Author + information
- Roberto De Ponti, MD⁎ (, )
- Hugh Calkins, MD and
- Alan Cheng, MD
- ↵⁎Department of Heart, Brain and Vessels, Ospedale di Circolo-University of Insubria, Viale Borri, 57, 21100 Varese, Italy
We thank Drs. Ren and Marchlinski for their interest in our paper. Their comments open 2 topics for further discussion.
The first concerns the use of simulators for electrophysiology training. Indeed, it would be desirable to have a simulated procedure as realistic and complete as possible with several degrees of freedom within the simulation to render the device adaptable to the different methodologies that different centers may employ. In the case of transseptal catheterization, it should certainly include a large number of anatomic variants. The addition of intracardiac ultrasound (ICE) as an imaging tool that can also be used during simulated procedures would be valuable as well. In fact, it has been recommended that trainees become familiar with ICE for this and other procedures during their fellowship (1). However, our report describes the initial step of a longer venture. To fully develop a complex simulation, time and resources are necessary and usually obtained only after preliminary studies that demonstrate proof of concept are complete. Nevertheless, our study illustrates that even a relatively basic simulation improves the post-training performance in transseptal catheterization, probably because trainees learn a complex workflow better by intensively practicing in a virtual environment than by actively participating in a few real procedures. Implementation of the transseptal simulation is currently our priority.
The second topic for discussion concerns the use of ICE to perform transseptal catheterization. It is clear that ICE is useful, especially in the presence of anatomical variants, but its routine use is not mandatory (2) nor required to safely and effectively perform a standard transseptal catheterization and an atrial fibrillation ablation procedure. Consistent with this statement is the fact that only 50% of centers routinely employ ICE for these procedures (3). Some centers feel strongly that ICE is a highly useful tool and employ it routinely. Other centers feel equally passionate about the opposing point of view and use ICE only in very selected cases, based on the following considerations: 1) ICE adds cost; 2) it requires an additional venous cannulation with its attendant risks; and 3) it does not necessarily improve the safety and the efficacy of the procedure. It is important to note that there are no randomized prospective clinical trials that have provided definitive data on this topic.
Please note: Dr. De Ponti has received consultancy and lecture fees from Biosense Webster; and lecture fees from Boston Scientific. Dr. Calkins has received consultancy fees from Biosense Webster and Medtronic. Dr. Cheng has received a research grant from Biosense Webster.
- American College of Cardiology Foundation