considered statistically significant.ResultsIn the SVA group puncture succeeded in 317 cases(puncture success rate was 98.8%), among the 4 failed cases 3 were diagnosed pneumothorax after postoperative examination, with the other one operation was cancelled due to miss-puncturation of the subclavian artery and a 6F sheath was inserted.One of the three pneumothorax patients needed closed thoracic drainage, the other two absorbed automaticly without medical intervention, all 4 patients was without any sequela. In the SVA group, complication rate was 1.2%.307 out of 320 was succeed in placing coronary sinus electrode, success rate of catheteration was 95.9%,12 of the failed 13 cases(4.1%) were successfully catheterized via femoral vein approach.All 333 cases (the 13 failed patients were alternated to this group.thus the number of this group is 333) were successfully punctured in the FVA group, the punture success rate was 100%,3 cases failed in coronary sinus catheterization,success rate of catheteration was 99.1%. The 3 failed cases was successfully catheterized via femoral venous pathways after retrograde coronary vein angiography.The success rate of electrode placement was significantlyhigher of the FVA group than the SVA group(99.1% vs 95.9%,p<0.01), severe complications rate was slightly higher in the SVA group than the FVA group without significant difference.The success rate of puncturation, exposure time (77±40s vs 75±46s, p>0.05) was similar between the two group.Overall success rate of the FVA group was significantly higher than the SVC group(99.1% vs 95.9%, p< 0.01).COLLUSION:Both of the two approaches were of high success rate in coronary sinus electrode placement and low incidence of complications, The the FVA is superior to the SVA with a significantly higher overall success rate and a superiority to avoid serious complications, and recommons to be commonly used.The importance of medical training has received great emphasis globally as medical procedures become increasingly specialized. The training of novices in interventional cardiology has been a concern for decades. According to the AHA/ACC/HRS documents, a young doctor needs at least 1-2 years of experience to be a competent electrophysiological physician. However, this training time seems short when considering the various complex manipulations for various arrhythmias that need to be mastered. Ideally, efforts should be made to shorten the training time without adversely impacting the training quality. With the rapid development of cardiac electrophysiology, the use of electrophysiological examination and radio frequency ablation have become commonplace in the diagnosis and treatment of arrhythmias. CS electrode placement is a prerequisite to electrophysiological operations, and thus an important step in training. However little research has been done on this basic step of electrophysiological training. The use of 3D simulators was reported to help shorten the training time of electrode placement including the CS electrode in comparison to the master/apprentice model, in which trainees were supervised by an experienced physician and granted more independence as time progressed with growing experience. However,3D simulators are not yet in widespread use, at least in China. One is compelled to ask whether any other simple procedure could help improve training? To our concern, whether the widely used steerable coronary sinus electrode benefits training is unknown. This study compares the learning curves of coronary sinus catheterization between the subclavian approach with a fixed curve electrode and the femoral vein approach with a steerable curve electrode and attempts to elucidate which approach is better in this regard.Methods:Study designEight fellows (7male,32±4.6 years) admitted consecutively with no prior experience in clinical electrophysiology were included in this study. Before commencing their training in patient-based procedures, the trainees were given formal lessons in anatomy, puncture, and catheter manipulation. Then trainees were shown procedures performed by an experienced trainer After this period, trainees were required to place an electrode in the CS in consecutive patient-based procedures under strict supervision. Each procedure was performed via either subclavian or femoral vein approaches, the approach being randomly selected. The procedural parameters were recorded for statistical analysis.Inclusion and Exclusion Criteria:After completion of the procedure, only those cases that fulfilled the following criteria were included for data analysis:(ⅰ) the CS catheter was placed successfully either by the trainees or trainer and (ⅱ) the subclavian or femoral vein could be accessed. Patients with left superior vena cava or iliac vein occlusion and/or an unusual CS anatomy were excluded.VenipunctureAccording to the randomly preassigned approach, either the subclavian or femoral vein was punctured using the Seldinger technique. If puncture failed on one side, the same vein on the contralateral side was used.Coronary sinus electrode placementAll CS electrode placements were performed on the same digital single plane cineangiography unit and underwent the same LAO 45°projection. A 6F fixed curve deca-polar catheter (901533, APT Medical, Shenzhen, China) was placed into the CS via the subclavian vein in the SVA group. A 6F steerable deca-polar catheter (901675, APT Medical, Shenzhen, China) was placed into the CS via the femoral vein in the FVA group. Successful CS catheterization was defined as achievement of a stable catheter position and intracardiac electrogram within 20 minutes.The following parameters were recorded:complications (defined by complications related to puncture, including pneumothorax, hemopneumothorax, and hematoma); total procedure time (TPT); fluoroscopic time (FT); radiation dose (RD, calculated dose in uGym2 as recorded in the laboratory log); the average number of cases needed to reach a 50% reduction in TPT in the novice stage (defined as when the total procedure time is less than the trainer’s mean TPT+1 standard deviation) total procedure time; average number of cases needed to enter the competent phase (defined as when the total procedure time is no more than the trainer’s mean TPT+1 standard deviation).Data analysisAll continuous variables were expressed as mean± standard deviation. Count data were expressed as frequencies. Comparative analyses between the two groups were performed using the Student’s T-test or Chi-square test. A P-value <0.05 was considered statistically significant. All analyses were performed using SPSS 13.0.ResultsThree hundred and sixty-two patients who presented consecutively for EPS and/or RFCA were enrolled. Relevant data is summarized in Table-1. For each trainee, every 5 procedures on patients constituted one phase, and parameters in each phase were compared between the two groups.Both approaches of placing the coronary sinus electrode displayed high success rates (175/180 vs 179/182, p>0.05) and low complication rates (3/180 vs 3/180, p>0.05) (Table-1) with no significant difference between the two groups. An inverse curve (Y=a+b/X) was fit for trainees’TPT, FT, and RD as time progressed, producing an estimated curve of best fit (Figure-1A, B and C). During the novice stage and the competent stage, parameters (TPT, FT and RD) in the two groups were similar, aside from the RD which was less in the FVA group during the novice stage, this difference being statistically significant. During the second and third stages, the average TPT, FT, and RD were significantly less in FVA group as well (Figure-3 A, B and C). Trainees had a steeper learning curve via FVA, with less procedures needed to reach a 50% reduction in the initial TPT (Figure-2A) and to enter the competent stage (Figure-2B). |
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