PVC ABLATION

EP PROCEDURE NOTE

DATE: 

ELECTROPHYSIOLOGIST: Michael Bui, MD 

ASSISTANT:  

PRE-OPERATIVE DIAGNOSIS:
1.  Symptomatic PVCs 

POST-OPERATIVE DIAGNOSIS:
1.  S/p PVC ablation 

PROCEDURES PERFORMED:
1.  PVC ablation
2.  Diagnostic EP Study
3.  Intracardiac Echocardiography
4.  3D Electro-anatomical mapping using Carto 3-Sound system 

ESTIMATED BLOOD LOSS:  < 20 cc

COMPLICATIONS: None

CLINICAL PROFILE: 

FLUORO TIME:  minutes
DAP:  mGycm2
AIR KERMA:  mGy 

 
SHEATHS AND CATHETERS:
Access the femoral veins were obtained using the seldinger technique:  The right
femoral vein was successfully cannulated with the micro-puncture needle.  A
guidewire was then passed through the needle easily.  A blade was used to make a
nick at the entry site to widen the entry point.  The needle was then retracted.
A sheath was then placed over the guidewire and then flushed.  This was repeated
in a similar fashion for the following access points:

Right Femoral Vein:
        8Fr Sheath:  We placed a  Biosense Webster 3.5 mm tip DF curve smart
                    touch irrigated catheter through, as well as a Biosense
                    Webster Decanav

    7 Fr Sheath:  We placed a Decapolar Polaris deflectable catheter into
        the coronary sinus

Right Femoral Artery:
        5FR Sheath: 

Left Femoral Vein:

        9 Fr Sheath:  A navstar ICE catheter was placed through this into the
                      right atrium and right ventricle

        6Fr Sheath:  A non-deflectable quadripolar catheter was positioned into
                    the Right Atrium. 

        6Fr Sheath:  A non-deflectable quadripolar catheter was positioned into
                    the Right Ventricle. 

PROCEDURE IN DETAILS:
The patient was brought to the EP lab in a fasting and hemodynamically stable
condition. 

We interrogated his device and reprogrammed it to turn of tachy-therapies
throughout the case. 

The patient was then prepped and draped in a sterile fashion.  The  Right and
Left groins areas were anesthetized with lidocaine solution.   Sheaths and
multipolar electrode catheters were placed and positioned as described in the
above section labeled, "Sheaths and Catheters." 

The patient had copious amounts of PVCs, and our clinical PVC had the following
morphology (dominant morphology):

        V1:  Negative with transition @ V3
        II, III, AVF:  (+)
        Lead I:  Negative
        AVR:  Negative
        AVL: Negative (AVL is more negative than AVR) 

We measured the time from QRS onset to RV apex signal, and it was 21 msec,
suggestive of a right sidded PVC source.

(Efimova, Elena et al.  "Differentiating the origin of outflow tract ventricular arrhythmia using a
simple, novel approach."  Heart Rhythm July 2015 Volume 12, Issue 7, Pages 1534-1540)

 QRS-RVA interval = or > 49 ms suggests an LVOT origin

We first mapped the RVOT by using a decanav multielectrode catheter into the
RVOT.  We found the earliest spot to be at the anteroseptal aspect of the RVOT -  just under the
pulmonic valve.  This location had the following characteristics:

    Activation:  -38 msec ahead of PVC onset

    Unipolar Map:  Nice "QS" configuration

    Pace Map:  11.5 / 12 match

We felt that this was a reasonable area to start with our RF applications, and ablation here resulted
in a flurry of ventricular followed by absence of PVCs.  We placed a few more RF applications around
this area and then pulled back the catheter for observation. 

Initially, she was quiet in regards to her PVCs, but then she started to have some PVCs, but
definitely less in quantity.  

We decided to then place a few more RF applications just inferior to the previous location and again
this resulted in a nice flurry of ventricular ectopy followed by absence of PVCs. 

We then decided to end the case.  The catheters were withdrawn, and the sheaths were pulled.  Manual
pressure was applied to both the right and left groins. The patient was then transported to a
monitored bed in stable condition.

ASSESSMENT:
1.  Symptomatic PVCs
2.  S/p PVC ablation in the anteroseptal aspect of the RVOT, just underneath the 
    valve

PLAN:
1.  Obtain limited TTE
2.  Bedrest until 15:00 PM
3.  No lifting anything heavier than 5 lbs x 1 week
4.  Place Zio patch on 5.17.18
5.  Follow up in EP clinic in ~ 8 weeks
        -If still high PVC burden, options include sotalol vs repeat ablation
        (possibility of left sided residual source, although QRS onset to RV
        apex signal suggests right sided etiology)