Remote technical support of nurse-lead electro-anatomic mapping during complex catheter ablation procedures

This invited commentary refers to ‘Comparison between remotely supported nurse-led electro-anatomic mapping and standard onsite engineer support for electrophysiological procedures’, by A. Müssigbrodt et al., https://doi.org/10.1093/eurjcn/zvae102. Catheter ablation has been established as the preferred treatment option of many cardiac arrhythmias and is often guided by electro-anatomic mapping (EAM) systems.1,2 The EAM system is usually operated from a control room by qualified staff or field technical engineers onsite. Travel restrictions (e.g. during the COVID-19 pandemic), long traveling distances to remote areas, and a worldwide shortage of skilled healthcare personnel are currently limiting the capacity of medical interventions and surgeries in general. Remote access and support may solve some of these hurdles.3 In their manuscript, Müssigbrodt et al.1 compared remotely supported nurse-led EAM with standard onsite field technical engineer support. This novel remotely supported nurse-led EAM approach involved an allied professional operating the EAM system onsite and a supporting technical field engineer offsite. The supporting technical field engineer had remote access to the data provided from the EAM system without direct ability to manipulate the EAM system. In this retrospective observational study of 166 patients with complex and non-complex procedures, the authors demonstrated the practicality and feasibility of this remotely supported nurse-lead EAM approach and showed that procedural characteristics, acute results, and complication rates were comparable between both groups. Müssigbrodt et al.1 indeed implemented an extreme of remote transatlantic technical support with the supporting technical field engineer operating from France and the allied professional operating the EAM system being located in the electrophysiology (EP) centre at the University Hospital of Martinique in the French overseas territory in the Caribbean region, almost 7000 km apart. Implementation of remote technical support may prevent long-haul flights with long travel time and a significant impact on environmental pollution. However, not just in the case of remote geographically estranged environments but also in a centre in Germany, travel burden and hypothetical CO2 emission could be significantly reduced by remote technical support.4 A stable and secured remote connectivity to address cyber security is a prerequisite for a remotely supported nurse-led EAM approach, as described in this article.3 Features such as a two-factor authentication system with encrypted data may therefore be considered as relatively safe. Besides data safety, the malfunction of the EAM system may impact procedure safety and success. Also, problems with hardware, signal noise, connectivity, and procedural complications may be difficult to manage remotely. In an ideal world, all hospitals performing electrophysiological procedures would have skilled allied professionals onsite who are able to operate the EAM systems individually without the need of support engineers. The remote support approach described in this study could be a useful tool for training of such allied professionals, for example, by supporting during the entire procedure in the early phase and serving as a backup for troubleshooting only at the end of the training. Therefore, remote technical support could be integrated in onsite procedures but will unlikely replace all onsite staff, which need to be trained to manage the above-mentioned conditions. Importantly, in the study by Müssigbrodt et al.,1 EAM was nurse-led onsite and the remote support engineer could not directly manipulate the EAM system. Previous reports, one from a German and one from a Spanish centre, have already shown the safety and feasibility of catheter ablation procedures, supported by remotely manipulated EAM systems.4–6 Heeger et al.4 upgraded their EP lab with an integrated audiovisual solution system to allow direct communication between the operating electrophysiologist onsite and the remote technical support, which was achieved using an incorporated internet-based common communication platform, headphones, and high-resolution cameras. Further steps might be completely remotely performed ablation by remotely controlled magnetic navigation.7 Additionally, mobile health-supported telemedicine will allow remote pre- and post-ablation rhythm monitoring and risk factor management in the future.8,9 However, scalability and stability of all such infrastructures need to be proven in the future. Remote access is a promising novel technology for supporting electrophysiological procedures. Additionally, remote technical support might provide educational opportunities, individual case interpretation by experts in the field of electrophysiology, and reduction of the lab downtime. In the future, this new solution might have a great impact on facilitating electrophysiological and other interventional procedures contributing to wider access of catheter ablation procedures and equity. Therefore, specific trainings and controlled exposure to remote support infrastructures and approaches are needed for allied professional and operating electrophysiologists to ensure clinical uptake and implementation of this novel technology in the future. Dominik Linz (Conceptualization, Writing – original draft, Writing – review & editing [lead]), and Ben Hermans (Conceptualization, Writing – original draft, Writing – review & editing [equal]). None declared. No new data were generated or analysed in support of this research.