David Weisman, MD discusses ablation vignettes and implementing a Fluoroless approach to ablation in electrophysiology at the first inaugural Heart & Vascular Symposium hosted by Georgia Heart Institute at Chateau Elan Resort & Winery in Braselton, Georgia.
Ablation. I've been challenged to discuss some ablation, vignettes and uh usually uh most electrophysiology ablation czar only interesting to electro physiologist. So I wanted to try to keep this talk a little bit more um interesting and more illustrative. And the title of my talk is implementing a floorless approach to ablation the unleaded experience. And this is something that really uh I've been doing for about 10 years and predominantly do in most of my cases and those who don't have cardiac devices. So we're all familiar with this diagram. This is a simple two D. Illustration of the cardiac structures but we what we when we look at this picture um This is really an oversimplification of what we see in our gross anatomy. What's on the right is not necessarily the right and what's on the left is not necessarily on the left and there's this dynamic interplay with all these venus and atrial and ventricular structures. So here we have this two D. Representation on the right on the left, we have a C. T. Merge uh image with some electrophysiology catheter is distinctly placed and you can see here in gray uh the left atrium and the pulmonary veins. You can see the left and right pulmonary veins here in blue with the coronary sinus catheter. You can see the relationship of the coronary sinus catheter to the left pulmonary veins and the left atrial appendage. Uh Sometimes this becomes important in uh mitral valve is mr ablation. Um you can also see as this image continues to spin uh the relationship of the S. V. C. In the right side of veins in particular. Right, superior pony vein. Now this is what we look at all the time. Most of us look at this simple two D. Chest X ray and were expected to be feel confident about the position and reliability of positioning of our electrophysiology catheters. But in reality when we're performing these flores, coptic procedures, we really have no idea where these things are. These are just simple two D. Representations. So in thinking about this um we obviously know that it's important to achieve the lowest reasonably achievable dose. And the background radiation that we get every year is approximately 3.1 millisieverts. Uh One milli Sievert just to give you um uh a a base sign is about equal to 10 chest x rays. Obviously these numbers are going to vary based on procedure and operator, but a diagnostic cath is about 7.6 millisieverts. A tavern could be as much as 25.6 a cardiac ct 8 to 12 millisieverts. And an a fib ablation could be 15 million sieverts which is about 100 and 50 chest x rays. And I don't know how many people would sign up to have 100 and 50 chest x rays. And if you're obese which in in Gainesville and Hall County we have a fair amount of obese patients. Uh you're gonna get about a 75% greater dose during imaging. So when looking at at this image, you know thankfully in electrophysiology we've developed three D. Three dimensional mapping and electro atomic mapping here. You see on the right and an R. E. O. In L. A. Of you. Um A three dimensional map of the right atrium with the sec. And I. V. C. Um And this is quickly collected with a multipolar multipolar electrode array catheter. Now adding to this we have inter cardiac echo. Inter cardiac echo only adds to these procedures and our ability to precisely and directly image what we're looking at and be confident about the positioning of our equipment. So on the left we have a three dimensional representation of the right atrium of advancing an ablation. Cath up into the uh S. V. C. On the right you can see the inter cardiac echo and its fan projecting over the S. V. C. And into the septum. And you can see the Catherine moving up into the S. V. C. Now the the the interest in doing this is and and every electrophysiology lab is that um And as dr Chen it's was just discussing um the different modalities and um potential future potential for P. F. A. Um There's a high risk of bleeding complications mostly related to trans septal punctures here. Um In this picture you can see there's a 98 centimeter uh B. R. K. One. And and uh it's an extra sharp and this is what we're using basically to access through the fossil of Alice into the left atrium with hope not to come out the other side and cause cardiac tamponade. And in the past historically this was done even without inter cardiac echocardiography. Um And and had been attempted just with even just simple contrast injections. So now we can reliably and safely perform transept the puncture without the use of any kind of flores, coptic imaging or contrast. Uh Here on the left we have a right actual structure. You can see the valve and this is an elio view the coronary sinus projecting out to the right. Um The inter cardiac echo probe is directly visualizing the S. V. C. And on the right. You can see me dragging down. And this is in real time from the S. P. C. And it's gonna drop down here onto the face of Alice here in a second. And once it's on the fossil Vallis, you'll see tenting. You'll hear, you'll see nice tenting. I'm here along the mid septum. If you look directly across, you can begin to see the left side of pulmonary veins. So I've got an adequate target will pop across the uh the fossils, relaxed, attempting is gone. Inject a little bit of sailing. We can see some micro bubbles here in the left atrium. I'm fairly confident that we're in the left atrium. You can measure left atrial pressure. Take the needle out. Exchange it for a guide wire which I'll then position in the pulmonary vein and within a few seconds we've gone from the S. P. C. Into the left atrium and have a sheath access into the left atrium all without ever actually stepping on an X ray. And here we go pushing over the wire. There you go. So now really the hard part is over so now we can proceed with ablation and uh this is just meant again to be illustrative. Typically I'll use a pen or a catheter. Um Here there's a multipolar catheter collecting volume uh collecting activations, collecting voltage all at the same time and quickly. Without pre. I typically don't use any kind of pre imaging such as ct R. M. R. I. I realize on my simple um three D electron atomic mapping acquired at the time of my procedure. And within typically about five minutes we can reconstruct the left atrium at least the relevant structures uh for a simple pulmonary vein isolation in this case you can see right now I'm about to try to get here into the right inferior pulmonary vein. And this this video goes on for several minutes. But um I think you get the point that you can really very quickly and rapidly acquire um very accurate three dimensional anatomy. So to move on this is another case. Um And let's see if we can figure out what this arrhythmia is. So I've got the same multipolar penury Catherine the S. V. C. I'm gonna drop it into the right atrium and quickly try to um just obtain some basic structural information. Right? So I'm gonna then drag it back down to the ibc. I'm gonna push it then back into the right atrium. Kind of wiggle and jiggle it around and really under under a minute we're gonna have all the information and all the location and anatomical information that we're gonna need to do this procedure hopefully. So now we're seeing this in the aria and elio projections. I'm gonna then take that same catheter and we can acquire electrical information, voltage activation using our coronary sinus as a reference and this is depicted in the various colors. Trying to achieve a trying to identify the the entirety of the cycle length of this atrial arrhythmia. And by moving this catheter around all with just using our three dimensional structure that we've created we can try to identify what the what arrhythmia this is. And here for just illustrative purposes again this is a propagation map. And here we can see propagation around the valve and elio view this is cabo is this dependent natural flutter. So we've quickly diagnosed this and we can proceed to ablation and here on the top we can see the ice image and using a car to sound Catherine draw the isthmus from the valve back to the inferior vena cava. Using this as an an atomic guide for ablation you can see the fan alignment in the bottom left hand pane as to where we're pointing this around six o'clock on the, on the analyst and under direct ice guidance. Place the ablation catheter along the isthmus. I typically put this through a long sheath to get a little bit more force and contact and stability and just proceed with the ablation along this isthmus on the bottom part. You can see an R. E. O. View and then an elio coddle view. The R. A. Tilted up. And you can see a nice catheter. My ablation catheter in correct position during the ablation as I'm delivering these lesions. Once, once this line is completed, we're gonna go ahead and target any potential gaps. Any residual electra grams that may have not been targeted during the initial ablation. Try to identify the critical gap. And hopefully if we find the right spot, we'll see this flutter terminate and right about here. The flutter will terminate. We can see conversion to sinus rhythm and no by the way. Ah nice. We can see the re synchronization of the hmm. The ventricle at the same time. So there's a nice correlation. So what are the benefits of Zero philosophy? I think they're obvious? Um Obviously uh selfishly there's a reduction in the risk of malignancy, premature cataracts, Benign tumors, genetic defects. Uh radiation burns if you ever have seen one that can be really devastating to the patient orthopedic injuries. I've hurt my back on more than one occasion. Um So the ability not to have to wear lead for myself as well as my staff nurse technicians as well as um anesthesia, colleagues, reduced flow really does have its advantages. Repeated exposure is dangerous to the patients, physicians and staff especially advantageous for childbearing women. We recently had a uh a pregnant nurse who was working in uh in the E. P. Lab all the way up until delivery and she was able to do that because we're not using any floor. Oh younger women who are planning a family in the future would not want to be exposed. Younger patients in general, those patients who have a history of cancer, skin damage and uh and patients who are undergoing repeat cardiac procedures. You know, we have to remember that uh these patients are not only undergoing ep ablation procedures, they may undergo watchman's. Many of them have had cardiac catheterizations, uh cardiac cts etcetera. And this is all cumulative over time. Thanks very much
