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.


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.




  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.




Free Registration for the Lakeland Regional Health Cardiovascular Symposium on February 25, 2017

We hope you will join us for Lakeland Regional Health’s 2017 Cardiovascular Symposium. We believe that you will find this opportunity to learn from leaders in our profession both educational and inspiring. Speakers from University of Pennsylvania, Vanderbilt University, University of Pittsburgh, and University of South Florida as well as local faculty will be presenting state-of-the-art topics in cardiovascular disease.

Lakeland Regional Health is committed to delivering nationally recognized healthcare, strengthening our community and advancing the future of healthcare. The experienced physicians of our Heart Center place patients at the heart of all they do. We are Polk County’s pioneer in expert cardiac care and have been for more than three decades.

Upon completion of our Symposium, participants should be able to:

  • Understand the latest research in managing patients with artificial hearts and/or ventricular assist devices.
  • Describe the long-term impact of cardiovascular care on function in the elderly.
  • Identify outpatients with pulmonary hypertension.
  • Recognize and describe the pros and cons of rate versus rhythm control for atrial brillation.
  • Identify and describe interventional cardiology technologies that are currently available to treat structural heart disease.
  • Describe the latest methods for outpatient management and diagnosis of peripheral vascular disease.
  • Describe the current inpatient and outpatient congestive heart failure care continuum.
  • Understand survival rates and long-term complications of adults with congenital heart disease.

    We look forward to seeing you in February. If you have any questions, please do not hesitate to contact us at 863.687.1190.

The Symposium offers 5.25 AMA Category 1 CME credits) and registration is free at 2017 Lakeland Regional Health Cardiovascular Symposium.

New Book Available for Patients Needing a Defibrillator

What is a Defibrillator? Cover

A defibrillator implant is a small device surgically implanted in the chest to maintain the heart’s electric rhythm. The surgery is very common: over 130,000 Americans receive a defibrillator implant every year.

If you or a loved one requires a defibrillator implant, you’ll undoubtedly have many questions—questions that can’t always be adequately explained in a forty-five minute doctor’s appointment. I recently published a complete, easy-to-understand guide to defibrillator implantation.

What Is a Defibrillator? begins with an explanation of how defibrillators work and the conditions they treat. I then discuss how doctors determine whether patients are good candidates for defibrillators and provides an overview of the implantation process. Potential complications both before and after defibrillator implantation are discussed, as is surgical recovery and follow-up treatment. For readers having difficulty with medical terminology, there is a helpful glossary at the back of the book.

Patients, caregivers, and family members alike will benefit from these straightforward explanations. If you’re a candidate for defibrillator implantation, this book can help you approach surgery with a full understanding of the procedure and what it means to your quality of life.

What is a Defibrillator? is available in print and electronic versions at Amazon.com (http://www.amazon.com/What-Defibrillator-Cardiologists-Patients-Providers-ebook/dp/B011EXAQL4/ref=sr_1_4?s=digital-text&ie=UTF8&qid=1438283493&sr=1-4).

Are specialty hospitals more or less relevant as we move towards value-based care?

A recent article from The Advisory Board Company found a group of hospitals that had an advantage when it came to providing an excellent patient experience: specialty hospitals. An Advisory Board analysis of recent Hospital Compare data suggests that specialty hospitals dominate the rankings when it comes to patient satisfaction.

Patient satisfaction may not be the only benefit of a specialty hospital or “center of excellence.”  We examined the demographics, complications, re-admissions, and accessibility of care in a community electrophysiology (EP) program to add to the body of knowledge of ‘real-world’ EP device implant complications. Two hundred and fifty consecutive patients who underwent device implantation by a single electrophysiologist in a new non-academic community hospital EP program starting from its inception in July 2008 were included for analysis. Standard procedures for implantation were used. Pacemakers, defibrillators, and generator changes were included; temporary pacemakers were excluded. Major complications were defined as in-hospital death, cardiac arrest, cardiac perforation, cardiac valve injury, coronary venous dissection, hemothorax, pneumothorax, transient ischemic attack, stroke, myocardial infarction, pericardial tamponade, and arteriovenous fistula. Minor complications were defined as drug reaction, conduction block, hematoma or lead dislodgement requiring re-operation, peripheral embolus, phlebitis, peripheral nerve injury, and device-related infection. This community cohort had similar ejection fractions but was older with worse kidney function than those studied in prior reports. There was one major early complication (0.4%) and seven minor early complications (2.8%). Left ventricular lead placement was successful in 64 of 66 patients (97%). This was the first community-hospital based EP program to examine device implant demographics and outcomes, and revealed an elderly, ill population with lower overall rates of complications than seen in national trials and available reports from single non-community centers. Contrary to current perceptions, these data suggest that community centers may subselect an elderly, ill patient population and can provide high-quality, cost-effective, and more accessible care.


“Specialty hospitals are under increasing scrutiny, but there may be a role for ‘niche’ hospitals that, while offering the full spectrum of general hospital care, can provide certain procedures at an exceptional level of quality and cost-effectiveness. Recent literature continues to document the paucity of data available on rates and predictors of ICD implantation in routine clinical practice.(24,25) The Ontario ICD Database (24) revealed major complications related to de novo defibrillator implantations in 4.1% of procedures. Adjusting our data to match their definition of major complications, our center had major complications in 1.0% of de novo defibrillator implantations (a 76% relative reduction in major complications). The cost of major complications among Medicare beneficiaries receiving implantable defibrillators was examined in 30,984 patients.(25) They found that 10.8% of patients experienced one or more complications resulting in an increase in length of stay by 3.4 days and costs by $7,251. Superiorly performing ‘niche’ hospitals that reduce major complication rates from defibrillator implants by 76% in the uS (conservative estimate of 100,000 yearly implants) could realize an estimated $60 million in cost savings while improving patient safety.” (Williams et al, 2010, full link to reference below)

Demographics and complication rates seen in this report versus those reported from non-community centers and national trials.
Demographics and complication rates seen in this report versus those reported from non-community centers and national trials.

Please take this one question poll about specialty hospitals:

For More Details Please See: