Digital health in the electrophysiological lab: Initial experience, safety and feasibility using remote support for complex ablation procedures – Results of the REMOTE-VA study

Background: In most electrophysiology (EP) labs, electroanatomical mapping (EAM) systems are operated on site by qualified staff or field technical engineers (FTE). However, due to lack of skilled personnel, the FTE usually must travel between different hospitals and procedures must be planned in advance. Ablation of ventricular arrhythmias (VA) represents one of the most complex procedures in the field and might be performed as a life-saving emergency intervention in selected cases requiring immediate FTE support.

The use of remote support (RS) to guide complex EP procedures has the potential to increase flexibility, reduce travel times and eventually save patients’ life in emergency situations.   
Purpose: To evaluate the safety and feasibility of remote support guided catheter ablation procedures for VA.  
Methods: All patients undergoing ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation using remote support were included. The electronical system of the clinic was searched for 30 days postprocedural emergency department (ED) visits, unplanned ambulatory presentations, and readmissions.  RS guided three-dimensional (3D) mapping was achieved by connecting the EAM software with an integrated audio-visual solution for remote support. Internet connection-based headphones and high-resolution cameras ensured the communication between the operator and the FTE, who worked exclusively from home office. All ablation procedures were performed using high density 3D mapping, as per institutional standard.   
Results: A total of 23 patients undergoing VT (8; 34.8%) and PVC (15; 65.2%) ablations were included between October 2022 and September 2023. One patient underwent epicardial VT ablation, while another one was treated for VT storm by means of bipolar ablation. The mean procedure time was 123.6 ± 42.6 minutes, while the median radiofrequency (RF) time was 6.7 (4.25; 21.75) minutes. The median fluoroscopy time and dose were 12 (7; 17.9) minutes and 457 (276.5; 733.5) cGy*cm2 respectively.  In one procedure (4.3%) the clinical PVC could not be eliminated, while in all others (95.7%) the procedural success could be achieved. No technical issues occurred and there was no need for change to on-site support. No minor and major intraprocedural complications were reported, while 6 (26%) patients had minor complications until discharge, five of them vascular access related and one pericardial effusion not requiring intervention. Two patients had ED presentations in the first 30 days postprocedural, none of them procedure related.  No unplanned ambulatory visits and readmissions in our clinic were reported.   
Conclusions: The use of remote support to guide VA ablation procedures was feasible and safe in this single centre study. No technical issues and intraprocedural complications occurred. This approach has the potential to increase the feasibility in case of emergency procedures, reduce travel times, and maximise healthcare resources.