PVI ABLATION (RFA)
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. Wide Area Circumferential Ablation (WACA) of Pulmonary Veins (RF)
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
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 an irrigated tip 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 nondeflectable 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
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Esophagus:
-An Attune Medical Esophageal Cooling Protection Device was placed into
the Esophagus
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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 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 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.
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.
RF ABLATION:
We then focused our attention on encircling the pulmonary veins. We exchanged
the Octaray mapping catheter for a Biosense Webster RF irrigated tip catheter.
We then encircled the veins, using 35 watts on the anterior side and 30 watts on
the posterior side. Our RF ablation was guided by the Visitag Surpoint Module,
with ablation settings as follows:
-Contact Force Range: 4-40 grams
-Stability Range: 2-3 mm
-Stability Time: 3-5 seocnds
-Force over time: 25% > 3 grams
-Tag Radius: 3 mm
-Visitag Surpoint Module Tag Index Targets:
-Posterior Wall: 400
-Anterior Wall: 550
-Intertag Distance < or = 6 mm
These settings and approach is based on the VISTAX trial (Duytschaever M et al.
Europace. 2020; 22(11): 1645-1652) which reported a 90% First-pass PVI rate,
low adverse events (3.6%) and a 90% 12 month freedom from atrial arrhythmia
rate.
We were able to successfully isolate all four veins. Of note, we identified the phrenic
nerve on ICE and marked it on our Map, and also paced around the right sided veins
to assess for any potential phrenic nerve capture (so as to avoid this).
We then exchanged the ablation catheter for our Octaray catheter and did a
voltage map of the LA post ablation, which showed low voltage around the WACA
area. In addition, placement of the Octaray catheter demonstrated that all four
veins were quiet.
Both Entrance and Exit Block were demonstrated for all 4 Pulmonary Veins
We then pulled our long sheath back into the right atrium.
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.
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 anesthesia. 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. PPI x 3 months (Rx order already entered in CPRS).
5. Recommend Aggressive Risk Factor Modification for Afib (Lau DH et al EHJ
2016)
-Encourage patient to lose 10% of their 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
6. The "Blanking Period for this patient will be between ____________
-Should they have a recurrence of Afib during this window, this does not
represent a failure of his PVI necessarily, but mechanistically due
to post PVI / RF irritation and inflammation
7. Follow up in the EP clinic appointment on _____ as previously scheduled