10 Days Since My Dr. Natale Ablation w/ Ablation Report

Hi All,

It's been 10 days since my ablation at CPMC in San Francisco performed by Dr. Natale. I wanted to post some of the notes from the ablation report, I won't post the entire thing because it's 10 pages and repeats itself here and there. Hopefully it helps others with their own journey, questions, issues that are comparable to their own situations, and stimulates conversation and consensus about my procedure (that would be especially appreciated).

Previously before making the decision to go see Dr. Natale, I had seen three EP's in the greater Los Angeles/Ventura county area and came away not very impressed to say the least. Two of these local EP's would have done only PV isolation, the third wanted to "manage" my a-fib because "not everyone needs an ablation" (his words). This despite my symptomatic a-fib, ten year progressive history with eventual persistent 24/7 a-fib, left atrial enlargement, and that Sotalol 3x was no longer able to keep my pulse in check. My belief, especially after reading the ablation report (ie: complex fractionated signals), is that especially in the last six months I had so many aberrant signals going on it explains that even with Sotalol my pulse would run around 87-100. The last few months felt like two trout flopping around in my chest instead of the one previously.

I believe that these PV only ablations would have either resulted in failure immediately or soon enough, or left me in atrial flutter. Be sure to read the "addl comments" and "Mapping and Ablation of a Secondary Arrhythmia" at the end of the report, I'm very emotional right now and so very thankful that I found someone like Dr. Natale willing to spend so much time taking care of these issues immediately and skillfully. This is huge.

Now please don't get me wrong here, I'm not saying Dr. Natale is the only guy around that could handle my procedure and situation. Personally I know myself though, if Dr. Natale's work needed a touch up I could tell myself "yes, he warned me that was a strong possibility, in the back of my mind I expected that". If I picked another EP and the work failed I would torture myself endlessly and really beat myself up. I think we all have some regrets in life..."woulda shoulda coulda" but I think my choice so far is working out fantastically. Traveling out of town, boarding the dogs, making my wife spend her birthday sitting in a hospital for hours all alone...all very inconvenient and cry me a river. But I'd do it again. She said she would too!

As a funny aside, I must have been talking some smack while waking up in the cath lab holding area. Somehow, I don't exactly remember, I made like eight people from the cath lab sing Happy Birthday to my wife!

In closing look forward to your comments...btw I'm sitting here in complete sinus since the procedure, pulse 67, BP 107/68. Mood? Euphoric!

----------------

Sutter Health
CPMC
We Plus You

Pacific Campus
2333 Buchanan St.
San Francisco, CA 94115

Report Status: Finalized
Anesthesiologist ROSE, BARRY M MD
Electrophyslologist NATALE, ANDREA MD

Procedure Type
Ablation: EPS w/Ablation of A-Fib, EPS & AFIB ABLATION (93656), ABLATION ADDITIONAL AFIB LOCATIONS (+93657), ABLATION 2ND ARRHYTHMIA (+93655), ENDOCARDIAL 3D MAPPING (93613), INTRACARDIAC ECHO (93662), ACTIVATED CLOTIING TIME (85347)
Indications Atrial fibrillation. Clinical Presentation
The patient is a 55 year old man with a history of persistent atrial fibrillation since 2004. The patient has had symptoms of
palpitations, fatigue, exertional dyspnea, dizziness, with episodes. There have been recurrent episodes of AF despite trials of sotalol and amiodarone.

CT angiogram of the chest was performed that reveals the anatomy of the left atrium and pulmonary veins. There were no PV
stenoses.

The patient presents to the cardiac electrophysiology laboratory for electrophysiology study and catheter ablation of atrial fibrillation.

Rivaroxaban has been taken by the patient for over 4 weeks consistently; the last dose was taken the evening before the procedure with food.

Procedure Description
Informed, written and witnessed consent obtained after the procedure and sedation were explained in full, including indications, benefits, risks and alternatives. All questions were satisfactorily addressed. The patient was transported to procedure room in a fasting, non-sedated state. General anesthesia was administered by the anesthesiologist. A temperature probe was advanced to the mid-esophagus thru the nasopharynx. The catheter insertion sites were prepared and draped in the usual sterile fashion. Local anesthesia was achieved with a combination of subcutaneous 2% lidocaine and 2% bupivicaine. Hemostatic sheaths were placed percutaneously into the vasculature under direct ultrasonic visualization using the modified Seldinger technique.

12-lead surface ECG and intracardiac electrograms were displayed in real time and recorded. After baseline recordings were obtained, sinus node, atrial, AV node, His-Purkinje system, and ventricular functions were evaluated by incremental pacing and programmed extrastimulation. In order to facilitate arrhythmia induction, programmed pacing was repeated during IV isoproterenol infusion. The etiology of the arrhythmia was determined with the aid of pacing maneuvers. The decision was made to proceed with catheter intervention.
lntraprocedural Anticoagulation: Heparin bolus was initiated prior to completion of transseptal punctures, and further boluses were given to maintain an ACT >300 sec.

lntracardiac Echocardiography: The AcuNav 1OF intracardiac echocardiographic catheter was inserted via the left femoral vein
10.5F sheath and was advanced into the RA guided by fluoroscopy. The catheter was maneuvered within the RA, and the RA, tricuspid valve, RV. intra-atrial septum, LA, left and right PVs, mitral valve, LV, and aortic valve were visualized.

Transseptal Punctures: Two transseptal punctures were performed with a Baylis NRG needle under fluoroscopic and intracardiac echocardlographic guidance and a LAMP and SL-0 sheaths were advanced into the LA. Proper placement in the LA was confirmed with fluoroscopy, intracardiac echocardiography, contrast injection and appropriate LA pressure tracings (mean, 18 mmHg).

At the end of the procedure all catheters and sheaths were removed after the ACT fell below 200. IV Protamine 40 mg was administered to normalize the ACT. The patient was extubated without issue. Hemostasis of vascular sites was achieved with manual compression and sterile dressings were applied. The patient was transported to a monitored holding area in stable condition.

Dr. Andrea Natale performed the electrophysiology study, mapping and ablation, intracardiac echocardiography, transseptal puncture, periprocedural device checks and was present and personally involved at all times during the procedure.

EPS/Ablatlon Summary
Summarv
1) Moderate LA scarring noted at the onset of the procedure
2) Successful isolation of all four PVs and SVC for the treatment of atrial fibrillation
3) Elimination of high-frequency fractionated signal in the LA including the roof, septum, posterior wall, LAA base, MVA, and other regions with organization to atypical atrial flutter
4) Isolation of LA posterior wall
5) Isolation of CS
6) Isolation of LAA
7) Triggered firing observed from an extrapulmonary site, CS and LA appendage
8) Inducible typical RA flutter; successful cavotricuspid isthmus linear ablation; achievement of bidirectional block and an activation gap of >120 msec across the ablation line
Recommendations
1) Observe at bed rest with both legs straight for 6 hours
2) Antiarrhythmic drug therapy:will continue for the next 2 months and then taper off; recurrence of atrial arrhythmia during the
next 2-3 months does not mean failure of the procedure as there can be nonspecific arrhythmia due to a post ablation inflammatory process
3) Oral anti coagulation: continue for a minimum of 6 months
4) Event recorder with daily recordings for the first week, then 3 times a week for 3-4 months
5) Follow-up with the primary cardiologist in 1-2 weeks

Complications
No complications. Signatures
Electronically signed by NATALE. ANDREA MD (Eiectrophyslologlst) on 12/18/2013 at15:43
Total Ablation Time: 7294 seconds.

Comments:
Mapping and Ablation of AF (PV Isolation):
Endocardial and 3-D electroanatomical mapping was performed with the Lasso catheter and a Navistar 3.5-mm SF J-curve ablation catheter utilizing the Biosense CARTO 3 system. The CT image of the LA and PVs were integrated into the CARTO image. Moderate LA scarring was noted at the onset of the procedure. Vein potentials were localized endocardially in the antra of all four PVs using the circular mapping catheter (Lasso). Targeting the vein potentials with ablation resulted in isolation of all PVs. High dose isoproterenol infusion (20 meg/min for 10 minutes) demonstrated no recurrent conduction into the PVs, induction of extrapulmonary trigger from CS and LA appendage, no induction of atrial arrhythmias. Additional ablation resulted in elimination of extrapulmonary triggers, inability to reinduce atrial arrhythmia, with retesting. The ablation points were guided by fluoroscopy, 3-D CARTO image. lntracardiac echocardiography was used to continually monitor the placement of the catheters relative to the PV. Radiofrequency energy was directed from the ablation catheter tip and a surface patch electrode. Temperature was limited to 40C and power was titrated 30-50W depending on effect on targeted electrograms. Saline flow of 2 cc/min was maintained at a minimum while the catheter was within the vasculature. The flow was increased to 15 cc/min during ablations. Phrenic nerve stimulation was not present with maximum output from sites of ablation near the right PVs. Continuous esophageal temperature monitoring was performed during catheter ablation energy delivery, and maximum esophageal temperature was maintained below
40C.

Addl Comments: Additional Linear or Focal Ablation for AF (separate from PVI):
After PV isolation, further ablation for the treatment of AF was performed. Complex fractionated signals were targeted in the LA roof, septum, posterior wall, LAA base, MVA, and eliminated with ablation. The LA posterior wall was electrically silenced. The proximal CS was isolated. The LAA was isolated. There was organization of the AF into atypical AFL during ablation. Cardioversion was performed to restore sinus rhythm. The ablation points were guided by fluoroscopy, 3-D CARTO image, and integrated CT image of the LA. lntracardiac echocardiography was used to continually monitor the placement of the catheters relative to the PV. Radiofrequency energy was directed from the ablation catheter tip and a surface patch electrode. Maximum temperature and power were limited to 40C and 30-50W, respectively. Saline irrigation was maintained at 15 ml/min during ablations. Saline flow of 2 cc/mln was maintained at a minimum while the catheter was within the vasculature. Phrenic nerve stimulation was not present with maximum output from sites of ablation near the right PVs and the SVC. Continuous esophageal temperature monitoring was performed during catheter ablation energy delivery, and maximum esophageal temperature was maintained below 40C.

Mapping and Ablation of a Secondary Arrhythmia (discrete from AF):
After PV isolation, AFL occurred spontaneously and diagnostic manuevers confirmed the arrhythmia to be atypical atrial flutter terminated with cardioversion. An cavotricuspid isthmus ablation line was created for treatment of typical RA flutter. The ablation catheter was extended across the tricuspid annulus into the RV and radiofrequency energy was delivered from the RV/TA junction to the TAIIVC junction as the catheter was slowly drawn back in a straight line at the 6:00 position (LAO projection). Maximum temperature and power were limited to 40C and 30-50W, respectively. Saline irrigation was maintained at 15 mUmin during ablation. Bidirectional block was achieved and an activation gap of >120 msec was confirmed across the ablation line. This result was observed beyond 45 mins.

Unbelievable detail WOW!
My report was like 5 bullet points of ablation areas and a brief summary of procedure.
Missing work done in my CS and SVC.
Man I pissed, still waiting on Dr Danik who assisted Natale to call me back from last week.
They lost my report and couldn't produce it on my follow up at 2 months.

Barb , Dennis how much detail do your reports have?

McHale



Edited 1 time(s). Last edit at 12/30/2013 12:40AM by McHale.

Hi McHale,

Your report in this sort of detail must exist somewhere, they have to document everything in case something goes wrong. I'm new here, have others posted their reports before?

Actually this is only about half the report, I left off the results from the CT scan that went on for a couple of pages, on those pages my PV's were detailed with sizes, as was the left atrium, and report showing there was no thrombus in the LA or LAA. There were also pages that extreme detail all the different devices with model numbers that went into each vein, the different dosages of Heprin and Vancomycin that were given and when, how much CT contrast, fluoroscopy times and dosages, sheath sizes, and pages of discharge instructions that have my name all over them so I didn't include them either. There was also a letter to my personal DO doctor with a couple of pages of follow up care for me.



Edited 2 time(s). Last edit at 12/29/2013 02:16AM by onewaypockets.

Thanks Oneway for the excellent report,

A bit later this morning I will review help translate some of the more medical-lese terms and abbreviations for those here that may not be as familiar with that lingo and what they mean and what your very comprehensive ablation implies.

Your ablation and mine with Dr Natale where very similar, being the kind of soup to nuts and whole kitchen sink that is really needed for the most challenging and highly symptomatic persistent AFIB cases.

And you need make no qualifying disclaimers on your feeling that Dr Natale may have been the only EP out there who could have, and would have, addressed the whole can of worms in one shot. That, and his true maestro-level skill with a catheter and unsurpassed knowledge and experience in dealing with such challenging cases is rather unique.

There are a small handful of others, most all of whom were mentored by Natale who has pioneered LAA isolation for persistent cases when the LAA is found to be a strong trigger source, who follow this same type of protocol, but you are on very safe ground in counting your blessings that you made the choice you did as its extremely unlikely any other EP could and would have done such a comprehensive index ablation with as much skill and experience under his belt.

You are a perfect example of the classic case type who really truly needs to make whatever effort they can to put themselves into Dr Ns hands for the first ablation onward to give themselves the best odds for best possible outcome with the fewest possible procedures needed to complete their ablation process and with the highest odds for the fewest complications.

While normally, with cases like ours, it's almost a certainty that two ablations will be needed to effectively put the genie back in the bottle, though the first one will typically make a huge improvement, yet needing a big index ablation plus one touch up is typically the norm with Dr Natale for such long standing cases though he has a large number of 'one and cones ' too. However, had you gone to any of those other EPs you interviewed and briefly described, with your tough scenario, the odds in your case for getting a great outcome in two or less procedures would have been close to nil.

This is one of the reasons why I so strongly advise folks here, particularly those with long standing and strongly symptomatic cases to go to the very best possible ablationist they can possibly arrange for themselves. You hit the jack pot with your choice.

With Dr N now doing the full LAA isolation in the index ablation when its clear it is going to be necessary anyway, you to have a fair chance to be 'one and done' as it is. Though, by far, the best psychological stance, particularly in cases like this with moderate to high levels of scarring or fibrosis and such a history as yours, is to expect a touch up being needed at some point down the road and that will very likely be the last one, and if you are done in one procedure consider it a bonus.

You could not have made a better choice for yourself either in pre-sight or hind-sight. No EP is 100% obviously with every procedure, but at least you knew up front that you gave yourself the best chance for a good outcome over the shortest possible course needed to minimize this beast to more of a fading memory than the ever present bummer it so often is when actively affecting one's life so strongly.

Send me a PM with your number if you'd like to discuss your report in more detail and the likely next steps and options relative to your LAA Isolation. Since you are new here I can bring you up to speed on some of these issues and have written extensively on this topic here previously regarding LAA isolation and the whole anti coagulation/ Lariat/Watchman options should those need to be addressed as well after your six month TEE procedure you will need to verify your LAA emptying velocity.

So glad you found Dr Natale and this site. I'll review your report once on my computer and not on this Iphone (excuse any typos) here as well a bit more in depth after my wife leaves for a day trip to Phoenix shortly, just after we returned from Santa Fe last night, am making her some breakfast first ... Priorities you know :-).

Shannon



Edited 1 time(s). Last edit at 12/29/2013 11:26AM by Shannon.

Very informative Oneway! Thanks so much for posting your ablation report. It makes me wish I had gone to the trouble of getting mine. Unfortunately, I wasn't aware of it's existence or availability at the time. However, mine was just a simple PVI ablation, so would not have been as interesting. Would have liked to know whether my EP actually performed the procedure, or one of his fellows, though.

Jim

Hi McHale,

Have you spoken to Dr. Danik again recently there at St Lukes about tracking down the rest of your report?

Onewaypockets, to bring you up to speed, McHale's was a unique situation when he was able to literally sneak in and get an immediate ablation with Dr Natale the very same day as his first appointment in NYC last May with no waiting time at all really. This was the very first week that Dr N was doing ablations in NYC at St Lukes Med Center, but the trade off for such quick access to Natale was that their clerical and front office staff wasn't yet up to speed and they were just starting their transition from a previous EP administration and ways of doing business to learning the way Dr N wants and demands it.

Alas, as a result of some early confusion with the staff, McHales full ablation report was misplaced in the shuffle, and though he did get a pretty standard-sized ablation report covering most of the steps Dr N did for him, it was not as detailed as your extremely detailed report, and more significantly, it was missing a few steps that Dr Natale had told him directly had been done. As you surmise, no doubt the notes exist somewhere within the system there and/or within the Carto-3 imaging files for his case, so there should well be a way to reconstruct it.

Also, Dr Natale will re-confirm with you McHale all the steps that were done either on a phone meeting if you request it or at the next time you can see him when he gets situated again in the NYC area.

Keep in mind too, each center has their own style and level of detail that is spelled out in their own ablation reports format and style and each is a little different than another center, even among Natale's centers. Also, until very recently few had the amount of detail as they are now using at Natale's centers. This is partly due to new requirements for Medicare reimbursement in which earlier in this year Medicare was starting to refuse to reimburse for anything beyond a simple PVI/PVAI ablation!! This was a real problem for EPs and Medical Centers and a solution was negotiated with Medicare and CMS.

By going into such added detail now, instead of just a numbered outline list of areas addressed that include all the additional extra-pulmonary vein ablation areas that are done, and labeling those with their own separate CPT codes, Dr N and the hospital as well as all other EPs out there are now able to properly claim and get reimbursed for the full extent of their procedures when they go beyond a standard PVI.

In your case, McHale, your report that we reviewed together was fairly complete except for them leaving out the part about the CS and ablation of the SVC which I believe they left out of your report as well? But both of which Dr N told you about right after the ablation and that you recorded I believe, is that right?

I know its a real drag not to have the full report in writing handy, but keep on the folks at St Luke's to get that full list of things done, since Dr N is no longer practicing there, before those files drift into the Mt Sinai records labyrinth.

Nevertheless, while I certainly appreciate why its feels like a pinch not to have the full report yet in writing, the main thing is that you got your ablation done by the best and he didn't leave any stone unturned while he was in there. And if any touch-up should be needed, Natale will quickly reaffirm in that follow up report exactly what had been done originally, as well as what was needed to be done in the touch up ablation to finally button everything down.

It may help ease the disappointment some, knowing that the huge majority of ablation patients have never even seen their ablation reports. Until a few of us here started to make it a point to emphasize to folks that they should ask for those reports right after their ablation, most often they were just filed in the patients records and their EP just reviewed the ablation results with them verbally and that was it.

The amount of info you had on yours was similar to what I have seen from several other St Lukes reports from the first month or two Natale was there at St Lukes, and though it wasn't quite the same as reports from CPMC and St Davids, it was pretty close, though in your case the pinch was that those two steps that you know were done were missing from the preliminary report you received so far.

Ask Dr Barrett too if you can, and speak to Julia there as well and see if they can dig up the rest of the details from the Carto-3 files? Failing that, then contact Dr Natale directly and see what he can do.

Rest assured though, that the most important thing is that you got an excellent ablation as it is, and were able to literally walk in and get it done with him the same day without waiting at all ... that is a first as far as I know ... where the vast majority of his patients have had to wait many months and most have had to travel long distances as well to get that opportunity.

While you will likely still be able to get written confirmation about having your CS and SVC ablated as well, also keep in mind that it may still not meet the same level of detail as indicated in Onewaypockets brand new ablation report that reflects what they are now asking Dr N to dictate during the procedure to meet new insurance requirements that only went into effect over the past number of months.

Happy New Years McHale!
Shannon



Edited 2 time(s). Last edit at 12/29/2013 01:45PM by Shannon.

mailman52 Wrote:
-------------------------------------------------------
> Very informative Oneway! Thanks so much for
> posting your ablation report. It makes me wish I
> had gone to the trouble of getting mine.
> Unfortunately, I wasn't aware of it's existence or
> availability at the time. However, mine was just
> a simple PVI ablation, so would not have been as
> interesting. Would have liked to know whether my
> EP actually performed the procedure, or one of his
> fellows, though.
>
> Jim

Hi Jim,

Knowing that Natale ( or your chosen EP) was the EP doing the full ablation as well as the most critical steps of the procedure is the single most important piece of info from any report. And it's one thing you can take for granted with Natale at the helm as he insists on doing all his own procedures under his name, always.

Also, your experience is like the vast majority who never knew an ablation report existed. You can still request yours for sure. However, if it was a long time ago they might have to do a little digging in their archives, but its worth having a copy,

Shannon



Edited 1 time(s). Last edit at 12/29/2013 02:42PM by Shannon.

b](Thanks to Onewaypockets for releasing his nearly full ablation report. below I'll try to highlight in bold some of the terms and abbreviations along with a few observations that might be useful for to him and others here.)[/b]


Report Status: Finalized
Anesthesiologist ROSE, BARRY M MD
Electrophyslologist NATALE, ANDREA MD

Procedure Type
Ablation: EPS w/Ablation of A-Fib, EPS & AFIB ABLATION (93656), ABLATION ADDITIONAL AFIB LOCATIONS (+93657), ABLATION 2ND ARRHYTHMIA (+93655), ENDOCARDIAL 3D MAPPING (93613), INTRACARDIAC ECHO (93662), ACTIVATED CLOTIING TIME (85347)

( Note: EPS means 'Electrophysiology Study' w/Ablation of A-Fib ... the additional break down of the various CPT codes is required within the ablation reports now to quality for full Medicare reimbursement of all aspects of a more complex ablation beyond just a standard PVI or PVAI ablation.)


Indications Atrial fibrillation. Clinical Presentation
The patient is a 55 year old man with a history of persistent atrial fibrillation since 2004. The patient has had symptoms of
palpitations, fatigue, exertional dyspnea, dizziness, with episodes. There have been recurrent episodes of AF despite trials of sotalol and amiodarone.

CT angiogram of the chest was performed that reveals the anatomy of the left atrium and pulmonary veins. There were no PV
stenoses.

The patient presents to the cardiac electrophysiology laboratory for electrophysiology study and catheter ablation of atrial fibrillation.

Rivaroxaban has been taken by the patient for over 4 weeks consistently; the last dose was taken the evening before the procedure with food.

Procedure Description
Informed, written and witnessed consent obtained after the procedure and sedation were explained in full, including indications, benefits, risks and alternatives. All questions were satisfactorily addressed. The patient was transported to procedure room in a fasting, non-sedated state. General anesthesia was administered by the anesthesiologist. A temperature probe was advanced to the mid-esophagus thru the nasopharynx

(the esophageal temp probe goes through the nose and down the esophagus to just behind the left atrium).

The catheter insertion sites were prepared and draped in the usual sterile fashion. Local anesthesia was achieved with a combination of subcutaneous 2% lidocaine and 2% bupivicaine. Hemostatic sheaths were placed percutaneously into the vasculature under direct ultrasonic visualization using the modified Seldinger technique.

12-lead surface ECG and intracardiac electrograms were displayed in real time and recorded. After baseline recordings were obtained, sinus node, atrial, AV node, His-Purkinje system, and ventricular functions were evaluated by incremental pacing and programmed extrastimulation. In order to facilitate arrhythmia induction, programmed pacing was repeated during IV isoproterenol infusion. The etiology of the arrhythmia was determined with the aid of pacing maneuvers. The decision was made to proceed with catheter intervention.

(Dr Natale, and most EPs use a pre-programed sequence of EP stimulation after administering isoproterenol infusion which is a very strong adrenaline-like stimulant used to very reliably trigger AFIB/Flutter in order to fully map, locate and ablate all sources of AFIB/Flutter origin they can find ... assuming the EP goes beyond solely PVI/PVAI ablation and both actively look for, and ablate, real-time non-PV triggers in addition to the basic anatomical isolation of the PVs ... and then they will typically use the same process for testing to insure an inability to trigger AFIB after ablation is finished but before removing the catheters)

lntraprocedural Anticoagulation: Heparin bolus was initiated prior to completion of transseptal punctures, and further boluses were given to maintain an ACT >300 sec.

(Natale and his group have pioneered and confirmed in several studies the wisdom of starting anti-coagulation at least 3 to 4 weeks prior to ablation and maintaining continuous unbroken AC through the actual ablation itself and afterwards for several months while also titrating with Heparin bolus' during the ablation itself to maintain an ACT ( activated clotting time) of around 350 sec up to 400sec, and certainly above 300sec. This protocol has been shown to essentially prevent silent transient eschemic spots on the brain seen in some studies when ablations are routinely done with an ACT of only around 250 second. Just one more safety step that pays off when going to the most experienced group of operators)

lntracardiac Echocardiography: The AcuNav 1OF intracardiac echocardiographic catheter was inserted via the left femoral vein
10.5F sheath and was advanced into the RA guided by fluoroscopy. The catheter was maneuvered within the RA, and the RA, tricuspid valve, RV. intra-atrial septum, LA, left and right PVs, mitral valve, LV, and aortic valve were visualized.

(This refers to the ICE camera placed in the Right Atrium via the left femoral vein, what isn't listed here and that OnewayPockets may have deleted from the report he sent to us here, is that both a Lasso mapping catheter and the Thermocool Ablation catheter are placed within separate sheaths and snaked up within the right femoral vein from the right groin into the left atrium. A 4th catheter is then placed in the right jugular vein on the right side of the neck to send a multipole 'Decaploar' mapping catheter to the Coronary Sinus where it can give a more global voltage mapping view of both the right and left atriums)

Transseptal Punctures: Two transseptal punctures were performed with a Baylis NRG needle under fluoroscopic and intracardiac echocardlographic guidance and a LAMP and SL-0 sheaths were advanced into the LA. Proper placement in the LA was confirmed with fluoroscopy, intracardiac echocardiography, contrast injection and appropriate LA pressure tracings (mean, 18 mmHg).

At the end of the procedure all catheters and sheaths were removed after the ACT fell below 200. IV Protamine 40 mg was administered to normalize the ACT. The patient was extubated without issue. Hemostasis of vascular sites was achieved with manual compression and sterile dressings were applied. The patient was transported to a monitored holding area in stable condition.

Dr. Andrea Natale performed the electrophysiology study, mapping and ablation, intracardiac echocardiography, transseptal puncture, periprocedural device checks and was present and personally involved at all times during the procedure.

(The above statement that Dr Natale performed all the most important steps of the EP study and ablation including transspetal puncture, ICE camera operation and was personally present and involved at all times is the single most important piece of info from this report, and can be taken for granted as being true as well for all other Natale ablations .. alas this is NOT always true with other lead EPs of record on their cases as many farm out some or even a majority of some of their procedures ... even often critical ablation work inside the left atrium ... to trainees. As such, its imperative that you confirm if this is going to be the case up front and tell your EP you will only go with them if they promise only they will be doing all the things listed above that Natale does inside your heart .. unless, that is, you are fine with rolling with an unknown student EP and helping with their learning curve??)

EPS/Ablatlon Summary
Summarv
1) Moderate LA scarring noted at the onset of the procedure

(Moderate to Severe LA scaring inidcates more extensive LA remodeling has taken place from the cumulative AFIB burden over the years. It almost always indicates the need for a more extensive ablation including addressing more non-PV sources, as was the case here for Onewaypockets)

2) Successful isolation of all four PVs and SVC for the treatment of atrial fibrillation
3) Elimination of high-frequency fractionated signal in the LA including the roof, septum, posterior wall, LAA base, MVA, and other regions with organization to atypical atrial flutter

(CAFE's are focal ablation triggers discovered through realtime mapping during the EP study at the beginning of the ablation and CAFE's were found and ablated along the Left atrial roof, the LA septal wall separating the LA from the RA, along the posterior wall and Left atrial Appendage (LAA) base, plus the Mitral Valve Annulus (MVA) as well as other regions within the left and right atriums)

4) Isolation of LA posterior wall
5) Isolation of CS
6) Isolation of LAA

(Isolation of all three structures above, the full LA posterior wall, the Coronary Sinus and Left Atrial Appendage is typical for more symptomatic persistent AFIB cases)

7) Triggered firing observed from an extrapulmonary site, CS and LA appendage

(Such triggered firing from both the CS and LAA is very often found in more challenging longer-standing cases of AFIB whether persistent or paroxysmal with longer episode periods and the majority of EPs rarely, if ever, fully address both of these two structures with ablation and many EPs will selectively screen out most patients whom they think might have more difficult cases, as a result)

8) Inducible typical RA flutter; successful cavotricuspid isthmus linear ablation; achievement of bidirectional block and an activation gap of >120 msec across the ablation line
Recommendations

(I also had this typical RA flutter ablation during my index procedure with Dr Natale in 2008 which is called the 'cavotricuspid isthmus linear ablation'. This will not prevent the possibility of atypical left atrial flutter from the left atrium, which is hard to predict, but can happen and about 50% of the time or more atypical left flutter requires a touch-up procedure to get rid of it and keep the heart very quiet thereafter.)

1) Observe at bed rest with both legs straight for 6 hours
2) Antiarrhythmic drug therapy:will continue for the next 2 months and then taper off; recurrence of atrial arrhythmia during the
next 2-3 months does not mean failure of the procedure as there can be nonspecific arrhythmia due to a post ablation inflammatory process
3) Oral anti coagulation: continue for a minimum of 6 months

(This part about maintaining oral AC drugs for 'a minimum of 6 months' is very important for Onewaypockets to observe and follow religiously until he has his follow up Transesophageal Echocardiogram at CPMC in 6 months to rule in or our whether or not his LAA emptying velocity has been slowed down too much to allow him to stop all blood thinners for good ( roughly 50% of the cases get this preferred news), or if he is among the other 50% (like I was) with a too low LAA velocity (<0.4m/sec) and an irregular A-wave at the mitral valve inflow from the LAA, that will either require life-long anti-coagulation or going for a Lariat or Watchman device to ligate or occlude the LAA entirely. Either step will be needed in that case to either minimize in the case of AC drugs, or eliminate in the case of Lariat/Watchman, the subsequent elevated clotting and stroke risk from the LAA).

4) Event recorder with daily recordings for the first week, then 3 times a week for 3-4 months
5) Follow-up with the primary cardiologist in 1-2 weeks

Complications
No complications. Signatures
Electronically signed by NATALE. ANDREA MD (Eiectrophyslologlst) on 12/18/2013 at15:43
Total Ablation Time: 7294 seconds.

Comments:
Mapping and Ablation of AF (PV Isolation):
Endocardial and 3-D electroanatomical mapping was performed with the Lasso catheter and a Navistar 3.5-mm SF J-curve ablation catheter utilizing the Biosense CARTO 3 system. The CT image of the LA and PVs were integrated into the CARTO image. Moderate LA scarring was noted at the onset of the procedure. Vein potentials were localized endocardially in the antra of all four PVs using the circular mapping catheter (Lasso). Targeting the vein potentials with ablation resulted in isolation of all PVs. High dose isoproterenol infusion (20 meg/min for 10 minutes) demonstrated no recurrent conduction into the PVs, induction of extrapulmonary trigger from CS and LA appendage, no induction of atrial arrhythmias. Additional ablation resulted in elimination of extrapulmonary triggers, inability to reinduce atrial arrhythmia, with retesting. The ablation points were guided by fluoroscopy, 3-D CARTO image. lntracardiac echocardiography was used to continually monitor the placement of the catheters relative to the PV. Radiofrequency energy was directed from the ablation catheter tip and a surface patch electrode. Temperature was limited to 40C and power was titrated 30-50W depending on effect on targeted electrograms. Saline flow of 2 cc/min was maintained at a minimum while the catheter was within the vasculature. The flow was increased to 15 cc/min during ablations. Phrenic nerve stimulation was not present with maximum output from sites of ablation near the right PVs. Continuous esophageal temperature monitoring was performed during catheter ablation energy delivery, and maximum esophageal temperature was maintained below
40C.

Addl Comments: Additional Linear or Focal Ablation for AF (separate from PVI):

After PV isolation, further ablation for the treatment of AF was performed. Complex fractionated signals were targeted in the LA roof, septum, posterior wall, LAA base, MVA, and eliminated with ablation. The LA posterior wall was electrically silenced. The proximal CS was isolated. The LAA was isolated. There was organization of the AF into atypical AFL during ablation. Cardioversion was performed to restore sinus rhythm. The ablation points were guided by fluoroscopy, 3-D CARTO image, and integrated CT image of the LA. lntracardiac echocardiography was used to continually monitor the placement of the catheters relative to the PV. Radiofrequency energy was directed from the ablation catheter tip and a surface patch electrode. Maximum temperature and power were limited to 40C and 30-50W, respectively. Saline irrigation was maintained at 15 ml/min during ablations. Saline flow of 2 cc/mln was maintained at a minimum while the catheter was within the vasculature. Phrenic nerve stimulation was not present with maximum output from sites of ablation near the right PVs and the SVC. Continuous esophageal temperature monitoring was performed during catheter ablation energy delivery, and maximum esophageal temperature was maintained below 40C.

Mapping and Ablation of a Secondary Arrhythmia (discrete from AF):
After PV isolation, AFL occurred spontaneously and diagnostic manuevers confirmed the arrhythmia to be atypical atrial flutter terminated with cardioversion. An cavotricuspid isthmus ablation line was created for treatment of typical RA flutter. The ablation catheter was extended across the tricuspid annulus into the RV and radiofrequency energy was delivered from the RV/TA junction to the TAIIVC junction as the catheter was slowly drawn back in a straight line at the 6:00 position (LAO projection). Maximum temperature and power were limited to 40C and 30-50W, respectively. Saline irrigation was maintained at 15 mUm/min during ablation. Bidirectional block was achieved and an activation gap of >120 msec was confirmed across the ablation line. This result was observed beyond 45 mins.

(The above paragraph is a very detailed description of a cavotricuspid isthmus ablation to prevent typical right atrial flutter . He also noted the presence of an atypical left atrial flutter that occured as further ablations of extra-PV sources caused his conversion of AFIB into an elongated atypical left flutter, which often happens during the conversion of AFIB to NSR. Sometimes though, and in cases like Onewaypockets and in my index ablation for persistent AFIB as well, Dr N. ( or any other EP ion this situation) will have to electro-cardiovert the final step of the atypical flutter into NSR rather than being able to get there all in one step via ablation.

While this doesn't mean Onewaypockets will necessarily need a touch-up at some point to put the final period to the sentence on a possible re-appearance of periodic atypical left flutter down the road, this step may well be why Dr N emphasized to him the possibility of needing a touch up. Although, keep in mind too that Dr. Natale and most EPs will emphasize this possibility, if not likelihood, with all persistent AFIB cases.

On the other hand, having addressed so much in this first ablation, it is certainly possible that Oneway might be 'one and done' already and that is certainly more likely than it was in my case where the LAA isolation had to wait for the touch up procedure that I needed 4 years later. But even if a touch-up ablation should be in the cards to finish off his full ablation process, it will almost certainly require only a true touch up, after all the good work done in his first procedure, and any touch-up that might be needed would be easier for sure all around than this first comprehensive ablation.)

Thats about it, again Onewaypockets, if you want to discuss what might be in store regarding the LAA isolation, follow-up TEE and the options that might be ahead to consider , you can send me a Private message above with you number and will give you a call to go over it. if you'd like.

Good report though and you do have a lot to be thankful for!

Shannon



Edited 3 time(s). Last edit at 12/29/2013 02:39PM by Shannon.

Shannon, thanks for your help in interpreting the harder to understand parts of the ablation report. Good information! Although I have been AFIB free for almost 2 years after my ablation, I wouldn't mind reading my ablation report. I may ask my EP about it on my next annual appointment in April. Thanks again for your help.

Jim

You are welcome Jim, good idea to ask your EP for your report. Consider calling well ahead and requesting a copy from his front office staff so that its there and waiting for you when you get there. It is your property and its fully within your right to request and receive a copy for your own records.

You never know when it might come in handy when seeing some other Doc even for a seemingly unrelated condition in the future.

Shannon

Hi Onewaypockets,

I'm curious as to what your report says about total fluoroscopy time, do you recall what that was?

Thanks Shannon

Hi Shannon,

Here is some of the additional information from the report I didn't include in my first post...there are some artifacts from the PDF to .doc to text process.

I actually wonder how long the actual "table time" was for the ablation, or where exactly I was for quite a few hours! I checked into the hospital admission at 8:11 am, they "sent" for me around 10:15 (I was changed into a hospital gown and waiting in a bed elsewhere in the hospital), I went into a room next to the cath lab where I met a few cath lab nurses and the Dr. Rose the anesthesiologist around 11:00 am. At 11:30 I was in the cath lab where they covered my back with quite a few sticky pads...and I didn't get back to my room upstairs until around 5:30pm. I have three hazy memories of one of the nurses pressing on my left femoral puncture (it didn't hurt actually), the inside of an elevator that had some green leaf design in the lights, and being lifted into my bed upstairs. That anesthesia did a number on me!

Originally I made an assumption that since they told my wife they "had to do quite a lot of work on me" and that I didn't get back to my room until after 5:00pm that it must of been a long procedure. Actually I have no real idea how long the procedure went!


CT HEART \f'N\/0 CONTR STRUCT MORPH AND CTA W COR CA EVAL 12/17/2013
9:37AM

MEDICAL HISTORY: Atrial fibrillation.

TECHNIQUE: Cardiac-gated CT of the heart with attention to the left atrium and pulmonary veins. Note, exam is not tailored for evaluation of the coronary arteries.

DOSAGE: Total exam DLP: 1420 mGy-cm. CTDivol (max): 64 mGy. Number of scans at max CTDivol: 1

COMPARISON: None. FINDINGS:
Presence of thrombus: No thrombus identified in the left atrium
or left atrial appendage.

Measurement of the left atrium: 4.2 x 8.3 CM.
Measurements of the pulmonary venous ostia are as follows: Right lower lobe: 17 mm
Right upper/middle lobe: 24 mm

Left lower lobe: 12 mm
Left upper lobe 13 mm

Procedure Date:12/18/2013 Start:11:45 End: 15:25
The procedure was explained in detail to the patient. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
Fluoroscopy Time: 84:50 minutes. Fluoroscopy Dose: 1568 mGy. Procedure Medications
• Heparini.V. bolus10units.

• Vancomycin 1g.

• Heparini.V. bolus2units.

• Heparini.V. bolus2units.

• Heparini.V. bolus2units. Entrv Locations
• Percutaneous access was performed through the right femoral vein. A 8 Fr sheath was inserted.

• Percutaneous access was performed through the right femoral vein. A 8 Fr sheath was inserted.

• Percutaneous access was performed through the left femoral vein. A 10.5 Fr sheath was inserted.
• Percutaneous access was performed through the right jugular vein. A 8 Fr sheath was inserted. Catheters
Entry Device name Placement \ USed for
.:,, ::..- ....
Comments {-
Right jugular vein SPR LG Duo-Deca 7F 2- CS, HRA Recording, Pacing
8-60

Left femoral vein Acunav-Uitrasound HRA Visualization,
10mm Transeptal puncture

Right femoral vein 7FR,DEF,20MM DIA., LA, HRA Recording, Pacing
CCW,LASSO
Right femoral vein Navistar Thermocool SF LA, HRA, CS Ablation, Mapping, J 3.5mm 7F Recording, Pacing
... ·-:; ;:.:£
. . ·...; easur:eme ,_ "" :;;;t:.:f:itF :.;;: I


ECG and Basic Intervals
Intervals are measured in ms

Thanks again Onewaypockets,

Sounds like you were likely in the Cath lab for a good three hours and 45 minutes to a little over 4 hours which sounds about right for all that Dr Natale did in your case.

My index ablation with him in Austin back in August 2008 was 4 hours and 14 minutes with 117 minutes of burn time and you had a very similar 7294 seconds or 121 minutes of actual ablation or burn time using around 84.50 minutes of fluoroscopy time.

For comparison, most average ablations range from a burn time around 35 to 40 minutes in length over a 2.5 to 3 hour total procedure max. So we were both in the more extreme end of needing the whole kitchen sink!

All the more reason to be totally grateful you hooked your star to Natale's for sure.

As my former local EP told me after reading my index ablation report five years ago. "Im so glad you went to Natale Shannon as we would likely have killed you had we tried ablating you here in 2008". He was half joking while conveying serious relief I had been in Natale's care.

Shannon



Edited 1 time(s). Last edit at 12/31/2013 01:20AM by Shannon.

Hey Shannon,
Actually I wasn't too upset due to the fact it was Natale doing my ablation so I was confidant in his skills and I questioned him about everything the next morning. With Napkin and pen in hand with all the questions written down I threw at him I know exactly what he did.
I just spoke to Dr Danik who called me back, he did remember me as he assisted Dr Natale during the ablation back in May he recalled.
I gingerly questioned him about how much ablation he did and if he just did the mapping. He adamantly told me Natale did everything and all he did was assist and observe.
I was a little concerned that Natale maybe didn't do the whole ablation because the report said it was done by both.
But then again Dr N told me during my 2 month followup any further ablation will involve the LAA. When I questioned him like a deer in headlights what about reconnections he resolutely told me his ablation lines just don't reconnect anymore. He just hasn't seen any in the last 5-6 years in 98% of his re-ablations so I knew right there he did the whole procedure.
Anyway Dr Danik was very accommodating and will try to rebuild my report from the Carto 3 Map and notes Natale and him might have scribbled down.He told me Natale was like a machine doing the whole mapping and ablation.

On a side note Dr Danik told me he and Dr Barrett are still shell shocked about Natale's departure as they both picked up their practices and left Mass General.
Hopefully Dr N can settle in New York and they can all join him again.

McHale



Edited 1 time(s). Last edit at 12/30/2013 05:05PM by McHale.

Wow, no reconnects. This guy really is a star.

______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.

Thanks for the update McHale.

There is never any doubt who does the whole show when Dr N is the EP of record on a case. He told me long ago he insist on doing all of his patients entirely as his reputation and the patients expectations are on the line each time.

And Iatrogenia,

The extremely limited number of PV reconnections and tiny fraction of other non-PV original burns that Natale finds that have reconnected on any of his patients needing repeat ablations is par for the course the last 5 of 6 years and even more so since using the Thermocool catheter which his level of manual dexterity and innate 'feel' for just how long and with how much pressure he needs to maintain each burn to achieve lasting transmurality.

The large majority of EPs don't approach anything close to that level of consistency... hopefully more will get close even without having to have maestro level skill once the new contact force catheters are closer to ready for prime time, but even then having those in the hands of a guy like Natale will be golden.

After my very long 117 minutes of actual ablation burns being made during my index ablation in 2008, he had to address nearly every structure and many focal CAFEs spots throughout my left and right atriums and yet four years later when I finally required my predicted touch-up procedure to finish isolating my LAA to stop the periodic left atrial flutter that had started to appear on a monthly basis like clock work for the prior 15 months after 3 years of near total heart silence following the first ablation, when Dr Natale went in and did a thorough challenge to every area on my heart he had previously ablated with so many burn points, they discovered exactly ZERO reconnections or leaky lesions four full years later!!

To me that is mind-blowing and when I said as much to his colleague Dr David Burkhardt when I met with him in Austin two days before he and Natale jointly did my Lariat procedure last August and I was sharing with him those surprising findings from my latest Aug 2012 LAA isolation ablation showing a perfectly solid ablation that stopped my persistent AFIB in its tracks in 2008, Dr Burkhardt laughed and said, 'yes its amazing indeed, but not at all surprising as we see this result all the time from him and even many of us who have worked with him in learning how to do these procedures the right way are getting similar excellent results with increasingly less reconnection issues as well'

Many otherwise top centers still report from 80% to 95% reconnected PVs found in their follow-up ablation patients and this is largely due to not enough pressure maintained for not long enough at the right temperature.

A large percentage of otherwise knowledgeable EP who know basically what to do, still err on the side of too much reticence and instinctively pull back a few seconds too soon and/or still lack the 'touch' to instinctively know when they have applied enough pressure and temp just long enough without risking tamponade.

That is a major difference between the guys who just can't get their reconnection rate down below a certain average level and guys like Natale and some of his top tier colleague who understand that doing too little is not in the patients best interest.

Shannon



Edited 1 time(s). Last edit at 01/01/2014 02:25AM by Shannon.

I have no doubt Dr. N leads his field!

______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.

Just chiming in here to answer your question, McHale. My ablation report was also much shorter than this as well. Maybe half as long, if that. My abalation was in early September at St. Luke's - and I have a feeling it has more to do wiht the hospital than it does with Dr. Natale.

I do agree with Shannon that the main thing is that we had the best doctor and we are doing well now, but it would be nice to see if there was more information that we should have.

Shannon - do you know if Dr. Natale is expected back in the NY area anytime in the near future? I had my 3 month follow up with Dr. Barrett, but would love to have Dr. Natale for my 6 month one - and expected TEE. I am still trying to taper off of the Flecainide...I actually went back to it again as I felt like my heart was acting up a bit and it was during the holidays...not a good time to need a doctor. Will try again in the next few days...keeping my fingers crossed.

Glad to hear of your success, onewaypockets! (do have a "real" name? May we all continue in NSR for the rest of our days ~ Barb

Hi Barb,

I will see Dr. N at Boston AFIB Symposium 2014 next week .. This year they have moved the big conference to Orlando. I guess January in Boston isn't the greatest time to visit bean-town for a big symposium... Anyway, I'll see where things stand then and will give you a ring Barb.

Take care. Shannon

That would be great, Shannon - thank you. Enjoy! Barb

Wow!!!! Very thorough.
I have a scheduled ablation with Dr. Natale in mid July. This will be my third and I fully expect the kitchen sink ablation myself as my last ablation has left me to be worse off it seams.

Hi Rocket,

I'm sure you'll be in good hands. Did Dr. Natale do any of your other ablations? Neil