Digital support for catheter ablation from the home office

In Case Studies, Testimonials9 October 2023


Prof. Dr. Christian-Hendrik Heeger, Dr. Julia Vogler and Prof. Dr. Roland Richard Tilz, Lübeck


Catheter ablation of cardiac arrhythmias in the electrophysiological examination laboratory (EPU laboratory) is supported by electroanatomical 3D mapping procedures. This requires a good knowledge of the software to be used in order to achieve the best possible results. This 3D mapping process is usually carried out by technical support who operates the software on site.

Due to the global COVID-19 pandemic, there were changes in electrophysiology: the number of cases decreased and restrictions on freedom of travel meant that technical support was repeatedly not available on site. This not only frequently delayed the procedure’s initiation but also had implications for the overall procedural planning. In addition, ecological aspects resulting from climate change are currently in focus. Long travel times for technical support do not make sense both ecologically and economically. In addition, unplanned traffic disruptions can lead to further delays. The need for technical support will continue to increase in the future due to the progressive number of procedures. In addition, there is an increasing shortage of skilled workers, making the use of “remote” support an ideal option.

A trained employee can provide remote support in various EPU laboratories from a workstation via WLAN in the shortest possible time. A high level of procedural efficiency and flexibility is required to meet future requirements. (1)

Thanks to new hardware and software solutions, it is now possible to receive more than just advice from technical support. Rather, they can directly control the software for creating a 3D map (“remote access”) and communicate audiovisually with the treating team on site. This remote access is made possible using a combination of Medinbox (Abbott) and Ensite TM Connect Remote Support (Abbott).


The aim of the remote study is to test the feasibility, effectiveness and security of remote support using remote access through Medinbox and Ensite TM Connect Remote Support  and to compare it with standard on-site support.


As part of the remote study, patients who received an electrophysiological procedure supported by the EnsiteX system (Abbott) between September 2022 and February 2023 were included in the analysis (n=50). All procedures were accompanied externally by an FTE (Field Technical Engineer ) as remote access support. The collective was compared with a matched control group of 50 consecutive previous procedures using EnsiteX on-site FTE support.

Remote Support/Access

The procedure was accompanied by remote support to create an electroanatomical map on defined days of the week. Audiovisual communication was facilitated using Medinbox (Abbott) was used and the FTE was invited to the procedure via a video conferencing system (Zoom) and screen shared. This enabled a complete audiovisual representation of the procedurally important information (ECG, electronic signals from the recording system, visualization of the electroanatomical mapping, X-ray fluoroscopy, ultrasound recordings, remote control of the visual controls (camera)). Remote support was able to communicate with the on-site team via Bluetooth headsets.

The EnsiteX TM mapping software (2) was controlled via the Ensite TM Remote Support software solution, so that the FTE could operate the EnsiteX system in real time from the home office. The employee was able to control and set all relevant aspects himself. It was not possible for the FTE to operate the recording system; it was carried out on site.


A total of 50 consecutive patients who were treated with remote support and an electrophysiological procedure were included. The procedures involved 20 pulmonary vein isolations, four CTI blocks, 13 ablations of atrial tachycardia, one ablation of ventricular premature beats, three ablations of ventricular tachycardia and nine procedures for the treatment of supraventricular tachycardia. The cohort was matched with a control group regarding the procedures performed. There were no demographic differences between groups.

Remote support was possible in all 50 cases without any relevant technical problems. The audiovisual transmission via the Medinbox is consistently available in good quality. The 3D mapping via EnsiteX was stable during the mapping and the maps were edited without delays, map shifts or software crashes. The internet-based connection was continuously available throughout all procedures. In no case was it necessary to switch to on-site support. This meant that the usual travel time could be reduced by a cumulative 8,340 minutes (= 139 hours; 166.8 min./case).

The median procedure time was:

Remote: 100 min [IQR 76, 120] vs. Onsite: 86 min [IQR 60, 110], p=0.051.

The median fluoroscopy time was Remote: 9.1 min [IQR 6, 13] vs, onsite: 8.7 min [IQR 5, 12], p = 0.109.

The procedure data were comparable to the control and showed no significant differences. Acute procedural success was observed in all studies. With regard to periprocedural complications, apart from one AV-III in the remote group, no other serious complications and no differences between the groups were observed.


This study showed that support for electrophysiological procedures can be carried out safely and stably using a remote FTE in everyday clinical practice. A trained person on site is not absolutely necessary. In addition, by using an audiovisual communication unit, it is possible to easily process various impressions from the EP laboratory in real time and incorporate them into the procedure. The only requirement for this is a stable internet connection.


  1. Müssigbrodt, Andreas et al. (2021) Feasibility of remote technical support for electrophysiological ablation procedures during the current COVID-19 pandemic, in: European Heart Journal of Digital Health. 25;3(1):77-80. doi: 10.1093/ehjdh/ztab107.
  2. Heeger, Christian et al (2023) Treatment of frequent premature ventricular contractions via a single very high-power short-duration application, in: Europace. 2023 Apr 15;25(4):1515. doi: 10.1093/europace/euac226.




Number of patients, n5050
Procedure time, min.100 (76, 120)86 (60, 110)0.051
Fluoroscopy time, min.9.1 (6, 13)8.7 (5, 12)0.109
Treated arrhythmia
CTI4 (8)4 (8)0.999
PVI20 (40)20 (40)0.999
AT13 (26)13 (26)0.999
VES1 (2)1 (2)0.999
VT3 (6)3 (6)0.999
AVNRT7 (14)7 (14)0.999
AVRT2 (4)2 (4)0.999
Pericardial tamponade000.999
Severe bleeding000.999
AV block III°1 (2)00.553

Table 1: Periprocedural data (C. Heeger)

remote support screen

Figure 1: Screen view of the Medinbox: Remote support from the home office during catheter ablation of atrial tachycardia at the University Heart Center Lübeck (C. Heeger)

Read the original article on herzmedizin.de

Dr Dale Yoo

In Testimonials24 May 2022


Electrophysiologist, Heart Rhythm Specialist at McKinney, Texas

I don’t think I have to state, or overstate, or even understate why remote support matters. With the Covid world we live in, I thought there would be an end to it but it’s just the new normal, we have been able to continue to do what we do day to day with the safety measures that we needed and the continuity of safety into healthcare; and still being productive and being everything that we want to do with new technologies is an important part of this.

We want to make sure that cases can be done, add-on cases occur, but your favorite mappers, clinicals, reps, they don’t always exist, they can’t be everywhere at the same time. So, it’s been fantastic to be able to utilize some of the support that we get (…) and then of course pulling in something new: that’s the Medinbox component. You can basically do this entire support remotely safely without taking longer. It’s basically the same time you normally do it with the best of the best anywhere in the world potentially supporting you. And I think that’s really great. Also, it enhances the education piece (…).

A lot of the new mappers, and a lot of the new support staff can kind of learn how to do what they need to do back home they can now do this live with us, like they’re part of the case, from where they are in the comfort of their own homes and labs, and I think that’s a really important part of that as well. So, of course we’ve kind of talked about a case support getting input from other sites, other leaders that have been a little bit more advanced in this field. Maybe they have experienced more cases than you and your team. I think that’s very important. We’ve talked about how this is going to really revolutionize our ability to do high-level mapping, high-level technology delivery to all parts of the globe, maybe to Mars if we get some help with Musk and other people! But at the end of the day, we’re able to help every nook and cranny of this planet because there is patients on every nook and cranny of this planet and they all deserve equal care, if you will.
Technical support has always been there, but this really highlights the opportunity to really use that 24/7 support from a team leader, somebody that you may know or somebody that you want to know, and they can help you again remotely. I think in terms of the world we live in; we’ve seen a lot of the movies that have already shown you what you can do but what’s great is, I think, this is the first time we’re actually bringing the future to today. We actually have the technology that allows us to meld all these things as of a couple of days ago, when we did our first live case with every integration as I know it, the first case in the world where we took the best of the best, we were able to do the support with the Medinbox that allowed the mapper, the support staff to actually control items in our lab live from a remote site, with minimal use of bandwidth; which has been a limitation for a lot of different companies and delivery technologies in the past.

"I don’t think I have to state, or overstate, or even understate why remote support matters."
Dr Dale Yoo

If you have a case that goes late, that goes early, a mapper is stuck in traffic, they’re in another site, they’re stuck in a plane; I mean I think a lot of us here, continue to see those problems where you’re basically at the whim of other people and you can’t really take care of your patient how you want to. But at the same time, theoretically you could be in a car you have a wi-fi connection you have some type of hotspot and you’re able to get on with enough bandwidth, you’re able to support it. In this case, we went early, and our mapper wasn’t there yet, and our senior mapper was available remotely, was able to chime in. (…) Our senior mapper and I have been able to work together really well over the last decade to revolutionize the zero-floor minimized fluoro techniques. But now enhancing that with remote support is amazing, so he’s able to help us.
And even if your staff is not experienced, you’re able to talk them through really how to do this, I mean we have this in almost every other arena with computer support. This computer support is on the other side of the planet usually. We hope that everyone speaks the same language but, in this case, we do, and if you don’t understand the technical parts, it’s okay because the remote staff is there to help you through that. And that’s exactly what happened so we can get the patches going so we have a case going early and we didn’t want to delay that case. This patient is on the table already under anesthesia and this shows you the utility of what you need to do to stay efficient and of course for safety for the patient as well. So, I kind of led into it, so the partnership with Medinbox is a very huge one. (…)

We did an Afib case. The Medinbox system allows you to get any inputs, up to eight, into the box, and allows that connectivity back to the remote staff. Previously, you had access as a remote staff to the mapping portion of it, but not necessarily to any other inputs from the lab. Now you have up to eight other inputs. You can access, change, manipulate, completely full operational effects from another site. We talk about this akin to drone usage, if you will you know, you have a master base that’s on the other side of earth and they’re controlling a very expensive modular aircraft on the other side of earth and able to do it. But in this case, it’s akin to that. The ability is there and it’s pretty amazing so we talked about also having audio capabilities too so we have direct communication with that remote staff wherever on earth they could be. I mean we do that already with Teams, Webex, we do that with Zoom as well. We’re just basically integrating that into the technical space and able to communicate both ways fairly seamlessly without any delay or any issues with lag.
We were able to do this live the other day, really no preparation, we just jumped in, both feet down and we see what we did. It went very successfully as a first global launch of this. I think it was the best it could be, and it was pretty amazing, and we’ll have a little footage of that as well. You can tell that they have access to the full map, starting to create it, start to do all the logistics with that; Medinbox again gives you the ability to have feedback with auditory. You don’t have to get on a phone. You don’t have to communicate via a separate way. This is all integrated and then also if you want to move a camera which there’s a camera part of this as well that can be either mounted or on wheels as we have it. It gives access to a camera that’s already there so if you have an advanced lab that has a bubble-cam as we do, they can actually integrate that to an input and move it around pan because it does matter: they can show you what the patient has in terms of their patches so you get feedback visually, you have feedback auditorily, you get feedback electrically.

So basically all aspects of it at the fingertips of the remote operator. And I think that’s very amazing, and I think this is showing you the capabilities of what we can do going forward. (We made) a little video. That was a camera on wheels that we had. This is a case literally from two days ago -the one that we did. (…) These are all the inputs that you had at the laptop station on the remote side. They could see a lot, we also used ultrasound to get access to the leg, then we switch over to the other module. Whatever’s coming out of that streaming out of that, they can see it at all times. They have the camera support, and you have the audio support on the backend. We obviously have our module there, but we had vacated it after we got it set up. We really had them do nothing but of course this is the first launch so in case there was something we had someone in support. But you can see that there really doesn’t need to be somebody. You train the staff. They don’t really need to do much except for turning on a computer if you will.

Everything is done remotely with the two strains, as you saw there, they have the ability to see all that you can see on here, including anesthesia if you want that as well, that’s another input that we had. And again, up to eight inputs of any kind. And even though we have more and more technology going into this, eight is fairly a lot that encompasses pretty much everything you need and then some. I think we had six going in, but if you wanted something additional, that gives you the extra capacity of that as well. In terms of mapping, there was no delay when I was asking them to rotate the map as my mappers hate and love me, for I love orthogonality; I like to have two separate views. I want them to follow me. I asked them to do it. They did it immediately, just like they’re in the lab. So, except I can’t throw things at them, so, I think they love the experience probably even more! So being there and being able to see it live and for our first case, we initially thought that maybe we’d do a simple Flutter, an Avian RT, let’s just, let’s tread lightly and figure out how we use this. It didn’t turn out that way, the real world doesn’t. This was an Afib ablation. We went in there, we identified, and we did everything like it was in the lab.

So again, the feasibility of this, it actually gave me no angst, I had no more stress than I normally would have, and the case finished on time – otherwise, I wouldn’t have made it here on time either, so everything really did come together just like it should be. And of course, there’s some things that we’re going to tweak going forward. Who knows, this is an intro to this remote world that we have, and Covid really helped us launch into that remote world anyhow. And this just utilizes what technology we had, some new ones thanks to Medinbox and being able to put that all together so we can go forward, forge this into potentially other spaces. (…)
I think the bounds are endless and so I’m very proud and very lucky and humbled to be a part of this experience. Hopefully more going forward and hopefully some of you out there will have this opportunity too going forward. (…) I think the utility is huge in developing and emerging markets. Of course, the education pieces need to be there more, but these are the types of technologies that allow us to do that in a safe manner, expand that knowledge to everyone around the world.

Dr Helmut Pürerfellner

In Testimonials28 October 2021


Cardiologist at Ordensklinikum Linz Elisabethinen

Because of the pandemic, contacts have been limited for future doctor’s trainings. In Austria, at the Ordensklinikum Linz Elisabethinen, medical education has been maintained live from the operating rooms.

The first digital transmission system has been permanently installed in Austria, meaning that heart experts from all over the would can now join in on the procedures as if they were physically attending.

Being able to attend an operating procedure is the basement of a solid education and training in the medical field. Procedures that take place at the cardiac catheter laboratory are now available all over the world on a digital platform, allowing experts to watch and work in real time.

"This is the future which we started right now, I think this is the kind of technique which we will need in the next years, not only in times of a pandemic."

In the heart rhythm laboratory are cameras and monitors that can be remotely controlled. All the data gathered can be manipulated individually; and thanks to a control room you can access the information worldwide, simply using the internet.

"There are different scenarios, for example I can be consulting, watching a procedure and giving tips to a foreign colleague, or they can be watching us, seeing how we do a procedure, maybe for the first time, and helping us because they are virtually with us.

There is also a zoom feature that allows to take a closer look, exactly at the right moment with the camera."

With a perfect transmission of every single detail, the Medinbox system gives doctors a real viewing and an insight as if they were standing in the operating room themselves – with a strict compliance of data protection.

"This works in real time, without noticeable latency. It is unbelievable the quality in which it is transmitted! How sharp the signals are which are normally just screens being taped, and this would not look so good. But now we have very clear and sharp images."

The experienced professionals can thus train their younger colleagues, and in this case, in interventional treatment of cardiac arrhythmia, allowing attendees to follow and participate interactively in the procedures. There are also significant advantages for the patients.

"The patients benefit from being in a center where the medical staff is up to date. Because such a system makes our rhythmology center a reference in Austria, to promote and make new developments."

Networking with other centers who possess digital platforms has become a prerequisite and can significantly enrich the exchange of knowledge in the medical field.