PVI ABLATION (Pulsed Field)

EP PROCEDURE NOTE

DATE:

ELECTROPHYSIOLOGIST:

ASSISTANT CARDIOLOGIST:

PRE-OPERATIVE DIAGNOSIS:
1. Paroxysmal Atrial Fibrillation
1. Persistent Atrial Fibrillation

POST-OPERATIVE DIAGNOSIS:
1. Successful Afib Ablation

PROCEDURS PERFORMED:
1. AFib Ablation with isolation of Pulmonary Veins via Pulsed Field Ablation
(PFA) energy
2. Transeptal Puncture
3. Intracardiac Echocardiography
4. 3D Electro-anatomical mapping using Carto 3-Sound system
5. Heparin infusion with serial ACT monitoring

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6. External DCCV x 1
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ESTIMATED BLOOD LOSS: 10 cc

COMPLICATIONS: None

CLINICAL PROFILE:

FLUORO TIME: 4.0 minutes
DAP: 14.0 Gycm2
AIR KERMA: 91.6 mGy

PFA APPLICATIONS DELIVERED:

SHEATHS AND CATHETERS:
Access the femoral veins were obtained using the seldinger technique and guided by ultrasound: The right femoral vein was successfully cannulated with the micro-puncture needle. Aguidewire 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: A Biosense Webster Octaray mapping catheter was placed
through this to map the right atrium and His Bundle Region.
This was subsequently exchanged out for a Biosense Webster
Vizigo Sheath. The Octaray Catheter was placed through
this to map the left atrium, and this was subsequently
exchanged for a PFA sheath and PFA ablation catheter

7Fr Sheath: A Biosense Webster Decapolar catheter was placed
through the sheath and positioned into the coronary
sinus.

Left Femoral Vein:

6Fr Sheath: A Josephson Deflectable quadripolar catheter was
placed into the right ventricle

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

Radial Arterial Line: Placed by anesthesia for hemodynamic monitoring

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

A Transesophageal Echocardiogram was performed on _________, which showed
no evidence of intracardiac mass or thrombus.

The patient was intubated by anesthesia please see their notes for details.

ACCESS:
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." A baseline ACT level was drawn,
and then a heparin bolus was given shortly after gaining femoral access, with
subsequent starting of a heparin gtt. Serial monitoring of ACTs to keep ACT in
the goal range of > 350.

MAPPING:
We next placed our Soundstar ICE catheter into the right ventricle and performed
a baseline survey of the heart, which did not reveal any significant pericardial
effusion. We then withdrew our ICE catheter into the RA, and constructed a 3D
sound map. We were able to identify and carefully mark the pulmonary veins, the
LAA, aorta, and esophagus, as well as taking multiple location marks of the fossa ovalis for our transseptal site.

We then took the Biosense Webster Octaray mapping catheter and made a Fast
Anatomical Map (FAM) for geometry of the right atrium *********and marked the His location******************.

We then placed our catheters (right ventricle and coronary sinus).

*******************Transseptal NEW TECHNIQUE***********************************
*******************Transseptal NEW TECHNIQUE***********************************
*******************Transseptal NEW TECHNIQUE***********************************

TRANSSEPTAL PUNCTURE
The transeptal system was then prepared and flushed. A guidewire was advanced
into the SVC. The Biosense Webster Vizigo Sheath and and dilator was advanced over the guide wire into the SVC. The guide wire and dilator were removed, and the sheath was then aspirated. The Octaray Catheter was placed through this, and then navigated to the Fossa (as identified previously via ICE and Cartomap). Under ICE, tenting was observed. We then withdrew the Octaray Catheter and the sheath was advanced to the fossa, with tenting observed on ICE. The sheath was then aspirated and flushed to ensure that there no air bubbles. The Baylis Medical dilator was then advanced halfway into the Vizigo and then aspirated, ensuring that there were no air bubbles. Next, the NRG RF needle was then advanced (and flushed forward as it was being advanced) into the system. We connected the RF needle to the Carto Mapping system using the Duomode feature, so as to be able to safely track the location of the needle on the map. The needle was positioned into the Fossa Ovalis (confirmed by both our Carto Map as well as by ICE). With the Fossa engaged, tenting of the interatrial septum was demonstrated on intracardiac echocardiography (ICE). We then turned on RF, and crossed the septum.

Right Atrial Pressure: mm Hg
Left Atrial Pressure: mm Hg

A saline injection was given through the needle to confirm Left Atrial Positioning. The Baylis Medical NRG RF Needle was then removed, and
we then placed a Baylis Medical ProTrack Pigtail Soft tip Wire through the dilator into the left atrium, which was confirmed on ICE. The dilator and sheath were then advanced into the left atrium, and we tracked its positioning on both ICE as well as on the Carto Map. The Protack Pigtail and Dilator were then removed, and then the Vizigo sheath was then connected to continuous flush.

*******************Transseptal OG TECHNIQUE***********************************

TRANSSEPTAL PUNCTURE:
The transeptal system was then prepared and flushed. A guidewire was advanced
into the SVC. The Baylis Medical Torflex 90 Degree Trans-septal Sheath and
dilator was advanced over the guidewire into the SVC. The tip of the
dilator was directed medially. The guidewire was removed, the dilator was then
aspirated and then the Baylis Medical NRG RF needle was then advanced into the
system. We connected the RF needle to the Carto Mapping system using the Duomode feature, so as to be able to safely track the location of the needle on the map. The transeptal system was then dragged down (with the handle pointing between 3 and 6 O'Clock position) into the Fossa Ovalis (confirmed by both our Carto Map as well as by ICE). With the Fossa engaged, tenting of the interatrial septum was demonstrated on intracardiac echocardiography (ICE). We then turned on RF, and crossed the septum.

Right Atrial Pressure: mm Hg
Left Atrial Pressure: mm Hg

A saline injection was given through the needle to confirm Left Atrial Positioning. While fixing the NRG needle, the dilator and then the sheath were then advanced across the septum, into the left atrium. The needle was then withdrawn from the dilator. A syringe was then attached to the dilator, and blood was drawn back. We then placed a Baylis Medical ProTrack Pigtail Soft tip Wire through the trans-septal sheath, and removed that sheath, exchanging it for a Biosense Webster Vizigo steerable sheath. The soft tip wire and dilator were removed, and then the Vizigo sheath was connected to continuous flush.

*******************Transseptal OG TECHNIQUE***********************************

LEFT ATRIAL MAPPING:
We then took a Biosense Webster Octaray mapping catheter and placed it into the
Left Atrium. We were able to navigate to the pulmonary veins and performed fast
anatomic mapping of the veins as well as the LAA. All four veins were
identified and geometry was built.

PFA ABLATION:
We then focused our attention on encircling the pulmonary veins. The Octaray Catheter was removed, and we then exchanged out the Vizigo sheath for a Medtronic 10 Fr FlexCath Contour Steerable Sheath (utilizing the Protract Pigtail soft tip wire). The Medtronic Flexcath Sheath was then connected to continuous flush.

Next, the Medtronic PulseSelect PFA Catheter was placed through the sheath into the left atrium. We were able to visualize the electrodes on our Carto Map. Each of the veins were ablated in the following manner: wire into the respective pulmonary vein and then advance the PulseSelect PFA catheter into the target location. PFA was then delivered around the ostium of the pulmonary veins. The catheter was then rotated 90 degrees and additional PFA applications were made. The PFA catheter was then placed a more antral location, and this process (applying PFA energy and then rotating the catheter 90 degrees and applying RF, with 90 degree rotations to make a 360 degree circle) was then repeated so that each vein had both ostial and antral ablations. This process was performed on all four veins. We isolated the veins in the following order:

RSPV --> LSPV --> LIPV --> RIPV

LSPV --> LIPV --> RSPV --> RIVP

POST ABLATION STUDY:
With all four veins isolated, we then reinterrogated the veins to check for electrical isolation.

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Both entrance and exit block were demonstrated in all four veins
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We then exchanged the Medtronic PulseSelect PFA catheter for the Biosense Octaray and performed a remap of the Left Atrium.

Voltage map showed low voltage / scar in the pulmonary veins.

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We then performed burst pacing from

coronary sinus

high right atrium

down to 180 msec without induction of any sustained atrial tachyarrhythmias

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We then pulled our long sheath back into the right atrium.

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With the patient in sinus rhythm, we obtained our intervals:

AA SCL =

PR =

QRS =

QT =

AH =

HV =

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We then took our ICE catheter and placed it in the RV where we could assess the
myocardium, and no significant pericardial effusion was observed.

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We were finished at this point in the case. Protamine was given, after a test
dose had revealed no reaction. We then performed a Figure of Eight Stitch in
both groins and pulled the sheaths.

The patient was successfully extubated by anesthsia. The patient was then
transported to a monitored bed in stable condition.

ASSESSMENT:
1. Symptomatic ****Paroxysmal / Persistent**** Atrial Fibrillation
2. S/p successful pulmonary vein isolation.
-Patient's s/p PVI can go into afib during the first 3 months
following afib ablation. This is the so called "blanking" period,
and is generally due to post ablation inflammation of the atrium

PLAN:
1. Bedrest until _____ PM
-Remove Figure of Eight Stitches @ _____ PM
2. Continue ___DOAC_____
3. Continue ___AAD____ as normally scheduled
-Can potentially dc after _____ if no afib
4. Recommend Aggressive Risk Factor Modification for Afib (Lau DH et al EHJ
2016)
-Encourage patient to lose 10% of his body weight, as this is
associated with the highest rates of freedom from Afib, and final
target BMI < 27 kg/m2
-Exercise 30 minutes 3-4 x a week
-Control of OSA (if present) with adherence
-Target BP < 130 / 80 mm Hg
-Target HBA1C < 6.5
-Smoking and EToH Abstinence
5. The "Blanking Period for this patient will be between ________________
-Should he have a recurrence of Afib during this window, this does not
represent a failure of his PVI necessarily, but mechanicastically due
to post PVI / RF irritation and inflammation
6. Follow up in the EP clinic appointment on _____ as previously scheduled