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State of the Art EP Lab
- 1. State of the Art EP Lab: What’s Going On in There? Bob West Iowa Heart Hospital
- 2. Disclosure of Relationships Bob West, B.S., RCVT, CEPS Participated in Bachmann Bundle pacing study. Currently working with Voltage mapping study.
- 3. Participated in TTOP trial ……………… Ablation Frontiers Participated in STOP AF trial …………..Arctic Front balloon CryoCath Briefly participated in ENABLE study …………….Cardiofocus Laser balloon Disclosure of Relationships
- 4. History of Arrhythmia Ablation 1969: Surgical division of WPW pathways 1982: Catheter ablation using DC shock 1987: Catheter ablation using radiofrequency energy (RF) cure of SVT‐ 1992: Catheter RF ablation of atrial flutter 1995: Catheter RF ablation of atrial fibrillation =20 years of RF catheter ablation experience
- 6. RF, standard and irrigated Radiofrequency energy---resistance heats tissue 4mm,5mm,8mm 10mm deeper and wider lesions
- 7. Cryo, standard and balloon nitrous oxide freezes tissue
- 8. Laser, balloon Cardiofocus diode laser
- 9. High intensity focused ultrasound focused ultrasound energy to selectively destroy biological tissue at depth
- 13. EP 120 channel physiology recorder with programmable stimulator
- 14. High resolution signals for diagnosis
- 15. PVI goal is to electrically isolate the pulmonary veins
- 16. Safe and reliable transeptal access a steerable introducer gives added flexibility for achieving good lesions
- 17. INTRA CARDIAC ECHO imaging for Ablation Pre ablation anatomic orientation
- 18. Ablation Goals (what is all this stuff for?) Maximize Success Reduce Complications
- 19. Death as a complication of catheter ablation of atrial fibrillation (AF) occurs in 1 of every 1000 patients Thirty-one centers reported 32 deaths in 32,569 patients tamponade (in 8 patients) stroke (5 patients) atrioesophageal fistula (5 patients) massive pneumonia (2 patients). J Am Coll Cardiol 2009;53:1798-1803,1804-1806
- 20. J Am Coll Cardiol 2009;53:1798-1803,1804-1806 32 deaths out of 32,569 patients tamponade 25% stroke 16% other 37% pneumonia 6% A E fistula 16% avoidable complications
- 21. Monitor the vital signs---old school!
- 22. We routinely monitor femoral artery pressure throughout the PVI procedure "It is of the utmost importance that tamponade (i.e., the most frequent cause of death in our survey) be recognized promptly, before it is too late." Dr. Riccardo Cappato from the Policlinico San Donato, Milan, Italy
- 23. Have the vital signs changed? Stable hemodynamics Early recognition
- 24. Quick action and calm heads Have equipment for tap available now Critical to act soon!
- 25. Can recent additions to technology improve outcomes?
- 26. 3-D Mapping Ensite and Carto Current improvement include CT or MRI fusion Better understanding of anatomic variable Map arrhythmia real-time and in review Pinpoint critical path to determine ablation strategy
- 27. Ensite with fusion on CT
- 28. Non-contact Array maps Left atrial tachycardia from right atrium
- 29. Carto- Merge
- 30. Right septal Accessory Pathway Mapping Retrograde map cryo lesions
- 31. Remote Robotic Navigation Magnetic Robotic
- 32. Sensei Robotic Catheter System
- 33. Steriotaxis
- 34. Steriotaxis Magnetic Navigation High initial cost Closed architecture No irrigated catheters Soft catheter (light RF contact) Applications for ventricular rhythms, coronary access and coronary sinus access. Natale, Gallinghouse,Horton 1/5/09 The Use of Remote Robotic Navigation in Complex Arrhythmias webcast
- 35. Hansen Medical Sensei Robot 14F introducer Only useful in atriums (primarily LA) Open architecture Complication rate similar to manual No cryo (8.5F lumen limitation) Natale, Gallinghouse,Horton 1/5/09 The Use of Remote Robotic Navigation in Complex Arrhythmias webcast
- 37. STOP AF trial Cryo balloon Pulmonary vein isolation
- 38. Round balloon in an oval/egg shape hole! Some part of the ring will be missed!!
- 39. To touch up missed area Freezor Max is used or the Balloon repositioned and repeated
- 40. PVI goal is to electrically isolate the pulmonary veins Pre cryo Post cryo
- 41. EGD damage afterEGD damage after PV Isolation with the CryoballoonPV Isolation with the Cryoballoon Catheter Presented at the Heart Rhythm Society 2008 Scientific Sessions, San Francisco, CA May 14-17.
- 42. To date no esophageal fistula has been seen in cryo procedures. Conclusions: This case clearly demonstrates that Cryoballoon ablation can cause esophageal ulceration. Perhaps the absence of atrial-esophageal fistula formation with cryoablation may be related to the post-ablation healing process, rather than an inherent inability of cryoenergy to cause esophageal damage. Ablation technology by definition causes cellular damage
- 43. TTOP Linear Ablation Ablation Frontiers
- 44. Linear lesions to the roof and Septum Ablation Frontiers
- 45. technology to improve outcome
- 46. Variation in anatomy Location, size, branching and number of pulmonary veins Size and location of atrial appendage Proximity of esophagus to PV antrum Phrenic nerve proximity to ablation site Coronary artery proximity to ablation site
- 47. Location, size, branching and number of pulmonary veins PA CT of Left atrium Red LA Green distal PV’s White esophagus
- 48. Size and location of atrial appendage
- 49. Proximity of esophagus to PV antrum
- 50. Pulmonary vein ostia are not round
- 51. If you know there is a risk Take every effort to avoid a bad outcome
- 52. Phrenic nerve proximity to ablation site (A)pre ablation (B)phrenic palsy (C)recovery
- 53. Sanchez-Quintana found the anterior wall of the RSPV is <2mm from the right phrenic nerve in 32% of their autopsy series
- 54. Coronary artery proximity to isthmus ablation site common atrial flutter 68 yo man
- 55. Is deeper and wider better? 13 yo male STEMI during Posterior wall accessory pathway ablation Early recognition of a complication is critical ……… emergent coronary stent interrupted this boys MI Distal RCA occlusion
- 56. Is something important near the ablation site?.......... Two reported coronary occlusions in Epstein’s WPW Incidence of coronary artery injury immediately after catheter ablation for supraventricular tachcardias in infants and children. Heart Rhythm, Volume 6,Issue 4, Pages 461-467
- 57. 15 year old male Epstein's anomaly with WPW pacing RV- right side posterior Accessory Pathway is common
- 58. RCA 4mm from right atrial endocardial surface
- 59. Cryo lesion paint to RCA posterior to Kent bundle No acute or residual symptoms Lower Incident of Thrombus Formation With Cryoenergy Versus Radiofrequency Catheter Ablation Khairy et al. ,Circulation 2003;107
- 60. What is the future? built in Safety and a quick arrival at the goal Beautifully engineered
- 61. Beautiful simplicity "Things should be made as simple as possible, but not simpler." — Albert Einstein (1879–1955)
- 62. addendum Fall and winter 2009 Voltage substrate mapping
- 63. LA voltage substrate map in NSR
- 64. Reflexion HD™ High Density Mapping Catheter
- 65. Criteria for defining Low voltage bridges HVR LVB HVR
- 66. Low voltage bridges occur in both atriums and their veins LSVC LSVC RAA
- 67. Importance of low voltage bridges “Ideally, a method to identify abnormal atrial substrate would offer the best chance to understand the underlying atrial disease, as well as, offer the best chance to intervene with ablation.” Steven J. Bailin, MD Iowa Heart Center
- 68. 10 patients undergoing AF ablation Cryo lesions
- 69. The ability to map atrial substrate makes apparent the fundamental structures necessary to maintain and propagate AF
- 70. In all 10 patients, AF was terminated to sinus rhythm
- 71. The voltage gradients as well as high voltage areas were dramatically altered Voltage pre ablation Voltage post ablation
- 72. Only time and follow up will tell if this is a better method.
Hinweis der Redaktion
- Not gonna drop a lot of names or quote statistics…… Not enough time and too early for physics lessons…….. A brief overview of the technology we work with daily………… and some items I’ve only seem at conventions.
- I was required to disclose this information
- I began working in cathlabs in 1975, working with EP in 1980, participated in surgical division of accessory pathways and open chest surgical and cryo ablation of VT’s……I’m glad that is not our only option today…..today we treat these patients with ablation.
- Different types of energy sources and technologies are used to make Ablation lesions.
- RF catheters heat the tissue to cause damage to the cells…….. Power and temperature feedback make the lesions much safer. We have used all sizes, we don’t use pediatric sized ablation catheters………. have used irrigated catheters with outside physician…….. irrigated systems have a lower tip to tissue temperature……as a result less char and thrombus…….RF lesions can cause vein stenosis.
- Cryo damages cells by freezing the tissue next to the ablator to between minus 70 to minus 80 degrees centigrade. We Use 10F flexcath introducer and 9F 8mm Freezor MAX…two doctors used 14F flexcath with 23mm and 28mm arctic front balloon during the STOP AF trial. ……………….Advantages include no discomfort during lesion creation, and the catheter does not move because it is frozen in place. …….the lesions have less thrombus and absolutely no char……no vein stenosis
- We did two ENABLE patients,………… the study has discontinued.
- Have not seen (HIFU, high intensity focused ultrasound. Parabolic balloon) only on their web-site………. study has been suspended
- TTOP with two EP doctors….. Technology was advertised to not need mapping and make the procedure simpler and quicker…..the electrograms off their catheters look great…. No activity after making lesions…… but……. We had problems getting isolation on the pulmonary veins according to signals from the constellation catheter.
- Those Research tools are not yet released, ….. so we work daily with the ones that are available to us in the US.
- LAO view Constellation catheter in the LSPV gives us 3 dimensional vein mapping ….64 electrodes can be display in a variety of ways……..Proximal to distal, distal to proximal, side by side………. CS catheter from below. We have Siemens Artis x-ray systems in both of our labs. quality is good enough to do coronary interventions in these rooms, but we don’t tell the angiographers!!!!!
- WHY 120 channels? Constellation is a 64 electrode catheter plus all the other diagnostic catheters. …Constellation in lspv, accompanied electrograms on the right. …We Continuously monitor the arterial pressure to watch for tamponade…….. Notice the arrowed esophageal temperature probe to watch for drop in temperature in the esophagus during arctic front vein lesions…. It also identifies the location of the esophagus behind the left atrium.
- We have two labs, each with EP Med workmates recorders…….. Correct diagnosis of the tachycardia is necessary for effective treatment. Constellation, duo-decapolar, spiral and variable loop catheters are used for diagnosis and mapping.
- Little yellow arrows show Proximal to distal progression down the vein pre ablation……………………the trace on the right is the goal, albeit a different vein….. Total electrical isolation pacing the distal cs at 800 ms. One down only three more to go!!!
- We use a fair number of steerable transeptal introducers… giving the doctor the ability to steer to the area with the introducer, and fine tune the Ablation catheter tip with the steerable catheter…..similar idea as robotic introducer and catheter, just manually steered.
- We don’t use ICE……. Phase array intra cardiac echo from right atrium? I think so, but I confessed my lack of experience. Some labs use ICE for Transeptal puncture………Pre ablation anatomic orientation……..Assessment of lesion formation………Identify structures relevant to the ablation………..Confirmation of catheter positioning………We rely on the fluoro or CT to tell us the anatomic variables. we do use echo for Detection of complications
- Why do we spend all this time and effort? …… Benefit must outweigh the risk….. So we must use the tools at hand to minimize risk and maximize good outcomes.
- May JACC report this year……………four main complications………..12 other causes………………. MI to TEE perforation…………….(Myocardial infarction, intractable torsades de pointes, septicemia, sudden respiratory arrest, extrapericardial pulmonary vein (PV) perforation, occlusion of both lateral PVs, hemothorax, and anaphylaxis caused 1 death each Asphyxia from tracheal compression secondary to subclavian hematoma, intracranial bleeding, acute respiratory distress syndrome, and esophageal perforation from intraoperative transesophageal echocardiographic probe caused 1 late death each)
- An early recognized tamponade should not be lethal…..We have had close calls with tamponade, …..that is why we monitor invasive arterial pressure. STROKE? Caused by air or clots…absolutely No air in any line!!!!!! Anti-coagulation is the responsibility of everyone in the room……… HOLES to the esophagus?? The atrial wall is a thin wall structure!!!!......Know that the esophagus can move side to side during the procedure, it is not a fixed structure, it is compressed between the spine, the descending aorta, and the left atrium. Others………… be careful, use safe technique….
- Quality care starts with the details……..Pulse, respirations, O2 sats, BP, ETCO2, arterial waveform.
- A visual change in the slope and pulse width of the arterial pressure must be watched. (1..2) Old school hemodynamics!!! If a tamponade is detected….The physician doing the procedure should be able to treat the problem with a pericardial tap.
- Normal pressure waveform with rapid upsweep and a dicrotic notch……….. Then decreased systolic pressure with slow up sweep, pointed peak pressure, and reduction or loss of the dicrotic notch.
- Having staff that recognizes the change in the pressure tracing……. and knows what to do by quickly prepping the patient and having the appropriate equipment for a rapid pericardial tap at hand will determine the safe conclusion of the procedure……………. 1200 ml of blood was removed and the procedure was able to continue without crisis.
- 3D mapping has helped take the mystery of EP away……(1 2 3 4).I’ve seen Carto at seminars and conventions, but have no hands on experience. We use Ensite either NAVX or ARRAY but do not map every rhythm………
- An example of a lesion set for our PVI procedure. This is a hybrid procedure, with cryo lesions in the four PV’s, and SVC….. and RF lesions on the atrial roof, walls, and flutter line………. We believe that drawing the lesions to the CT anatomy give us a better idea of individual results. …………. THESE ARE COMPLEX PROCEDURES.
- This patient was known to have salvo’s of atrial tachycardia, so an array (NON-CONTACT balloon technology) was placed in the right atrium. The earliest signals during tachycardia were seen in the distal CS…… So a transeptal access was done, and the left atrium geometry added, and mapped for earliest activation with the ARRAY in the Right atrium.. ………. The red lesions are the left atrial lesion set…………………………..Dx landmark map
- I’ve only seen Carto in other peoples presentation. An example of merging the anatomy onto a CT image.
- Ensite 3D map of A right sided pathway…. Right atrium Electrical anatomy drawn with a constellation. Retrograde mapping with pacing in the RV. Pathway was defined and ablated with freezing.
- I have not seen the remote navigation except in presentations, but this is what they tell me they look like.
- Here are images of the Hansen medical system utilizing the steerable introducer and catheter manipulation.
- Magnetic navigation………entails……… steering the wire or catheter with large electro magnets outside the patient.
- Texas Cardiac Arrhythmia Institute, (St Davids Medical Center), Austin TX……(tab)... Did a Complementary web cast….. Jan 2009…..worth looking at……….. from the largest single center experience with these systems……these two slides are a review from their experience.
- Same source (tab)
- These research tools are not released for general use in the US.
- This is the image Cryo cath has to show inadequate vein occlusion. Complete venous Occlusion is necessary, for the balloon to be in contact with tissue with no blood flow to create an adequate ring lesion. Early on , as it is frozen in place, the doctor puts additional pressure against the vein with the introducer to ensure good contact.
- Lateral ct image… AP fluoro image ….The old wooden puzzle toddlers play with, tells us that the round piece doesn’t fit well in the egg shaped hole…. There will be some area of the wall that is not covered… fluoro image on the right… The constellation is monitoring the RSPV while the balloon is freezing the LSPV antrum. When the two are switched, a catheter is passed up the SVC to do phrenic stimulation during the freezing in the RSPV….. If diaphragmatic stim is interrupted, you shut off the cryo to minimize damage to the phrenic nerve.
- After the cryo balloon is thawed, the Constellation catheter in lspv with residual conduction on two splines, Doctor steers the freezor max to that spline using the constellation locator and lay down some spot lesions. Also can change the size of the balloon (23mm or 28mm) and reapply another ring lesion.
- Rejoice, this vein is isolated!!!!!! (tab) Stim in CS at 800ms not transmitted down the vein
- Is cryo used without risk to adjoining tissue?....maybe less than RF but not without risk.. post pvi Scoping the esophagus… All ablation does damage to tissue. This type of damage has not been life threatening. But it is concerning.
- (1….2) None of the atrioesophageal fistula (5 patients) out of 32,569 patients….. were caused by cryo lesions. All 5 were rf related.
- This is the (PVAC) the Pulmonary Vein Ablation Catheter that shows contact electrograms and burns a linear ring around the vein antrum. Note the NG tube full of contrast to mark the Esophagus.
- On the left is the (MAAC) the Multi Arrayed Ablation Catheter used to burn lines on the Left atrial roof. On the right image is the (MASC), the Multi Array Septal Catheter that burns a three pointed star into the left side of the septum. ………….NG tube full of contrast to mark the Esophagus ………….
- Not yet released research technology , ….. so we work daily with the tools that are available to us in the US.
- One of the most useful tools we have acquired is CT’s of the patients anatomy fused onto the 3D mapping system…(12345)………..Anatomy is like snow-flakes, each patient is a little,…. or a lot, ……different……knowing the individual variability is very useful.
- Our standard of care, all PVI’s have CT done prior to the procedure…………..RIPV branches early and gets skinny in a hurry. Possible rotors in any and all branches. LSPV splits superior and anterior.
- Same patient as last slide left lateral Mushroom like atrial appendage on a stalk… left superior pv splits superiorly and wraps anteriorly right next to the appendage…. Notice how close the esophagus is to the posterior wall.
- This obese female had her esophagus compressed to the left very near the left pulmonary vein antrums. When the patient shifts, or move onto the table the position can change.
- Same patient with the atrium cut away.. Notice the oval or egg shaped antrum…. All the weight of the right and left atrium as well as the blood inside, compresses the veins against the esophagus, the spine and the descending aorta.
- Doing damage to the phrenic nerve is not fatal…….but can be debilitating…(tab)………………If you think you are near the nerve, test before you burn or freeze. The recovery may take months or years if much damage is done.
- Anytime you are working in the SVC, high RA, Right superior pulmonary vein, check phrenic stim with pacing. If loss of diaphragm stimulation, stop! Don’t burn or freeze there!!! Short term palsy may be seen Damage seen with RF, HIFU, laser, and cryotherapy….. No safe source…. Need to better define the anatomy Only physician “vigilance” may minimize the risk
- Whenever you see pathologic specimens, the outcome was not good. This 8mm ablation catheter caused an intramural hemorrhage adjacent to the side of the lesion……..despite this finding no apparent injury of other layers of the coronary artery was detectable.
- the realtor’s mantra … Location location … location ______ Ask the question…… is the ablation site safe?.......... Having the doctor realize a risk exists is the first step of having a safe procedure. ……………………………..13 year old boy right posterior pathway ablation caused a RCA occlusion……(tab). emergency RCA stent interrupted MI…….. on plavix!!!!! IF they had known the location, would they have used another method?????
- 15 yo male with Epstein’s anomaly and SVT….. Displaced septal and posterior tricuspid valve with ventricularized tissue above the valve ring. The av groove is not normal. Due to published problems with coronary occlusions during Epstein’s ablations… our doctor ordered a Coronary CT study to be done. (1…..2) Incredible skill by Matt Korthas segmented out the posterior right atrium and the septal wall and coronary sinus, as well as the Ascending aorta and the right coronary artery.
- Posterior caudal ……Kent bundle mapped by pacing the RV and mapping for early activation on the right atrial posterior wall.
- The right posterior endocardial surface was 4mm from the middle of the RCA in this still image.
- You can see the cryo lesions painted on the coronary artery as well as the atrial endocardium………..So far…………. cryo lesions have not caused occlusion of the coronary artery in our experience…… If a large tip RF or irrigated RF catheter had been used, a fifteen year old with a posterior MI could have resulted………the doctor used multiple technologies to ensure a good outcome… CT imaging. ..3D mapping with fusion…., and cryo lesions for a safe outcome without serious complications.
- The future is full of possible solutions that will streamline and improve the procedures we do today. Mathematical beauty and simplicity can be the answer.
- I hope and pray for a simpler life for all of us.
- After the summer, a new theory (originating here in Des Moines) of what causes afib (or any reentry rhythm) to start and continue within the heart was being pursued……..
- Using a Constellation basket or HD Reflexion catheter, 3D anatomy was constructed and voltages obtained in SR and in AF. Regions were then determined to be high voltage regions (HVR) or low voltage regions (LVR) .
- 20 electrode coiled catheter conforms to shape of thin walled atrium and give a high density electrical map of the endocardial surface. A higher level of sampling points ensure a greater confidence in the substrate maps both before and after ablation therapy.
- The presence of a low voltage gradient within the LVB Connection to isolated HVRs The ability to demonstrate a narrow connection from one region to the other.
- This patient has a persistent left SVC connecting to the coronary sinus. Low voltage areas are visible in both the left and right sided SVC as well as at the OS of the coronary sinus.
- Abstract written and submitted, and the theory was tested in the lab.
- Ablation was targeted to the LVB. AF was terminated in all patients following LVB ablation in both the right and left atrium. Large areas of low voltage regions became electrically silent following HVR isolation and residual HVR were isolated from other HVR. Importantly, LVB were observed in all pts and were independent of the rhythm during mapping.
- Fusion of the cryo lesion onto the CT of the left atrium and pulmonary veins show lesions effecting the bridges occur in areas that are common to ablate for WACA and PVI ablations.
- The voltage gradients between high voltage areas (the purple areas) were dramatically different after the ablation. Therefore we conclude the atrial substrate is different, theoretically less prone to initiation and continuation of Atrial Fibrillation.