PROCEDURE PERFORMED:
1. Catheter ablation of atrial fibrillation by pulmonary vein isolation.
2. Catheter ablation of complex fractionated electrograms at the left atrial
roof.
3. Comprehensive EP study with left ventricular pacing and recording.
4. Intracardiac electrophysiologic 3D mapping.
5. Intracardiac echo.
6. Transseptal puncture x1.
7. Programmed stimulation and pacing after IV drug infusion isoproterenol.
8. Implantation of St. Jude implantable cardiac memory loop recorder system.
PREOPERATIVE DIAGNOSIS:
Atrial fibrillation.
POSTOPERATIVE DIAGNOSIS:
Paroxysmal atrial fibrillation.
COMPLICATIONS:
None.
SPECIMEN TAKEN:
None.
ESTIMATED BLOOD LOSS:
10 mL.
CONTRAST:
Zero.
SEDATION:
Per general anesthesia.
BRIEF SYNOPSIS:
XXXXXX is a XXXXXX with past medical history of
tachycardia mediated cardiomyopathy, EF 40 to 45%, diastolic heart failure,
hypertensive heart disease, paroxysmal atrial fibrillation on amiodarone
therapy. He is seen and examined, deemed appropriate for atrial fibrillation
for rhythm control.
DESCRIPTION OF PROCEDURE:
The patient was brought to the EP lab in a fasting state whereupon he was
connected to blood pressure, pulse oximetry, and electrocardiographic
monitoring. An anesthesiologist was present and participated in the entire
procedure for administration of sedation and continuous monitoring vitals. He
presented in normal sinus rhythm. After the right groin was prepped and draped
in usual sterile fashion, 3 venous access were obtained in the right femoral
vein. Three J-tipped 0.035 inch guidewires were advanced into the right
femoral vein via modified Seldinger technique. Two SL0 and 1 short 8-French
sheath were advanced over the guidewires into the IVC. At different points in
time, catheters were placed within the high right atrium, His, coronary sinus,
right ventricle, left atrium, left ventricle.
A single transeptal puncture was performed guided by fluoroscopic, hemodynamic,
and intracardiac echo. A BRK needle was advanced into the SL0 sheath. This
was withdrawn to the level of the fossa ovalis. Tenting of the septum was
observed on intracardiac echo. Following this a SafeSept guidewire was
inserted through the BRK needle across the interatrial septum into the left
superior pulmonary vein. The BRK needle, dilator, and sheath were then
advanced into the left atrium. Intravenous heparin was administered to
maintain an ACT of 300 to 350 throughout the course of the procedure.
A Biosense Webster 3.5 mm irrigated tip, J-curve SmartTouch SF ablation
catheter was inserted into the second SL0 sheath and advanced across the
initial transseptal puncture site in the left atrium.
A 3D electroanatomic mapping system (CARTO) and PentaRay catheter were utilized
to recreate geometry of the left atrium and pulmonary veins. The PentaRay
catheter was inserted into the left ventricle and mitral annular points were
marked on CARTO. All 4 pulmonary veins demonstrated potential wide area.
Antral encircling lesions were delivered to isolate all 4 pulmonary veins. An
esophageal probe marked the esophagus and careful attention was paid to avoid
damage to it. At no point in time did the esophageal temperature rise more
than 0.3 degree during ablation. Careful attention was also paid to avoid
damage to the phrenic nerve prior to ablation of the right-sided pulmonary
veins. High-output pacing at 20 milliamps 10 milliseconds was performed at the
ostium of the right-sided pulmonary veins prior to ablation. There was no
evidence of diaphragmatic stimulation over those parts. Following isolation of
all 4 pulmonary veins, I then targeted complex fractionated electrograms at the
left atrial roof between the left and right superior pulmonary veins
effectively creating a roof line. Bidirectional block was achieved across the
roof. 18 mg of adenosine was administered and there was evidence of right-
sided pulmonary vein reconnection. Further ablation was performed around the
roof as around the right inferior pulmonary vein, which subsequently resulted
in re-isolation of those veins. An additional 18 mg of adenosine was
administered and there was no evidence of pulmonary vein reconnection.
Comprehensive EP study was then performed. Sinus cycle length was 720
milliseconds, PR 130, QRS 135, QT 42, AH 85, HV 35, AV block 310, VA block 510,
AV node ERP less than 200 at 500.
Isoproterenol was then initiated up to 10 mcg. On isoproterenol, sinus cycle
length was 680 milliseconds, PR 166, QRS 115, QT 360, AH 73, HV 35, AV block
290, VA block 350, AV node ERP less than 200 at 400. Intracardiac echo post
ablation showed no evidence of pericardial effusion. 50 mg of protamine was
delivered intravenously. All sheaths and catheters removed and hemostasis was
achieved with manual pressure.
Following this, a St. Jude cardiac memory loop recorder system was implanted.
The skin was incised using the implant tool at the fourth intercostal space, 2
cm lateral to the left edge of the sternum. The implant trocar was used to
tunnel into the subcutaneous tissue and the loop recorder was advanced into
place using the plunger tool. The implant tool was removed and pressure was
held. A sterile sleeve was applied and confirmed adequate R-wave measurements.
Pressure was held until there was minimal bleeding and then the wound was
dressed and covered with Dermabond, Telfa, and Tegaderm