This is the fourth podcast in the What are Palpitations? series and it focuses on what to expect during a visit with the heart rhythm specialist. We will be discussing the information we hope to glean from the patient during our initial visit and what may help us determine if one is at risk for heart rhythm disorders. A brief outline includes:
Thousands of patients every year are admitted to hospitals because of irregular, fast, or strong heartbeats. For the portion that will eventually be diagnosed with a heart condition, there are important choices to make moving forward. But there is rarely time in a short doctor’s visit to go over all the details.
The Heart Rhythm Center’s podcast What are Palpitations? serves as a comprehensive overview fills that information gap by imparting everything there is to know about abnormal heart rhythms through all stages of care. Dr. Jeffrey L. Williams, MD, MS, FACC, FHRS, CPE, has worked to provide patients with complete information. There are various types of arrhythmias, and the benefits and risks of treatments for each will vary for each individual patient. Patients, as well as their families, need a thorough understanding to make a fully informed decision.
Along with types of treatments, Dr. Williams discusses what is happening on a physiological level and explains the full evaluation process that doctors use. His knowledge, gained over years of study and practice, offers the what, why, and how of this medical issue, so anyone can make the best decisions for the health of his or her family.
Thanks to all the faculty and attendees of the 2018 Lakeland Regional Health Cardiovascular Symposium! We appreciate the time away from family and hope the education proves to be worthwhile. You will find link to PDF’s of all lectures below; please note that faculty may have altered their presentations from these files.
The following PA and Lateral CXR was obtained the day after an uneventful dual chamber pacemaker implantation placed via left cephalic cutdown.
One can see a radiopaque ribbon near the pacemaker can in both views raising the suspicion of a retained operative sponge. All skin dressings were removed and repeat CXR was performed.
Repeat PA CXR performed after dressing removed leaving steri-strips in place reveals that wound dressing had inadvertently used a radiopaque lap sponge as part of a pressure dressing. Nice case of “pseudo” sponge in the pocket but certainly caused some initial stress during CXR reading!
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.
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
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.
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).
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.
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 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.
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).
For more information about the use of radial ICE during EP studies: