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Preventable complications
- 1. Preventable complications- How toavoid bad outcomes. Bob West Mercy Hospital Electrophysiology
- 2. Disclosure of Relationships Bob West,B.S., RCVT, CEPS Still employed!!
- 3. Disclosure of Relationships Participated inTTOP trial ………………Ablation Frontiers adverse device complications. Participated in STOP AF trial …………..Arctic Front balloon CryoCath Briefly participated in ENABLE study …………….Cardiofocus Laser balloon study stopped Participating in Voltage mapping collection for a novel approach to guided therapy
- 4. History of ArrhythmiaAblation 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 =26 years of RF catheter ablation experience
- 5. RF, standard andirrigated Radiofrequency energy---resistance heats tissue 4mm,5mm,8mm 10mm deeper and wider lesions
- 6. Cryo, standard andballoon nitrous oxide freezes tissue
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- 9. EP 120 channelphysiology recorder with programmable stimulator
- 10. PVI goal isto electrically isolate the pulmonary veins
- 11. Safe and reliabletranseptal access a steerable introducer gives added flexibility for achieving good lesions
- 12. INTRA CARDIAC ECHOimaging for Ablation Pre ablation anatomic orientation
- 13. Ablation Goals (what isall this stuff for?) Maximize Success Reduce Complications
- 14. Death as acomplication 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
- 15. J Am CollCardiol 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
- 16. Other 12 deathsincludes…….. 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)
- 17. Monitor the vitalsigns---old school!
- 18. We routinely monitorfemoral 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
- 19. Have the vitalsigns changed? Stable hemodynamics Early recognition
- 20. Abnormal central Aopressure Pulsus paradoxus Tamponade COPD Pulmonary embolism
- 22. Quick action andcalm heads Have equipment for tap available now Critical to act soon!
- 23. Can recent additionsto technology improve outcomes?
- 24. 3-D Mapping Ensite Velocity 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
- 25. Ensite with fusionon CT
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- 27. RELEASED IN JANUARY2011 STOP AF trial Cryo balloon Pulmonary vein isolation
- 28. Round balloon inan oval/egg shape hole! Some part of the ring will be missed!!
- 29. To touch upmissed area Freezor Max or RF lesions are used or the Balloon repositioned and repeated
- 30. PVI goal isto electrically isolate the pulmonary veins Pre cryo Post cryo
- 31. Esophagus damage afterEsophagusdamage 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.
- 32. To date noesophageal fistula has been seen in cryo procedures. NOT true anymore!!!! 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
- 33. Fistula causing airembolus to brain
- 34. TTOP Linear Ablation AblationFrontiers
- 35. Linear lesions tothe roof and Septum Ablation Frontiers
- 36. technology to improveoutcome
- 37. 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
- 38. Location, size, branchingand number of pulmonary veins PA CT of Left atrium Red LA Green distal PV’s White esophagus
- 39. Size and locationof atrial appendage
- 40. Proximity of esophagusto PV antrum
- 41. Pulmonary vein ostiaare not round
- 42. If you knowthere is a risk Take every effort to avoid a bad outcome
- 43. Phrenic nerve proximityto ablation site (A)pre ablation (B)phrenic palsy (C)recovery
- 44. Sanchez-Quintana found theanterior wall of the RSPV is <2mm from the right phrenic nerve in 32% of their autopsy series
- 45. Phrenic nerves areindependent
- 46. Coronary artery proximityto isthmus ablation site common atrial flutter 68 yo man
- 47. Is deeper andwider 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
- 48. Is something importantnear 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
- 49. 15 year oldmale Epstein's anomaly with WPW pacing RV- right side posterior Accessory Pathway is common
- 50. RCA 4mm fromright atrial endocardial surface
- 51. Cryo lesion paintto 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
- 52. RF lesion intoVenticle
- 53. Steam pops? Whatcauses bubbling and popping? Local heating causes water content to vaporize High temperature inside tissue causes water vaporization and explosion, which is popping At high power Inadequate cooling capacity of irrigation flow High temperature inside tissue, which is not cooled directly by irrigation flow, can cause popping as well SJM Solution Controlling the amount of power according to preset temp
- 54. Typical rupture ofintramyocardial structure due to overheating. Evaporation of tissue liquid led to the formation of gas bubbles that escaped by tearing the endocardium. Visible is a crater discolored by carbonization
- 55. What is thefuture? built in Safety and a quick arrival at the goal Beautifully engineered
- 56. Beautiful simplicity "Things shouldbe made as simple as possible, but not simpler." — Albert Einstein (1879–1955)
- 57. Low voltage bridgesoccur in both atriums and their veins LSVC LSVC RAA
- 58. Importance of lowvoltage 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
- 59. 10 patients undergoingAF ablation Cryo lesions
- 60. The ability tomap atrial substrate makes apparent the fundamental structures necessary to maintain and propagate AF
- 61. In all 10patients, AF was terminated to sinus rhythm
- 62. The voltage gradientsas well as high voltage areas were dramatically altered Voltage pre ablation Voltage post ablation
- 63. Published in Europace 19April 2011 13, 1188–1194 Direct visualization of the slow pathway using voltage gradient mapping: a novel approach for successful ablation of atrioventricular nodal reentry tachycardia Steven J. Bailin , Matt A. Korthas, Neal J.Weers, and Craig J. Hoffman
- 64. It looks likethis is a good tool! AVNRT PW anatomy Voltage guided cryo
- 65.
Editor's Notes
- #2 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.
- #3 I was required to disclose this information
- #5 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.
- #6 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 our physician…….. irrigated systems have a lower tip to tissue temperature……as a result less char and thrombus…….RF lesions can cause vein stenosis.
- #7 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
- #8 We did two ENABLE patients,………… the study has discontinued.
- #9 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 all three of our labs. quality is good enough to do coronary interventions in these rooms, but we don’t tell the angiographers!!!!!
- #10 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.
- #11 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!!!
- #12 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.
- #13 We occasionally 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. ICE is used for complex anatomy or to rule out thrombus. we do use echo for Detection of complications
- #14 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.
- #15 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)
- #16 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….
- #18 Quality care starts with the details……..Pulse, respirations, O2 sats, BP, ETCO2, arterial waveform. Watch for elevated central venous pressure.
- #19 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.
- #20 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.
- #22 WATCH FOR: Patient in variable degrees of shock or extremis. Neck veins distended,heart sounds distant,venous pressure elevated, and……………. Finally decreased arterial and pulse pressures.
- #23 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.
- #25 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………
- #26 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. We have stopped using Hybrid with cryo and either use RF or Arctic Front balloons for most AF patients.
- #27 These research tools are not released for general use in the US.
- #28 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.
- #29 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.
- #30 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.
- #31 Rejoice, this vein is isolated!!!!!! (tab) Stim in CS at 800ms not transmitted down the vein
- #32 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.
- #33 (1….2) None of the atrioesophageal fistula (5 patients) out of 32,569 patients….. were caused by cryo lesions. All 5 were rf related.
- #35 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.
- #36 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 ………….
- #37 Not yet released research technology , ….. so we work daily with the tools that are available to us in the US.
- #38 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 anatomic variability is very useful.
- #39 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.
- #40 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.
- #41 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.
- #42 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.
- #44 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.
- #45 Anytime you are working in the SVC, high RA, Right superior or inferior 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
- #47 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.
- #48 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?????
- #49 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.
- #50 Posterior caudal ……Kent bundle mapped by pacing the RV and mapping for early activation on the right atrial posterior wall.
- #51 The right posterior endocardial surface was 4mm from the middle of the RCA in this still image.
- #52 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.
- #56 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.
- #57 I hope and pray for a simpler life for all of us.
- #58 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.
- #59 Abstract written and submitted, and the theory was tested in the lab.
- #60 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.
- #62 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.
- #63 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.
- #64 It took 2 years to get this technique published!!!
- #65 Direct visualization of the slow pathway using voltage gradient mapping: a novel approach for successful ablation of atrioventricular nodal reentry tachycardia Steven J. Bailin 1*, Matt A. Korthas2, Neal J.Weers3, and Craig J. Hoffman4 Figure 1 (A) The anatomy of the Triangle of Koch is displayed. The triangle is formed by an area bounded by the Tendon of Todaro, the coronary sinus ostium, and the septal leaflet of the Tricuspid valve. The atrioventriular node and bundle of His are located at the apex of Koch’s triangle (Image courtesy of Robert H. Anderson). (B) The Triangle of Koch is outlined over a 3-D voltage gradient map. The region of interest containing the slow pathway associated low-voltage bridge is contained within this outline. (C) The 3-D map is projected over the anatomic preparation. The atrioventriular nodal region is projected over the apex of Koch’s triangle. Figure 2 (A) A discrete Type I low-voltage bridge connection is seen in the voltage gradient map recorded at baseline. Here the low-voltage bridge is seen spanning the atrial septum from the coronary sinus ostium to the AV node. (B) An ablation lesion placed within the slow pathway associated low-voltage bridge changes the voltage gradient map following ablation. No low voltage bridge is observed and the high-voltage region of the coronary sinus ostium no longer connects with the atrioventriular nodal region. This finding correlates to a successful slow pathway ablation and inability to re-induce atrioventricular nodal reentry tachycardia or consistent atrioventriular nodal echoes. (C) A Type II low-voltage bridge is shown narrowly connecting two high-voltage regions with a small high-voltage isthmus. Successful ablation required lesions below and above the high-voltage isthmus. (D) Following ablation, no further connection is seen linking the coronary sinus ostium to the atrioventriular node. No further tachycardia was inducible
- #66 Figure 3 (A) A Type I slow pathway associated low-voltage bridge is observed during the initial voltage gradient map. (B) During programmed stimulation, progressive S2 pre-mature stimulation results in refractory slow pathway conduction. As noted in this figure, the slow pathway associated low-voltage bridge is now absent. (C) Following ablation, the slow pathway associated low-voltage bridge is gone and no further voltage connection is seen connecting the coronary sinus ostium to the atrioventriular node.