Avoidable Complication of Defibrillator Implantation: Retained Operative Sponge

This PA and Lateral CXR was taken the day after an uneventful defibrillator implantation. I have saved these images for close to a decade as I never wanted to forget this is always a possibility. In full disclosure, this was not a procedure I performed.

This was an eye opening case of an operative sponge left in the pocket. As I recall, the patient was very gracious and sponge was extracted uneventfully the following day. Years later a practice partner of mine called me about an interesting case he was doing on a generator change in a can that went ERI at 8 years. He found an oddly healing pocket and ultimately dissected this sponge (see following picture) out from the pocket. Amazing that the pocket healed at all though clearly the pocket was very abnormal.

Insights into Esophageal Damage in the Setting of Atrial Fibrillation Ablation

Introduction: From the initial report of intraoperative radiofrequency (RF) ablation causing esophageal injury,GIL01 atrioesophageal fistulas (AEF) have been reported in percutaneous atrial fibrillation RF ablations.SCA04,PAP04 Atrioesophageal fistulas have been estimated to occur in as many as 1% of AF ablationsDOL03 but a commonly accepted event rate is 0.1%.PAP04,SCA04,CUM06 The mortality associated with AEF is devastating and found to be 100% in the largest published registry of AEF.CUM06 This is in stark contrast to a near zero death rate of atrial perforations during RF ablation.BUN05 An article by Müller et al (http://www.heartrhythmjournal.com/article/S1547-5271(15)00418-X/abstract) examined the high incidence of esophageal lesions after atrial fibrillation ablations related to the use of esophageal temperature probes. Multivariate analysis revealed the use of the temperature probe was the only independent predictor of esophageal lesions. Finally, recently published data in Heart Rhythm examined the rate of atrioesophageal fistula formation with contact force (CF) sensing catheters versus non-CF-sensing catheters. Black-Maier et al found the “occurrence of atrioesophageal fistula formation accounted for a 5-fold higher proportion of all MAUDE medical device reports of injury or death with CF-sensing catheters compared with non-CF-sensing catheters.”

 

Value of Imaging: The value of intracardiac imaging via radial intracardiac echo (ICE) cannot be underestimated given the nonuniform thickness and variable course along the posterior wall of the left atrium.SAN05,GOO05,REN06 The proximity of the esophagus to the left pulmonary venous antrum is depicted in Figure 1. Typically, patients with AEF present a mean of 12.3days after their procedure;CUM06 however, presentation within 3-5days of the ablation has been reported.PAP04 Findings on CT scans can be non-specific but, infected pleural and pericardial effusions may suggest esophageal contamination of the pleural spaces. CT scan of the chest (without oral contrast) with the presence of intravenous contrast seen in the esophagus or surrounding posterior mediastinum would imply a fistulous connection.MAL07 Additionally, one may note a narrowed, irregular, and ulcerated pulmonary vein, posterior left atrial wall thickening, posterior mediastinal fat induration, or pneumomediastinum.MAL07

Imaging Demonstrated Proximity of Esophagus to Left Pulmonary Veins. The top left inset of the figure depicts the 3D reconstruction of the left atrium and pulmonary veins with the esophagus tagged in red. The course of the esophagus is along the posterior left atrium in contiguity to the left pulmonary vestibule. The ICE image of the left pulmonary vestibule shows the characteristic echocardiographic signature of an esophageal temperature probe in the 8 o’clock position.
Imaging Demonstrated Proximity of Esophagus to Left Pulmonary Veins. The top left inset of the figure depicts the 3D reconstruction of the left atrium and pulmonary veins with the esophagus tagged in red. The course of the esophagus is along the posterior left atrium in contiguity to the left pulmonary vestibule. The ICE image of the left pulmonary vestibule shows the characteristic echocardiographic signature of an esophageal temperature probe in the 8 o’clock position.

 

Mechanism of Esophageal Injury: Finite-element analysis supports that esophageal injury is exclusively due to thermal conduction from the atrium.BER05 Esophageal injury can occur despite small electrode size, low power (<30W), and low electrode temperature (34°C). There are two caveats however, irrigated electrodes and electrode-endocardial contact verification (direct visualization with ICE or force-sensing) may increase power delivery to the tissue.

 

Avoiding Esophageal Injury: There has been much enthusiasm to determine means by which esophageal injury can be avoided. These include echocardiographic monitoring for microbubble formation,CUM05 the use of cryoablation to lower esophageal ulceration,RIP07 plan ablations to avoid esophagus by creating virtual esophageal tube using electroanatomic mapping,SHE07 esophageal irrigation to lower esophageal temperature,TSU07 and physically deflecting the esophagus away from the ablation site.HER06 The study by Muller et alMUL15 suggests the possibility that esophageal temperature probes may increase susceptibility to esophageal lesions. Figure 2 shows ICE images before and after orogastric tube removal. One notes the signature of the OGT at 8 o’clock in the left image. There is a small indentation in the posterior left atrial wall at the site of the OGT. On the right, imaging demonstrates this indentation is resolved after removal of the OGT. I make efforts to remove esophageal instrumentation to avoid any possible displacement of the esophagus towards the left atrium.

Intracardiac Echocardiography (ICE) of Orogastric Tube (OGT). The left image depicts the ICE signature of the OGT at ~8 o’clock. There is a small indentation in the posterior left atrial wall at the site of the OGT. On the right, ICE demonstrates the resolution of this indentation after removal of the OGT.
Intracardiac Echocardiography (ICE) of Orogastric Tube (OGT). The left image depicts the ICE signature of the OGT at ~8 o’clock. There is a small indentation in the posterior left atrial wall at the site of the OGT. On the right, ICE demonstrates the resolution of this indentation after removal of the OGT.

CF-sensing catheters have certainly enhanced ability to deliver more consistent lesions however, there are clearly limitations when the operator cannot see real-time electrode-endocardial contact. There have been many times where I have seen left and right atrial tenting due to catheter contact at less than 10g of force. Force sensing has certainly added to our armamentarium but I would caution all that there is more to ablation than contact force.

 

Note:  These radial ICE images would not be possible without my mentor, Dr. David Schwartzman (Pittsburgh, PA).

REFERENCES:

GIL01  Gillinov AM, Pettersson G, Rice TW, “Esophageal injury during radiofrequency ablation for atrial fibrillation,” J Thor Card Surg, V. 122, No. 6 (December 2001), pp. 1239-1240.

SCA04  Scanavacca MI, D’Avila A, Parga J, Sosa E, “Left Atrial-Esophageal Fistula Following Radiofrequency Catheter Ablation of Atrial Fibrillation,” J Cardiovasc Electrophysiol, V. 15, No. 8 (August 2004), pp. 960-962.

PAP04  Pappone C, Oral H, Santinella V, Vicedomini G, Lang CC, Manguso F, Torracca L, Benussi S, Alfieri O, Hong R, Lau W, Hirata K, Shikuma N, Hall B, Morady F, “Atrio-Esophageal Fistula as a Complication of Percutaneous Transcatheter Ablation of Atrial Fibrillation,” Circulation, V. 109 (June 8, 2004), pp. 2724-2726.

DOL03  Doll N, Borger MA, Fabricius A, Stephan S, Gummert J, Mohr FW, Hauss J, Kottkamp H, Hindricks G, “Esophageal perforation during left atrial radiofrequency ablation: Is the risk too high?” J Thor Cardiovasc Surg, V. 125, No. 4 (April 2003), pp. 836-842.

CUM06  Cummings JE, Schweikert RA, Saliba WI, Burkhardt D, Kilikaslan F, Saad E, Natale A, “Brief Communication: Atrial-Esophageal Fistulas after Radiofrequency Ablation,” Ann Int Med, V. 144, No. 8 (18 April 2006), pp. 572-574.

BUN05  Bunch TJ, Asirvatham SJ, Friedman PA, Monahan KH, Munger TM, Rea RF, Sinak LJ, Packer DL, “Outcomes After Cardiac Perforation During Radiofrequency Ablation of the Atrium,” J Cardiovasc Electrophysiol, V. 16, No. 11 (November 2005), pp. 1172-1179.

SCH06  Schwartzman DS, Nosbisch J, and Housel Debra, “Echocardiographically guided left atrial ablation: Characterization of a new technique,” Heart Rhythm, V. 3, No. 8 (August 2006), pp. 930 –938.

SAN05  Sanchez-Quintana D, Cabrera JA, Climent V, Farre J, de Mendonca MC, Ho SY, “Anatomic Relations Between the Esophagus and Left Atrium and Relevance for Ablation of Atrial Fibrillation,” Circulation, V. 112 (September 6, 2005), pp. 1400-1405.

GOO05  Good E, Oral H, Lemola K, Han J, Tamirisa K, Igic P, Elmouchi D, Tschopp D, Reich S, Chugh A, Bogun F, Pelosi F Jr, Morady F, “Movement of the Esophagus During Left Atrial Catheter Ablation for Atrial Fibrillation,” JACC, V. 46, No. 11 (December 6, 2005), pp. 2107-21190.

REN06  Ren J-F, Lin D, Marchlinski FE, Callans DJ, Patel V, “Esophageal imaging and strategies for avoiding injury during left atrial ablation for atrial fibrillation,” Heart Rhythm, V. 3, No. 10 (October 2006), pp. 1156-1161.

MAL07  Malamis AP, Kirshenbaum KJ, and Nadimpalli S, “CT Radiographic Findings: Atrio-esophageal Fistula After Transcatheter Percutaneous Ablation of Atrial Fibrillation,” J Thorac Imaging, V. 22, No. 2 (May 2007), pp. 188-191.

BER05  Berjano EJ and Hornero F, “What affects esophageal injury during radiofrequency ablation of the left atrium? An engineering study based on finite-element analysis,” Physiol Meas, V. 26 (2005), pp. 837-848.

CUM05  Cummings JE, Schweikert RA, Saliba WI, Burkhardt JD, Brachmann J, Gunther J, Schibgilla V, Verma A, Dery MA, Drago JL, Kilicaslan F, Natale A, “Assessment of Temperature, Proximity, and Course of the Esophagus During Radiofrequency Ablation Within the Left Atrium,” Circulation, V. 112 (July 26, 2005), pp. 459-464.

RIP07  Ripley KL, Gage AA, Olsen DB, Van Vleet JF, Lau C-P, Tse H-F, “Time Course of Esophageal Lesions After Catheter Ablation with Cryothermal and Radiofrequency Ablation: Implication for Atrio-Esophageal Fistula Formation After Catheter Ablation for Atrial Fibrillation,” J Cardiovasc Electrophysiol, V. 18, No. 6 (June 2006), pp. 642-646.

SHE07  Sherzer AI, Feigenblum DY, Kulkarni S, Pina JW, Casey JL, Salka KA, Simons GR, “Continuous Nonfluoroscopic Localization of the Esophagus During Radiofrequency Catheter Ablation of Atrial Fibrillation,” J Cardiovasc Electrophysiol, V. 18, No. 2 (February 2007), pp. 157-160.

TSU07  Tsuchiya T, Ashikaga K, Nakagawa S, Hayashida K, Kugimiya H, “Atrial Fibrillation Ablation with Esophageal Cooling with a Cooled Water-Irrigated Intraesophageal Balloon: A Pilot Study,” J Cardiovasc Electrophysiol, V. 18, No. 2 (February 2007), pp. 145-150.

HER06  Herweg B, Johnson N, Postler G, Curtis AB, Barold SS, Ilercil A, “Mechanical Esophageal Deflection During Ablation of Atrial Fibrillation,” PACE, V. 29 (September 2006), pp. 957-961.

MUL15  Müller P, Dietrich J-W, Halbfass P, Abouarab A, Fochler F, Szöllösi A, Nentwich K, Roos M, Krug J, Schade A, Mügge A, Deneke T, “Higher incidence of esophageal lesions after AF ablation related to the use of esophageal temperature probes,” Heart Rhythm, Published Online: April 03, 2015.

What did you learn from your first “real” job?

The iconic Olga’s Diner in Evesham, NJ

Delivering papers, cutting grass, washing cars and shoveling snow were all formative jobs of mine and I suspect most would jump to their first job out of college or intern year. Given my engineering degrees, my first “real” job should have been selling apps I developed programming in BASIC with my dad’s state-of-the-art Radio Shack TRS-80 but alas there was not a large market for Pong at the time. My first “real” job was bussing tables at Olga’s Diner where I got that first paystub and the reality of paying taxes hit hard. I learned a lot during that summer and certainly it registered enough “likes” in my daughter’s brain to trigger a quick text from her when she was visiting family. My kids have heard me go on and on about this job and my daughter recently sent me a picture showing the South Jersey icon Olga’s Diner being demolished. The picture made me smile thinking about the lessons I learned from that job.

Honesty. The first day on the job I was offered a deal to sneak tips into the bus pan and the dishwashers would split the take with me 50:50. This was an easy first lesson. Don’t steal.

Punctuality. You don’t show up on time, you don’t get those hours on the paycheck.

Humility. It builds character to be the bottom rung of the restaurant ladder and doesn’t hurt to be forced to change before you walk into the house because of the kitchen smell embedded into your clothes.

Interpersonal Communication. At the end of summer, I had to give my 2 weeks notice so I could return to school. My middle-aged boss with a heavy Greek accent initially refused to accept my resignation. Ultimately he did accept my resignation but I translated his first response to mean that I was a hard worker and my absence would be his loss.

Parenting. My parents had to drop me off and pick me up every day (I was only 15 and biking to the corner of Routes 70 and 73 was not a great idea). They knew the lessons the job would teach me were more valuable than that pine-scented tree hanging on the dash to overcome the South Jersey diner kitchen stink that I reeked of.

Career Planning. I learned about career preferences such as air conditioning and whether I not to continue with the hard work and long hours of the restaurant business.

Pride. It’s a good feeling to tell your friends how hard you worked all day. Even nicer to have your work ethic rewarded by a boss who wanted you to abandon school and bus dishes full time.

Work Ethic. The diner was a frenetic place and every job has got to be done efficiently or the whole process breaks down. No dishes or glasses translate into angry patrons. One work-averse employee hurts everyone.

Learning on the job. Like any job, people may just assume you know the nuances but you’ve got to adapt. I was handed a large, gray bus pan and told to get started; I looked around for a server that already seemed to be angry with me and brought my new gray partner. Once I dealt with every dirty table, I then learned the most important 3 lessons in work life: Keep your head down, mouth shut and always be seen working! I can usually follow two of those three at any given time.

Preparing for a job interview. Clearly, my resume at the time was somewhat thin but got my first experience with interview questions such as “Will you show up on time?” “Do you have a ride?” and “Are you a hard worker?”

Respect for others. Simple courtesies like “please” and “thank you” go a long way. Respect servers at a restaurant… especially before you get your meal!

Common sense. I met hard working people who may not have scored well on standardized tests but had tons of common sense… Don’t scoop ice with a glass, only enter the right side of swinging doors, and reward hard work with a tip when appropriate. I learned nonsmokers looked younger and didn’t cough all day.

Great desserts can follow humble meals. To this day, I have never had better cheesecake than Olga’s Diner!

Pay attention to the new young, unfamiliar face at your factory, hospital, or office; this may be their first “real” job and what are you going to teach them?

Radial Intracardiac Echocardiography (ICE) Anatomy of Coronary Sinus

Radial intracardiac echocardiography adds significant anatomic correlation during invasive EP studies. In particular, coronary sinus (CS) anatomy can be evaluated during CS access or ablation of the slow AV nodal pathway during AVNRT ablations.  A steerable sheath (Agilis, St. Jude Medical) flushing with saline holds a 9MHz radial ICE catheter (UltraICE, Boston Scientific Corporation) and is positioned along the inferoseptal aspect of the tricuspid annulus.

Radial ICE CS Os Anatomy Final

The left image shows the posterior aspect of the CS os and you can often visualize the right coronary artery (RCA) in this view. One can see a thickened roof of CS (or often a prominent Eustachian ridge).  As the steerable sheath holding the ICE probe is advanced toward the right ventricle (RV), the main CS is brought into view as seen in the middle image.  As you move more ventricular, the septal insertion of the tricuspid valve leaflet is brought into view.  Finally, the right image depicts the radial ICE view when the anterior aspect of the CS os is brought into view as the probe is advanced even closer to the RV.  This is where the traditional position of the slow AVN pathway is found – the slow AV node pathway is generally located at the anterior edge of the CS os near the septal insertion of the tricuspid leaflet.

A nice anatomic study from Choure et al (“In Vivo Analysis of the Anatomical Relationship of Coronary Sinus to Mitral Annulus and Left Circumflex Coronary Artery Using Cardiac Multidetector Computed Tomography: Implications for Percutaneous Coronary Sinus Mitral Annuloplasty,” JACC, Vol. 48, No. 10, 2006) shows some detailed CT imaging of the relation between the coronary arteries and coronary sinus.  The following image (taken from Choure et al) gives a nice visualization of the CS os and its relation to the RCA.  One can see the circumflex crossing the mid-distal CS.  They found the circumflex artery crossed the CS at a variable distance from the CS os (ranging 37 to 123 mm).

RCA and Circ Relation to CS on CT

For more information about the use of radial ICE during EP studies:

Radial Intracardiac Echo Guided Ablation of AVNRT

Radial Intracardiac Echocardiography Guidance in the Electrophysiology Lab

Radial Intracardiac Echo (ICE) Guided Atrial Fibrillation Ablation

Intracardiac echo guided atrial fibrillation ablations: From transeptal puncture guidance to intra left atrial ICE guided ablation.

Atrial fibrillation ablations can be accomplished using radial intracardiac echocardiographic (ICE) guidance and can help minimize fluoroscopic use.  ICE imaging is initially used during left-sided ablations by facilitating transeptal punctures. Next, radial ICE can be placed in the left atrium to guide atrial fibrillation ablations and demonstrate stable ablation electrode-endocardial contact. Clearly, contact force-sensing ablation catheters have helped assess electrode-endocardial contact but radial ICE allows the operator to directly visualize contact. Furthermore, direct ICE visualization permits assessment of endocardial tissue deflection as well as anatomic guidance to help make left-sided ablations safer (e.g., location of esophagus, thickness of left atrial regions, etc). A full description of radial ICE-guided atrial fibrillation ablation has been previously described (1,2,3) but we will take a more detailed ICE tour of the ablative process.

Radial ICE Guided Transeptal Puncture:

Transseptal Punctures can be safely performed using radial ICE guidance.  A suitably sized Mullins introducer sheath (10-11 French) can be used to position the radial ICE catheter along the interatrial septum as shown in Figure 1.  The Mullins sheath provides enough maneuverability to adjust the ICE catheter position in both inferior-superior and anterior-posterior directions to optimize the location of transseptal puncture in the fossa ovalis.  Once ICE localization of transseptal needle showing tenting of the septum in suitable fossa is obtained LAO fluoroscopy is then used to guide the transseptal puncture and advancement of left atrial sheath.

 Radial ICE Guidance of Transseptal Puncture for Left Atrial Access
Radial ICE Guidance of Transseptal Puncture for Left Atrial Access

Figure 1 Radial ICE Guidance of Transeptal Puncture for Left Atrial Access.  The left and right atria are well-visualized with the ICE catheter in the right atrium along the interatrial septum in the fossa ovalis.  One can see the tenting evident when transseptal needle is in good contact with the interatrial septum.

 

The following video shows the interatrial septum with radial ICE located in the right atrium. You see tenting of the septum and subsequent transeptal puncture facilitating left atrial ablation. Once transeptal access is achieved using an 8F Mullins sheath, a long wire exchange is performed to allow placement of the steerable sheath through which radial ICE is placed. An additional transeptal puncture is performed and wire exchange placement of 8.5Fr SRO sheath through which an irrigated tip ablation catheter is placed.

Intra Left Atrial Radial ICE:

Left Atrial Ablations can be enhanced and accomplished using intra left atrial radial ICE (with intraprocedural heparinization for target ACT>300).  [1,2,3] Radial ICE is a useful adjunct imaging technique for several reasons.  First, direct visualization of the electrode-endocardial interface allows precise positioning of the ablation electrode to guide lesion formation.  Second, radial ICE permits the delivery of “focal” left atrial ablative lesions; the electrode kept in same location throughout energy application by manipulating the ablation electrode into firm, stable endocardial contact during continuous ICE imaging of the electrode–endocardial interface.  Third, the use of continuous radial ICE during atrial fibrillation ablations allows close monitoring of catheter position and endocardial contact while minimizing dependence on fluoroscopy.  Figure 2 depicts a typical view obtained when radial ICE is positioned in the left atrium using a steerable sheath (Agilis, St. Jude Medical, Inc., St. Paul, MN).

Intra Left Atrial Radial ICE Imaging During Atrial Fibrillation Ablation Left Pulmonary Venous Antrum Isolation
Intra Left Atrial Radial ICE Imaging During Atrial Fibrillation Ablation Left Pulmonary Venous Antrum Isolation

Figure 2  Intra Left Atrial Radial ICE Imaging During Atrial Fibrillation Ablation Left Pulmonary Venous Antrum Isolation. The radial ICE catheter is positioned at the entrance to the left PV antrum with the tip of the ablation catheter (Thermocool irrigated tip, Biosense Webster Inc, Diamond Bar, CA) located at ~9 o’clock on the antrum.  The inset shows the analogous location of ablation catheter on 3D CT reconstruction of the left PV antrum.

Detailed anatomy of the pulmonary veins can also aid in catheter positioning and stability as well as monitor for procedural complications. Figure 3 provides views of the left and right pulmonary vestibules. The left upper (LUPV) and lower pulmonary veins (LLPV) are visualized as are the saddles. The right intervenous saddle is not as clearly differentiated as the left in this particular example to give the reader a better overall view of the structures surrounding the right pulmonary vestibule such as SVC, main PA, and Waterston’s groove (WG). Waterston’s groove is a fat-filled depression formed as the left and right atria fold into one another; Waterston’s groove is often dissected by surgeons to expose the left atrium. Radial ICE can be carefully placed within each individual pulmonary veins to guide catheter ablation as previously described. [1,2,3]

 

Radial ICE Anatomy of Left and Right Pulmonary Vestibules
Radial ICE Anatomy of Left and Right Pulmonary Vestibules

Figure 3  Radial ICE Anatomy of Left and Right Pulmonary Vestibules. The right pulmonary vestibule is shown with the early portions of the upper and lower pulmonary veins. Superior to the right pulmonary veins one can see the main pulmonary artery and superior vena cava. The approximate location of Waterston’s groove is depicted by the solid line.  A more distal view of the left pulmonary vestibule (compared to Figure 2) clearly differentiates the upper and lower PV’s as well as the intervenous saddle.

 

Intra Left Atrial ICE-Guided Atrial Fibrillation Ablation via Wide Pulmonary Venous Antrum Isolation:

Left Pulmonary Venous Antrum Isolation

Once double transeptal access is obtained, the posterior left atrium pulmonary antrum isolation is started. I generally create a Fast Anatomic Mapping (FAM and CARTO, Biosense Webster, Inc., Diamond Bar, CA) shell of the left atrium trying to capture the anatomy of the left and right pulmonary veins to accurately recreate similar anatomy from the preoperative CT scan.  This FAM shell is a complement to the real-time radial ICE that actually guides my ablation catheter placement.  The left pulmonary vestibule is first encircled by placing a series of focal lesions applied contigously. Ablation is performed during sinus rhythm. High-frequency ventilation is used to minimize posterior LA motion. Each encircling lesion is composed of a series of contiguously applied (defined by direct contact of adjacent CARTO icons) “focal” (e.g., electrode kept in same location throughout energy application) lesions. For each focal lesion, the ablation electrode is manipulated under ICE guidance into firm, stable endocardial contact. RF energy was delivered during continuous ICE imaging of the electrode–endocardial interface.

 

The following video shows catheter position while ablating the posterior aspect of the left pulmonary vestibule. Note the appearance of “bubbles;” this is saline irrigation during ablation.  The 3D reconstructions CT scan below the video shows the approximate site of ablation catheter and the overall goal ablative lesion set pathway for the primary encircling of the left pulmonary vestibule.

                                                               

After deployment of this primary line of encircling lesion, I document that the myocardium subtended by the lesion is electrically isolated using entrance and exit block criteria.  The radial ICE catheter is then placed into the left upper pulmonary vein (LUPV) and entrance block is assessed by examining pulmonary vein (PV) potentials; PV potentials in the LUPV are ablated down to the first branch of the LUPV.  Exit block is assessed by unipolar pacing from the ablation catheter; any LUPV capture site is ablated as I pull back toward the primary encircling lesion set. The following video shows the ICE catheter inserted into the LUPV with an esophageal probe at 11AM and the ablation catheter at 5PM.  The course of the esophagus is a bit unusual in this case and clearly lower power ablative lesions are carefully delivered (and sometimes deferred) to minimize the risk of esophageal damage.

If entrance and exit block are not documented secondary lesions are placed within the primary line to obtain isolation. One can see that radial ICE is used to guide ablation catheter position, maintain catheter stability, and watch for any endocardial damage (such as “heaping”).  Once LUPV lesions (if necessary) are completed, the ICE catheter is moved into the LLPV and the PV potential mapping/ablation process is repeated as above. The following video shows the ICE catheter being moved from the LUPV into the LLPV.

The following video shows mapping in the LLPV down to the first branch of the LLPV that is evident on ICE.

After the left pulmonary antrum is isolated, this procedure is repeated for the right pulmonary antrum.

Right Pulmonary Venous Antrum Isolation

Figure 3 depicts still frames of the pulmonary venous antrums.  The following video shows a typical view of the right pulmonary venous antrum.  The initial portion shows a real-time view of the right pulmonary venous antrum and then the ICE catheter is advanced into the RUPV; towards the end of the video you can see the ablation catheter enter the RUPV and located at the roof ~12P.

Similar to the left pulmonary venous antrum, the right pulmonary vestibule is first encircled by placing a series of focal lesions applied contigously. After deployment of this primary line of encircling lesion, I document that the myocardium subtended by the lesion is electrically isolated using entrance and exit block criteria. The radial ICE catheter is then placed into the right upper pulmonary vein (RUPV) and entrance block is assessed by examining pulmonary vein (PV) potentials; PV potentials in the RUPV are ablated down to the first branch of the RUPV.  Exit block is assessed by unipolar pacing from the ablation catheter; any RUPV capture site is ablated as I pull back toward the primary encircling lesion set. Once RUPV lesions (as necessary) are completed, the ICE catheter is moved into the RLPV and the PV potential mapping/ablation process is repeated as above. The following video shows the ICE catheter being moved from the RUPV into the RLPV.

Ultimately, a complete right and left pulmonary venous antrum isolation is completed. The final figure below shows a typical final CARTO lesion set with the analogous course of ablative lesions (including ablation within the pulmonary veins) shown on the 3D CT reconstruction.

Summary:

Left and right pulmonary venous antrum isolation can be completed using intra left atrial radial ICE guidance with the complementary use of 3D intracardiac mapping.  The radial ICE ensures stable endocardial contact and guides catheter/lesion placement. In addition, real-time radial ICE guidance can enhance safety by highlighting esophageal location as well as provide electroanatomic correlation.

Note: Many thanks to my mentor Dr. David Schwartzman who took the time to teach me radial ICE and atrial fibrillation ablations!

References:

1     Schwartzman D, Nosbisch J, Housel D. Echocardiographically guided left atrial ablation: characterization of a new technique. Heart Rhythm, V. 3 (2006), pp. 930–938.

2     Schwartzman D, Williams JL, “On the Electroanatomic Properties of Pulmonary Vein Antral Regions Enclosed by Encircling Ablation Lesions,” Europace , V. 11 (2009), pp. 435–444.

3     Chandhok S, Williams JL, Schwartzman DS, “Anatomical analysis of recurrent conduction after circumferential ablation,” J Intervent Card Electrophysiol, V. 27, No. 1 (January 2010), pp. 41-50.

Radial Intracardiac Echo Guided AVNRT Ablation in a Patient with Persistent Left Superior Vena Cava

Atrioventricular nodal reentrant tachycardia (AVNRT) is one of the more common arrhythmias ablated in the U.S.  There is an estimated 2-6% major and minor complication rate during electrophysiology (EP) studies with ablation. [1-3]  The average age of AVNRT patients in a prior analysis of my cases [4] was 53+/-21 years.  These patients are often young with no major comorbidities and the risk of damaging the compact AV node and causing complete heart block is low but always present.

Radial intracardiac echo (UltraICE™, Boston Scientific, Natick, MA, USA) can be used to anatomically guide slow pathway modification and ensure stable endocardial-catheter contact.  The example below is a patient with AVNRT (and persistent left superior vena cava) that could not be ablated via the traditional fluoroscopy and electrogram (EGM) guided technique despite “good” EGM’s and multiple lesions.  The ICE video shown below depicts the initial catheter position encountered when ICE catheter first placed in right atrium using steerable sheath (St. Jude Medical, Agilis).  You can see the ablation catheter adjacent to the ICE catheter and overlying the tricuspid valve though not in contact with the anatomic location of the slow AV nodal pathway.

We then positioned the ablation catheter at the anatomic location of the the slow AV nodal pathway; near the anterior aspect of the coronary sinus (CS) os at the septal insertion of the tricuspid valve leaflet.  You can see the ablation catheter positioned right on this area and single RFA resulted in long run of junctional beats and successful ablation.

I use adjunctive ICE-guidance for most AVNRT ablations; though it adds some time and complexity, I feel it maximizes patient safety and successful outcomes.  There is a great summary article by Fisher et al [5] and I have shown one of their figures below to better show the anatomy of the AV node and coronary sinus.

References:

1     Chen S-A, Chiang C-E, Tai C-T, et al. ‘‘Complications of diagnostic electrophysiologic studies and radiofrequency catheter ablation in patients with tachyarrhythmias: An eight-year survey of 3,966 consecutive procedures in a tertiary referral center’’. Am J Cardiol 1996; 77:41–46. 12.

2     ZadoES,CallansDJ,GottliebCD,etal.Efficacyandsafetyof catheter ablation in octogenarians. JACC 2000; 35:458–462. 13.

3     O’Hara GE, Philippon F, Champagne J, et al. Catheter ablation for cardiac arrhythmias: A 14-year experience with 5330 consecutive patients at the Quebec Heart Institute, Laval Hospital. Can J Cardiol 2007; 23(Suppl B):67B–70B.

4     Williams JL, Valencia V, Lugg D, Gray R, Hollis D, Toth JW, Benson R, DeFrancesco-Loukas MA, Stevenson R, Teiken PJ, “High Frequency Jet Ventilation During Ablation of Supraventricular and Ventricular Arrhythmias: Efficacy, Patient Tolerance and Safety,” The Journal of Innovations in Cardiac Rhythm Management, 2 (2011), 1–7.

5    Fisher WG, Pelini MA, Bacon ME, “Adjunctive Intracardiac Echocardiography to Guide Slow Pathway Ablation in Human Atrioventricular Nodal Reentrant Tachycardia,” Circulation, V. 96 (1997), pp. 3021-3029.

Is atrial fibrillation the “canary in the coal mine” of population health?

Perhaps we should be using atrial fibrillation (AF) as a marker for an at-risk population rather than a target for ablation? Ablations for atrial fibrillation (AF) have grown exponentially in the last few years as the technology has become widely available and catheter technology has evolved. Indeed, approximately 75000 AF ablations are performed per year at an estimated total cost of just over $1billion. AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least one Vaughan Williams class I or III anti-arrhythmic medication when a rhythm-control strategy is desired. [1] AF ablations are justified based upon a vague definition of what constitutes “symptoms” and no concrete guidance on what defines an adequate attempt at anti-arrhythmic drug therapy. There are a few caveats to proceeding with an AF ablation [1]:

 

  1. Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended.
  2. Before initiating anti-arrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended.

 

Procedural Risks and Outcomes of Ablation: When discussing the “risks, benefits, and alternatives” of any treatment recommendation, it is important to recognize inherent biases in this discussion. A recent study in JAMA [2] highlighted the worrisome issue that clinicians rarely had accurate expectations of benefits or harms of a wide variety of clinical therapies. Clinicians more often underestimated rather than overestimated harms and overestimated rather than underestimated benefits. Are the vast majority of AF ablation candidates counseled on the 4.5-12% rate of major complications [3,4,5] stemming from these procedures? This level of major complications rivals that stemming from CABG in many areas of the United States. Clearly, procedural risks of this magnitude suggest that, for persons with minimally symptomatic AF, the risk of ablation may outweigh the benefits. If only there were means by which to noninvasively reduce the burden of atrial fibrillation while we address overall population health…

 

Reversible Causes of Atrial Fibrillation: The ACC Guidelines state “Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended.” Clinical risk factors for AF include: Hyperthyroidism

Increasing age, Hypertension, Diabetes mellitus, Myocardial Infarction, Valvular Heart Disease, Heart Failure, Obesity, Obstructive Sleep Apnea, Smoking, Lack of Exercise, and Alcohol Use.  I worry a generation of electrophysiologists are missing an opportunity to profoundly impact population health by performing ablations on patients with multiple, incompletely treated systemic diseases driving their arrhythmic burden. AF ablation in these patients may be tantamount to tacit approval we have done what we can for the patient and ablative therapy is the end rather than the beginning of their atrial fibrillation management.

 

Diet and Lifestyle: Smoking is associated with more than a two-fold increased risk of AF. In addition, a trend toward a lower incidence of AF appeared among smokers who quit compared to continued smokers. [6] In healthy women, BMI was associated with short- and long-term increases in AF risk, accounting for a large proportion of incident AF independent of traditional risk factors. [7] Among elderly adults, consumption of tuna or other broiled or baked fish, but not fried fish or fish sandwiches, is associated with lower incidence of AF. [8] Consumption of alcohol is associated with an increased risk of atrial fibrillation or flutter in men (but not women). [9]

 

Blood Pressure and Lipid Control: HTN doubles the risk for AF and accounts for more AF than any other risk factor. Antihypertensives reduce the risk for AF mainly by BP lowering and there is some evidence these drugs may reduce AF via other means as well. Both ACEIs and ARBs appear to be effective in the prevention of AF. This benefit appears to be limited to patients with systolic left ventricular dysfunction or LV hypertrophy. [10] The use of statins in patients with lone AF was associated with a significant decrease in the risk of arrhythmia recurrence after successful cardioversion. [11]

 

Obstructive Sleep Apnea: Obstructive sleep apnea is associated with an increased risk of AF after undergoing AF ablation. [12] Treatment of OSA with continuous positive airway pressure reduces the risk of recurrent AF after catheter ablation. [13] Obesity is one of the strongest OSA risk factors and has become an epidemic. [14]

 

There is a disorder which, when effectively treated, may result in the primary and secondary prevention of AF. Indeed, obesity is a major influence on the development and progression of cardiovascular disease and effects physical/social functioning as well as quality of life. [15]

 

Obesity and Atrial Fibrillation: Obesity has become an epidemic and is a major risk factor for cardiovascular diseases as well as quality of life. There is extensive data indicating that weight loss can reverse the deleterious effects of obesity and are further evidence of the causal link between obesity and disease. [15] Long-term sustained weight loss is associated with significant reduction of AF burden and maintenance of sinus rhythm. [16] Indeed, Pathak et al found that this effect persisted in patients with and without antiarrhythmic drugs or ablations. Even more significant, Jamaly et al reported the effects weight loss had on primary prevention of AF. They found the risk of AF was reduced by 29% in obese patients who underwent bariatric surgery, despite a less favorable cardiovascular risk factor profile at baseline. Weight loss has demonstrated success in both primary and secondary prevention of AF.

 

 

Summary: The current AF ablation recommendations (that have led to upwards of 75000 AF ablations yearly and cost of over $1billion [18]) are based upon studies that included a few hundred patients carefully enrolled that would have excluded many current AF ablation candidates based upon age and/or comorbidities. AF clinics are an opportunity to address the population health issue and provide care for the aforementioned chronic care issues however, I worry many of these AF clinics may simply be a means to enlarge the pipeline towards AF ablation referrals. What if we took a step back from AF ablation and focused our efforts on a patient-centered approach to AF using it as a population health outcomes measure and work on addressing the non-communicable diseases such as HTN, obesity, tobacco abuse, and inactivity? This may be a good mistake to make (in terms of overall population health) if I have undervalued the role of AF ablation.

 

References:

 

  1. January CT et al, “2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society,” JACC, Vol. 64, No. 21 (2014) e1-e76.
  2. Hoffman TC and Del Mar C, “Clinicians’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests A Systematic Review”, JAMA, January 9, 2017.
  3. Cappato R et al, “Updated Worldwide Survey on the Methods, “Efficacy, and Safety of Catheter Ablation for Human Atrial Fibrillation,” Circ Arrhythm Electrophysiol, V. 3 (2010), pp. 32-38.
  4. Packer et al, “Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial,” JACC 2013 Apr 23;61(16):1713-23.
  5. Kuck et al, “Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation,” NEJM, 2016; 374:2235-2245.
  6. Chamberlain AM et al, “Smoking and incidence of atrial fibrillation: results from the Atherosclerosis Risk in Communities (ARIC) study,” Heart Rhythm, V. 8, No. 8 (Aug 2011), pp. 1160-6.
  7. Tedrow UB et al, “The Long- and Short-Term Impact of Elevated Body Mass Index on the Risk of New Atrial Fibrillation: The WHS (Women’s Health Study),” JACC, 2010;55(21):2319-2327.
  8. Mozaffarian D et al, “Fish Intake and Risk of Incident Atrial Fibrillation,” Circulation, 2004; 110: 368-373.
  9. Frost L, Vestergaard P. Alcohol and Risk of Atrial Fibrillation or Flutter: A Cohort Study. Arch Intern Med. 2004;164(18):1993-1998.
  10. Healey JS, Baranchuk A, Crystal E, et al. Prevention of Atrial Fibrillation With Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: A Meta-Analysis. J Am Coll Cardiol. 2005;45(11):1832-1839.
  11. Siu C-W et al, “Prevention of atrial fibrillation recurrence by statin therapy in patients with lone atrial fibrillation after successful cardioversion,” The American Journal of Cardiology, V. 92, No. 11, 1 December 2003, Pages 1343–1345.
  12. Neilan TG, Farhad H, Dodson JA, Shah RV, Abbasi SA, Bakker JP, Michaud GF, van der Geest R, Blankstein R, Steigner M, John RM, Jerosch-Herold M, Malhotra A, Kwong RY. Effect of sleep apnea and continuous positive airway pressure on cardiac structure and recurrence of atrial fibrillation. J Am Heart Assoc. 2013; 2:e00042110.1161/JAHA.113.000421
  13. Fein AS, Shvilkin A, Shah D, Haffajee CI, Das S, Kumar K, Kramer DB, Zimetbaum PJ, Buxton AE, Josephson ME, Anter E. Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. J Am Coll Cardiol. 2013; 62:300-305.
  14. Schwartz AR, Patil SP, Laffan AM, Polotsky V, Schneider H, and Smith PL, “Obesity and Obstructive Sleep Apnea Pathogenic Mechanisms and Therapeutic Approaches ,” Proc Am Thorac Soc. 2008 Feb 15; 5(2): 185–192.
  15. Kumanyika SK, Obarzanek E, Stettler N, Bell R, Field AE, Fortmann SP, Franklin BA, Gillman M, Lewis CE, Poston WC, Stevens J and Hong Y, “Population-Based Prevention of Obesity,” Circulation. 2008;118: 428-464.
  16. Pathak RK, Middeldorp ME, Meredith M, et al. Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study (LEGACY). J Am Coll Cardiol. 2015;65(20):2159-2169.
  17. Jamaly et al, “Bariatric Surgery and the Risk of New-Onset Atrial Fibrillation in Swedish Obese Subjects, JACC, V. 68, No. 23 (December 2016), pp. 2497-2504.
  18. Mansour M, Karst E, Heist EK, Dalal N, Wasfy JH, Packer DL, Calkins J, Ruskin JN, Mahapatra S, “The Impact of First Procedure Success Rate on the Economics of Atrial Fibrillation Ablation,” JACC, V. 3, No. 2 (February 2017), pp. 129-138.