Help expose other EP staff to learning situations/problems you have encountered

[steve]

Simply write about an EP experience you found interesting or educational by clicking on reply.  Over 130 staff came to this page in December, to learn something new.  Your comments can help provide that information.  Thanks. 

[epstaff]

Perforation of Left Atrial Appendage:  This was an early experience with Carto Mapping for an Atrial Fibrillation case.  It involved a normal mapping of part of the left atrium.  Then the Left Superior Pulmonary vein was obtained in its superior/lateral course, then the left lower pulmonary vein was obtained in a lateral/inferior course.  The os of the left inferior PV was a little anterior of the superior os.  The Mitral Valve annulus was mapped next, then the PV's on the right side, and the rest of the atrium.  We then began to ablate.

Shortly afterwards the Patients BP started to drop.  An echo showed a pericardial effusion, and we placed a catheter into the pericardial space.  When we went back and disected what went wrong, we feel that when we mapped the Left Inferior PV, the catheter moved along the lateral aspect of the Left Atrial Appendage, punctured through the Appendage and snaked inferiorly into the pericardial space.  The puff of contrast at the "os" of the LIPV showed what was thought to be a large trunk, but was the opening to the Appendage.

We learned that inferior/anterolateral direction of the Left Inferior PV is an uncommon course and should be immediately viewed with suspicion, expecially with the os anterior to the superior PV.  We have also improved the quality of anatomic verification with contrast prior to advancing the mapping catheter by visualizing more of the Pulmonary Veins, and have not had the problem repeat.

[epstaff]

60 year old male with history of SVT with palpitations presents to the Electrophysiology (EP) Lab for RF ablation.  After informed consent was achieved, baseline vital signs were obtained and intravenous (IV) access placed.  Patient was brought to the procedure room and prepared and draped in the usual sterile fashion.  Slide 1 shows baseline 12-lead EKG.  Sedative medications were given IV in the form of Versed and Fentanyl, and tapered to stable vital signs and level of consciousness 1-2.  2% Lidocaine was used for local anesthesia in the right and left groins.  A 5 FR quad, 6 FR quad, and a 6 FR sheath/placeholder were inserted in the right femoral vein (RFV).  Another 5 FR quad and a 6.5 FR steerable octopolar were placed in the left femoral vein (LFV).  In the RFV, the 5 FR quad was passed into the right ventricular apex (RVA), the 6 FR quad passed up to the high right atrium (HRA), and the 6FR sheath was left open as a placeholder for later upgrade to an 8 FR  sheath for the RF catheter.  The LFV 5 FR quad was passed up to the His Bundle area and the 6.5 FR steerable octopolar was placed in the coronary sinus.  Slide 2 shows baseline interval measurements for intracardiac signals.
      Atrial pacing maneuvers found AV Wenckebach to 300 ms.  An A-H jump was seen at 240 ms with S1-S2 atrial pacing, suggesting dual AV-Nodal physiology.  Ventricular pacing revealed a VERP at 280ms.  SVT was unable to be induced with atrial or ventricular pacing maneuvers.  Thus, an Isoproterenol infusion was started at 1 microgram/minute.
       S1-S2 atrial pacing was repeated on 1 mcg/min Isoproterenol infusion, and SVT was induced at 240 ms (Slide 3).  The SVT was classic AVNRT with midline intracardiac signals and no discernible P-waves.  VA timing was 0ms. Ventricular overdrive pacing during SVT revealed a post pacing interval (PPI) returning a V-A-V response, thus ruling out atrial tachycardia (which would have returned a V-A-A-V response) {Slide 4}.   
     The 6FR “placeholder” sheath in the RFV was upgraded to an 8.5FR SRO sheath for better stability of the ablation catheter.  A 7FR Marinr (Medtronic) ablation catheter was then inserted via the SRO sheath and a slow pathway ablation was performed.  Several RF applications produced slow junctional rhythms with return to sinus rhythm (Slide 5).  RF application was halted at the hint of A-V dissociation or rapid junctional rhythm.  The patient was sedated with IV Versed and IV Fentanyl prior to the start of RF applications and tolerated the procedure well.
     Post-ablation, the Isoproterenol infusion was restarted at 1 mcg/min once again.  SVT was no longer inducible despite aggressive atrial pacing maneuvers.  One high-low echo beat was seen.  Post RF intervals (i.e. HV & AH) were unchanged from baseline (Slide 6).  Procedure was considered a success.  All catheters ands sheaths were removed from both groins and pressure held by the MD until hemostasis achieved.  Patient remained alert & oriented throughout the procedure.  Dressing were applied to the right and left groin puncture sights and patient was transferred to the telemetry unit for overnight observation.  The patient was discharged the following morning without complication.
For clarified text with slides access the May/June Newsletter on the EP Links / Education page.

[epstaff]

I am an inexperienced EP staff.  We had a case yesterday where a 67 yo male 65 kg patient with a good EF was undergoing an A Fib ablation.  These patients in our facility are intubated with general anesthesia.  The patients systolic BP was hovering below 100 after induction.  It was not much higher before.  After about 15 minutes into the ablation the CRNA reported that the BP was dropping and having intermittant no readings on the automatic BP cuff.  The Physician who has caught pericardial bleeds before by watching the heart border and movement on the fluoro did not notice a change.  A stat Echo was called for, while the scrub tech put together the pericardiocentesis tray.  During this time, the CRNA was giving fluids and I'm not sure what drugs, there were intermittant lost BP readings, with other readings below 90.  When echo arrived they found a minimal effusion, which the Dr decided not to treat with a pericardiocentesis.  The BP responded to fluids and RX and we proceded with the rest of the procedure without any problems.
Are there other things we could have done to prevent or treat this?     

[manuel]

Our anesthesia department intubates all transeptal cases.  They place an arterial line in patients with a baseline systolic pressure below 110 or an EF < 35%.  This gives us reliable BP readings.

[epstaff]

 Message in a bottle;  The anesthesia or cardiologist could have placed a Transesophageal probe in along with the endo tube and left it in during the procedure to reference for an pericardial bleeds.  We do this with lead extractions to see if there is a myocardial perforation with a lead removal.

[kweeks]

We use acunav ICE cath for continuouse echo during the procedure to avoid need to call echo dept..we also use arterial lines for BP measurement..both of these allow quick and definitive answers to hypotension issue under anesthesia.