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Amélioration des techniques d’ablation pour le traitement des arythmies cardiaques : nouvelles modalités diagnostiques et thérapeutiques par ultrasons

Abstract : At the crossroads of medicine and physics, this work aimed to provide innovative diagnostic and therapeutic tools based on ultrasound, in the field of cardiac electrophysiology. A system capable of delivering HIFU into the heart by a transesophageal route using ultrasound (US) imaging guidance was developed and tested in vivo in six male pigs. HIFU exposures were performed on atria and ventricles. At the time of autopsy, visual inspection identified thermal lesions in the targeted areas in three of the animals. These lesions were confirmed by histologic analysis (mean size: 5.5 mm2 x 11mm2). No esophageal thermal injury was observed. One animal presented with bradycardia due to an atrio-ventricular block, which provides real-time confirmation of an interaction between HIFU and the electrical circuits of the heart. There was still a lack of accuracy, mainly related to cardiac motion, and to anatomical structures in between the targets and the transducer. It was mainly related to the in vivo model and its anatomy, far from the human’s. The search for a better model led to conclusive imaging tests on baboons. Additional experiments were conduced in order to improve the mapping of ventricular arrhythmias and the monitoring of lesion formation during ablation. First, experiments were conducted on left ventricles of four isolated working mode swine hearts. The protocol aimed at demonstrating that different patterns of mechanical activation could be observed whether the ventricle was in sinus rhythm, paced from the epicardium, or from the endocardium. Electromechanical wave imaging (EWI) acquisitions were recorded on the anterior, lateral, and posterior segments of the left ventricle. Loop records were blindly assigned to two readers. EWI sequences interpretations were correct in 89% of cases. The overall agreement rate between the two readers was 83%. When in a paced ventricle, the origin of the wave front was focal and originating from the endocardium or the epicardium. In sinus rhythm, wave front was global and activated within the entire endocardium towards the epicardium at a speed of 1.7±0.28 m.s-1. Wave front speeds were respectively measured when the endocardium or the epicardium were paced at a speed of 1.1 ± 0.35 m.s-1 vs 1.3±0.34 m.s-1 (p=NS). Lastly, we investigated the feasibility of a dual therapy and imaging approach with the same transoesophageal device. We demonstrated on ex-vivo samples that transoesophageal shear wave imaging (SWE) can map the extent of the HIFU lesions. HIFU ablation was performed with the transoesophageal probe on ex-vivo chicken breast samples (n=3), then atrium (left, n=2) and ventricle (left n=1, right n=1) of swine heart tissues. SWE provided stiffness maps of the tissues before and after ablation. Areas of the lesions were obtained by tissue color change with gross pathology and compared to SWE. Shear modulus of the ablated zones increased from 4.8±1.1 kPa to 20.5+/-10.0 kPa (ratio 5.0±3.2) in the chicken breast, from 12.2±4.3 kPa to 30.3±10.3 (ratio 3.2±2.0) in the atria and from 21.2±3.3kPa to 73.8±13.9kPa (ratio 3.7±1.2) in the ventricles. On gross pathology, the size of the lesions ranged from 0.1 to 1.5cm2 in the imaging plane area and morphometric characteristics were fitting with elasticity-estimated depths and widths of the lesions
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Submitted on : Wednesday, January 22, 2020 - 9:13:09 AM
Last modification on : Thursday, January 23, 2020 - 1:40:33 AM
Long-term archiving on: : Thursday, April 23, 2020 - 2:35:50 PM


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  • HAL Id : tel-02448084, version 1



Francis Bessière. Amélioration des techniques d’ablation pour le traitement des arythmies cardiaques : nouvelles modalités diagnostiques et thérapeutiques par ultrasons. Médecine humaine et pathologie. Université de Lyon, 2019. Français. ⟨NNT : 2019LYSE1225⟩. ⟨tel-02448084⟩



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