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EHRA educational review and preparatory course for accreditation examination Invasive Cardiac Electrophysiology examination preparatory course
Basic concepts techniques and safety
issues of arrhythmia ablation
Prof Dr M Antz Oldenburg Heart Center Germany
European Heart House Sophia-Antipolis France
25th of February 2011 900 - 1030
Matthias Antz
Power How RF ablation works
bull RFC is passed through the patient circuit The tissue around the probe tip is heated by the electric current
bull The rise in tissue temperature causes a lesion and interrupts transmission of myocardial signals
bull The tip does not get hot itself
bull The temperature rise takes place directly in the tissue and is measured in the tip by a
Thermocouple exactly in the
center of a full metal tip
for best thermal conductivity
or
Thermistor compatible with older
generator technologies
Tissue Heating
Electrode tip
heated from
the tissue
Heat lost to
circulating blood
Zone of resistive
heating
Zone of conductive
heating
Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
Current flow
The current follows two pathways blood and tissue each with different impedance (R)
bull RBlood is smaller than RTissue most current ist lost to blood bull Good wall contact more contact area more current
enters the tissue
Temperature controlled ablationEffects of low and high blood flow
Low blood flow High blood flow target temperature reached target temperature reached with 15 W small lesion with 30 W large lesion
Conventional Electrodes 4 mm vs 8 mm Tip
18 W
60deg 60deg
35 W
4 mm Tip 8 mm Tip
Electrode Electrode plt005 vs
Blood Flow 350 mlmin 4mm Tip
Otomo et al JCE 1998947-54
Experimental Experience
1) High blood flow allows higher power delivery to
the tissue and this results in deeper lesions
2) Larger electrodes provide greater electrode
cooling allowing higher power delivery and this
results in deeper lesions
3) Small electrodes have a higher recording
resolution
Different electrodes
4mm 8mm irrigated
Recording resolution high low high
Risk of thrombus high high low
Large lesions possible no yes yes
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Power How RF ablation works
bull RFC is passed through the patient circuit The tissue around the probe tip is heated by the electric current
bull The rise in tissue temperature causes a lesion and interrupts transmission of myocardial signals
bull The tip does not get hot itself
bull The temperature rise takes place directly in the tissue and is measured in the tip by a
Thermocouple exactly in the
center of a full metal tip
for best thermal conductivity
or
Thermistor compatible with older
generator technologies
Tissue Heating
Electrode tip
heated from
the tissue
Heat lost to
circulating blood
Zone of resistive
heating
Zone of conductive
heating
Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
Current flow
The current follows two pathways blood and tissue each with different impedance (R)
bull RBlood is smaller than RTissue most current ist lost to blood bull Good wall contact more contact area more current
enters the tissue
Temperature controlled ablationEffects of low and high blood flow
Low blood flow High blood flow target temperature reached target temperature reached with 15 W small lesion with 30 W large lesion
Conventional Electrodes 4 mm vs 8 mm Tip
18 W
60deg 60deg
35 W
4 mm Tip 8 mm Tip
Electrode Electrode plt005 vs
Blood Flow 350 mlmin 4mm Tip
Otomo et al JCE 1998947-54
Experimental Experience
1) High blood flow allows higher power delivery to
the tissue and this results in deeper lesions
2) Larger electrodes provide greater electrode
cooling allowing higher power delivery and this
results in deeper lesions
3) Small electrodes have a higher recording
resolution
Different electrodes
4mm 8mm irrigated
Recording resolution high low high
Risk of thrombus high high low
Large lesions possible no yes yes
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Tissue Heating
Electrode tip
heated from
the tissue
Heat lost to
circulating blood
Zone of resistive
heating
Zone of conductive
heating
Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
Current flow
The current follows two pathways blood and tissue each with different impedance (R)
bull RBlood is smaller than RTissue most current ist lost to blood bull Good wall contact more contact area more current
enters the tissue
Temperature controlled ablationEffects of low and high blood flow
Low blood flow High blood flow target temperature reached target temperature reached with 15 W small lesion with 30 W large lesion
Conventional Electrodes 4 mm vs 8 mm Tip
18 W
60deg 60deg
35 W
4 mm Tip 8 mm Tip
Electrode Electrode plt005 vs
Blood Flow 350 mlmin 4mm Tip
Otomo et al JCE 1998947-54
Experimental Experience
1) High blood flow allows higher power delivery to
the tissue and this results in deeper lesions
2) Larger electrodes provide greater electrode
cooling allowing higher power delivery and this
results in deeper lesions
3) Small electrodes have a higher recording
resolution
Different electrodes
4mm 8mm irrigated
Recording resolution high low high
Risk of thrombus high high low
Large lesions possible no yes yes
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Current flow
The current follows two pathways blood and tissue each with different impedance (R)
bull RBlood is smaller than RTissue most current ist lost to blood bull Good wall contact more contact area more current
enters the tissue
Temperature controlled ablationEffects of low and high blood flow
Low blood flow High blood flow target temperature reached target temperature reached with 15 W small lesion with 30 W large lesion
Conventional Electrodes 4 mm vs 8 mm Tip
18 W
60deg 60deg
35 W
4 mm Tip 8 mm Tip
Electrode Electrode plt005 vs
Blood Flow 350 mlmin 4mm Tip
Otomo et al JCE 1998947-54
Experimental Experience
1) High blood flow allows higher power delivery to
the tissue and this results in deeper lesions
2) Larger electrodes provide greater electrode
cooling allowing higher power delivery and this
results in deeper lesions
3) Small electrodes have a higher recording
resolution
Different electrodes
4mm 8mm irrigated
Recording resolution high low high
Risk of thrombus high high low
Large lesions possible no yes yes
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Temperature controlled ablationEffects of low and high blood flow
Low blood flow High blood flow target temperature reached target temperature reached with 15 W small lesion with 30 W large lesion
Conventional Electrodes 4 mm vs 8 mm Tip
18 W
60deg 60deg
35 W
4 mm Tip 8 mm Tip
Electrode Electrode plt005 vs
Blood Flow 350 mlmin 4mm Tip
Otomo et al JCE 1998947-54
Experimental Experience
1) High blood flow allows higher power delivery to
the tissue and this results in deeper lesions
2) Larger electrodes provide greater electrode
cooling allowing higher power delivery and this
results in deeper lesions
3) Small electrodes have a higher recording
resolution
Different electrodes
4mm 8mm irrigated
Recording resolution high low high
Risk of thrombus high high low
Large lesions possible no yes yes
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Conventional Electrodes 4 mm vs 8 mm Tip
18 W
60deg 60deg
35 W
4 mm Tip 8 mm Tip
Electrode Electrode plt005 vs
Blood Flow 350 mlmin 4mm Tip
Otomo et al JCE 1998947-54
Experimental Experience
1) High blood flow allows higher power delivery to
the tissue and this results in deeper lesions
2) Larger electrodes provide greater electrode
cooling allowing higher power delivery and this
results in deeper lesions
3) Small electrodes have a higher recording
resolution
Different electrodes
4mm 8mm irrigated
Recording resolution high low high
Risk of thrombus high high low
Large lesions possible no yes yes
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Experimental Experience
1) High blood flow allows higher power delivery to
the tissue and this results in deeper lesions
2) Larger electrodes provide greater electrode
cooling allowing higher power delivery and this
results in deeper lesions
3) Small electrodes have a higher recording
resolution
Different electrodes
4mm 8mm irrigated
Recording resolution high low high
Risk of thrombus high high low
Large lesions possible no yes yes
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Different electrodes
4mm 8mm irrigated
Recording resolution high low high
Risk of thrombus high high low
Large lesions possible no yes yes
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Irrigated tip ablation ndash Lesion size
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Irrigated Tip Ablation ndash Lesion shape
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Ablations using irrigated tip (Oldenburg)
bull Irrigation flow - mapping 2 mlmin - ablation 17 mlmin (lt30W) - ablation 30 mlmin (ge30W)
bull Power control - CSMCV 10 W (increase in 5 W steps) - other parts 30 W (max 40 W caveat 50W)
bull Temperature limit 43degC bull Duration of ablation 120 sec bull Cave volume overload due to irrigation fluid
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Effect of Irrigation Flow on Ablation (50W 60s)
10mlmin 17mlmin 30mlmin 60mlmin
Electrode Temp 59 6degC 47 5degC 39 3degC 34 2degC
85 33 0 0
46 13 0 0
Irrigation Flow
35 mm Irrigated Tip Electrode (7F)
Thrombus
Impedance Rise
plt005 between flow rates
Matsudaira Nakagawa et al NASPE 1999
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
26 W 36 W
2 mm versus 5 mm Irrigated Electrode
30 W 30 W
Irrigated Tip Irrigated Tip 2 mm 5 mm
Nakagawa et al Circulation 1998 98 458-465
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
RF Generator 50 V
RF Generator 50 V
RRemoteRRemote
RTissueRTissue
RBloodRBlood
Ablation ElectrodeAblation Electrode
Circuit for RF Ablation
RRemote 30 W 30 WRTissue 199 W 198 WRBlood 103 W 50 W
RRemote 30 W 30 W RTissue 199 W 198 W RBlood 103 W 50 W
2 mm 5 mm2 mm 5 mm perpendicularperpendicular
Blood
Tissue
Nakagawa et al Circulation 1998 98 458-465
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Summary
bull RFC heats the tissue which then heats the ablation electrode
bull Blood flow and electrode-tissue contact have the largest impact on lesion formation during conventional RFCablation
bull During ablation the electrode temperature power and impedance should be monitored
bull Risk of thrombus formation is increased at high electrode temperatures
bull High electrode temperatures predominantely occur at highpower and can be avoided by using an irrigated tip electrode
Matthias Antz
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
Literature
1 Antz M Otomo K Yamanashi WS Nakagawa H Jackman WM Kuck KH Radiofrequency current catheter ablation with the
split tip electrode in the temperature controlled mode Pacing Clin Electrophysiol 2001 24(12)1765-1773
2 Dorwarth U Fiek M Remp T Reithmann C Dugas M Steinbeck G Hoffmann E Radiofrequency Catheter Ablation
Different Cooled and Noncooled Electrode Systems Induce Specific Lesion Geometries and Adverse Effect Profiles PACE
2003261438-45
3 Huang and Wilber Radiofrequency Catheter Ablation of Cardiac Arrhythmias Futura Publishing 2000
4 Matsudaira K Nakagawa H Wittkampf FH Yamanshi WS Imai S Pitha JV Lazzara R Jackmann WM High incidence of
thrombus formation without impedance rise during radiofrequency ablation using electrode temperature control Pacing Clin
Electrophysiol 200326(5)1227-37
5 Nakagawa H Wittkampf FHM Yamanashi WS Pitha JV Imai S Campbell B Arruda M Lazzara R JackmanWM Inverse
Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling
Circulation 199898458-465
6 Otomo K Yamanashi WS Tondo C Antz M Bussey J Pitha JV Arruda M Nakagawa H Wittkampf FH Lazzara R
Jackman WM Why a large tip electrode makes a deeper radiofrequency lesion effects of increase in electrode cooling and
electrode-tissue interface area J Cardiovasc Electrophysiology 19989(1)47-54
7 Petersen HH Chen X Pietersen A Svendsen JH Haunso S Lesion Dimensions During Temperature-Controlled
Radiofrequency Catheter Ablation of Left Ventricular Porcine Myocardium Impact of Ablation Site Electrode Size and
Convective Cooling Circulation 199999319-25
8 Rodriguez LM Nabar A Timmermans C Wellens HJJ Comparison of results of an 8-mm split-tip versus a 4-mm Tipp
ablation catheter to perform radiofrequency ablation of type I atrial flutter Am J Cardiol 200085(1)109-112
9 Rosenbaum R Greenspon AJ Smith M Walinsky P Advances radiofrequency catheter ablation in canine myocardium Am
Heart J 1994127(4)851-857
10 Weiss C Antz M Eick O Eshagzaiy K Meinertz T Willems S Radiofrequency catheter ablation using cooled electrodes
impact of irrigation flow rate and catheter contact pressure on lesion dimensions Pacing Clin Electrophysiol 200225(4)463-
Matthias Antz
469
