Background

Catheter ablation of cardiac arrhythmias in the electrophysiological examination laboratory (EPU laboratory) is supported by electroanatomical 3D mapping procedures. This requires a good knowledge of the software to be used in order to achieve the best possible results. This 3D mapping process is usually carried out by technical support who operates the software on site.

Due to the global COVID-19 pandemic, there were changes in electrophysiology: the number of cases decreased and restrictions on freedom of travel meant that technical support was repeatedly not available on site. This not only frequently delayed the procedure’s initiation but also had implications for the overall procedural planning. In addition, ecological aspects resulting from climate change are currently in focus. Long travel times for technical support do not make sense both ecologically and economically. In addition, unplanned traffic disruptions can lead to further delays. The need for technical support will continue to increase in the future due to the progressive number of procedures. In addition, there is an increasing shortage of skilled workers, making the use of “remote” support an ideal option.

A trained employee can provide remote support in various EPU laboratories from a workstation via WLAN in the shortest possible time. A high level of procedural efficiency and flexibility is required to meet future requirements. (1)

Thanks to new hardware and software solutions, it is now possible to receive more than just advice from technical support. Rather, they can directly control the software for creating a 3D map (“remote access”) and communicate audiovisually with the treating team on site. This remote access is made possible using a combination of Medinbox (Abbott) and Ensite ^TM Connect Remote Support (Abbott).

Goal

The aim of the remote study is to test the feasibility, effectiveness and security of remote support using remote access through Medinbox and Ensite ^{TM Connect Remote Support}  and to compare it with standard on-site support.

Methods

As part of the remote study, patients who received an electrophysiological procedure supported by the EnsiteX system (Abbott) between September 2022 and February 2023 were included in the analysis (n=50). All procedures were accompanied externally by an FTE (Field Technical Engineer ) as remote access support. The collective was compared with a matched control group of 50 consecutive previous procedures using EnsiteX on-site FTE support.

Remote Support/Access

The procedure was accompanied by remote support to create an electroanatomical map on defined days of the week. Audiovisual communication was facilitated using Medinbox (Abbott) was used and the FTE was invited to the procedure via a video conferencing system (Zoom) and screen shared. This enabled a complete audiovisual representation of the procedurally important information (ECG, electronic signals from the recording system, visualization of the electroanatomical mapping, X-ray fluoroscopy, ultrasound recordings, remote control of the visual controls (camera)). Remote support was able to communicate with the on-site team via Bluetooth headsets.

The EnsiteX ^TM mapping software (2) was controlled via the Ensite ^TM Remote Support software solution, so that the FTE could operate the EnsiteX system in real time from the home office. The employee was able to control and set all relevant aspects himself. It was not possible for the FTE to operate the recording system; it was carried out on site.

Results

A total of 50 consecutive patients who were treated with remote support and an electrophysiological procedure were included. The procedures involved 20 pulmonary vein isolations, four CTI blocks, 13 ablations of atrial tachycardia, one ablation of ventricular premature beats, three ablations of ventricular tachycardia and nine procedures for the treatment of supraventricular tachycardia. The cohort was matched with a control group regarding the procedures performed. There were no demographic differences between groups.

Remote support was possible in all 50 cases without any relevant technical problems. The audiovisual transmission via the Medinbox is consistently available in good quality. The 3D mapping via EnsiteX was stable during the mapping and the maps were edited without delays, map shifts or software crashes. The internet-based connection was continuously available throughout all procedures. In no case was it necessary to switch to on-site support. This meant that the usual travel time could be reduced by a cumulative 8,340 minutes (= 139 hours; 166.8 min./case).

The median procedure time was:

Remote: 100 min [IQR 76, 120] vs. Onsite: 86 min [IQR 60, 110], p=0.051.

The median fluoroscopy time was Remote: 9.1 min [IQR 6, 13] vs, onsite: 8.7 min [IQR 5, 12], p = 0.109.

The procedure data were comparable to the control and showed no significant differences. Acute procedural success was observed in all studies. With regard to periprocedural complications, apart from one AV-III in the remote group, no other serious complications and no differences between the groups were observed.

Conclusion/Conclusion

This study showed that support for electrophysiological procedures can be carried out safely and stably using a remote FTE in everyday clinical practice. A trained person on site is not absolutely necessary. In addition, by using an audiovisual communication unit, it is possible to easily process various impressions from the EP laboratory in real time and incorporate them into the procedure. The only requirement for this is a stable internet connection.

Credentials

1. Müssigbrodt, Andreas et al. (2021) Feasibility of remote technical support for electrophysiological ablation procedures during the current COVID-19 pandemic, in: European Heart Journal of Digital Health. 25;3(1):77-80. doi: 10.1093/ehjdh/ztab107.
2. Heeger, Christian et al (2023) Treatment of frequent premature ventricular contractions via a single very high-power short-duration application, in: Europace. 2023 Apr 15;25(4):1515. doi: 10.1093/europace/euac226.

Table 1: Periprocedural data (C. Heeger)