My EP study report

Dr Natale EP study report:
Procedure Description
The patient was brought to the EP lab in the fasting, post absorptive state. Risks, benefits and alternatives of the procedure and general anesthesia were explained to the patient and the written informed consent was obtained. The patient was prepped and draped in the usual sterile fashion. Vascular access was obtained by the modified Seldinger technique and ultrasound guidance. Surface ECG leads I aVF and V1, and intracardiac electrograms from the CS, HIS bundle and RVA were displayed in real time and recorded on CD. After baseline records were obtained, sinus node function, atrial function, atrioventricular conduction and ventricular function were evaluated by the extrastimulus method and by rapid pacing in the basal state. Intracardiac echocardiography, transseptal puncture, endocardial mapping and radiofrequency ablation was performed as described below.

An heparin bolus of 14,000 units was initially given to maintain an ACT 300-500 sec. An esophageal temperature probe was inserted and maneuvered under fluoroscopy to monitor esophageal temperatures throughout the case.

At the end of the procedure, Protamine was given, sheaths and catheter were removed and hemostasis was achieved with direct manual pressure.

Ice and Three-Dimensional Mapping
A three-dimensional reconstruction of the left atrium was created with the use of the Carto system. The following structures were visualized with ICE: the right atrium, fossa ovale, tricuspid valve, coronary sinus, crista terminalis, RA appendage, LA, mitral valve, left atrial appendage, left superior pulmonart vein, left inferior pulmonary vein, right superior pulmonary vein, right inferior pulmonary vein, aortic valve, left ventricular outflow tract, ascending aorta, pulmonic valve, right ventricular outlflow tract and pulmonary artery. ICE was also used to guide transseptal.

Transseptal
Left atrial instrumentation was achieved by double transseptal punctures. The Baylis transseptal system was used to facilitate the transseptal punctures. Proper placement was confirmed by fluoroscopy, intracardiac, echocardiography, contrast injection, left atrial pressure tracings and left atrial pressure.

LA mean pressue 35/6/17 (mmHg)

Procedure Description
The patient arrived to the Electronphysiology laboratory in sinus rhythm. After left atrial instrumentation was achieved by double transseptal puncture, the circular mapping catheter was placed in all four pulmonary veins, antrums and along the posterior wall of the left atrium. During mapping, all of the pulmonary veins and posterior wall of the left atrium remained isolated from the previous procedure. Potentials along the anterior roof were eliminated. Electrograms were mapped to the left atrial appendage with spontaneous bursts of tachycardia, 273 msec, that conducted abberantly. The left atrial appendage was isolated with dissociated firing documented. Radiofrequency power was titrated if overheating was observed by intracardiac echocardiography and/or elevation of esophageal temperature.

Isuprel was infused up to 20 mcg/min for 10 minutes to elicit right or left atrial arrhythmias and to assess pulmonary vein reconnections. Following infusion of isuprel, the left atrial appendage regained conduction and was re-isolated. There were frequent PAC's originating from distal coronary sinus. There was a spontaneous atrial tachycardia, 299 msec, originating from the left atrial septum with aberrant conduction, also. Ablation along the left atrial septum terminated the tachycardia. Ablation endocardially and epicardially of the coronary sinus was done with distal isolation and no further PAC's.

The circular mapping catheter was then placed in the superior vena cava and the superior vena cava was partially isolated using rediofrequency energy related to phrenic nerve stimulation. A total of XX minutes of radiofrequency energy was delivered.

At the end of the procedure, protamine was given, sheaths and catheters were removed and hemostasis was achieved with direct manual pressure. The patient tolerated the procedure well and was transferred in stable condition.

Plan
1. Continue long-term anticoagulation with apixaban.
2. Discontinue antiarrhythrmic therapy with sotalol.
3. Follow up in 6-12 weeks.
4. continue to monitor loop recorder

Conclusion
1. All of the pulmonary veins remained isolated from the previous procedure.
2. The posterior wall of the left atrium remained isolated.
3. There was a atrial tachycardia, 273 msec, originating from the left atrial appendage which conducted abberantly. Successful isolation of the left atrial appendage with dissociated firing documented.
4. On high dose isoproterenol (20-mcg/min) there were frequent PAC's from distal coronary sinus.
5. Atrial tachycardia from the left atrial septum, 288 msec, that conducted abberantly, as well. Successful ablation along the left atrial septum to terminated the tachycardia.
6. Successful isolation of the superior vena cava with dissociated firing documented.

Complications
none

Number of ACTs performed
4

Total contrast used
2 ml

Estimated Blood Loss
<10 ml

Specimens Collected
None

Post Procedure diagnosis
Atrial tachycardia status post redo left atrial ablative procedure

Could Shannon or someone explain the Post Procedure diagnosis to me? It is the last part of my report .
Overall, I am doing good.

Thanks to ALL!



Edited 1 time(s). Last edit at 06/26/2016 06:19PM by smackman.

Smackman, it just means you had atrial Tachycardia .. i.e.CS/LAA-based atrial flutter in your case ... that brought you back for the follow up ablation and you are now 'post redo ablative left atrial procedure'. That means you have now completed your follow-up procedure that in your case did not require any re-ablation of any areas along the PV antrum, posterior wall or SVC done in your first ablation all those key areas from the first ablation were 100% solid and transmural. A finding that is very common when reviewing touch ip reports from Dr Natale.

Every now and then there will be one to two spots around the PV antrum or posterior wall that need reinforcing during the second procedure, but extremely rarely anything more than that from the areas he already ablated in the index procedure. No one else whose ablation reports I get sent to me, comes anywhere close to Natale's actual super low reconnection rates. Having such low reconnections is the #1 hallmark of a true master with a catheter when most other even elite EPs not infrequently will find 20 to even 30% reconnections on one of their follow up ablations to an index procedure they had previously done.

In your case Smack, you had a bang up first ablation with no real repeat work at all required. But since you had had Long standing persistent AFIB for an indeterminate time prior to your first ablation, it was almost a 100% guarantee you would need that follow up, and in your case all that was needed to address in round two entailed full isolation for the first time of your coronary sinus and left atrial appendage.

Shannon



Edited 1 time(s). Last edit at 06/27/2016 01:45AM by Shannon.

Thanks Shannon.

Very detailed report and interesting to read.

Mine from Bordeaux was very brief (can post it here if anyone is interested) but I have no complaints since I am now half way through my 14th year of nsr after many years of paroxysmal AF and 18 months of continuous AF. (Somehow I don't think it's placebo effect!)

Gill