Erich L. Kiehl, M.D., presents a patient case where he performs an ablation to correct atrial fibrillation and flutter.
Hi my name is eric keel. I'm a cardiac electrophysiology gist from Sentara cardiovascular specialists. And this is a video of an atrial fibrillation and flutter ablation on a patient that was kind enough to let us videotape the case. So in this video we're starting by getting intravascular access into the vein using ultrasound guidance. And on the left of the screen you can see the bifurcation of the femoral artery. That's the way that we reduce complications. Here is an ultrasound in the heart called an inter cardiac ultrasound for which we're drawing contours of the pulmonary veins which will be the target for the atrial fibrillation ablation. And although these are being drawn on our ultrasound screen, they're gonna eventually transpose over to our magnetic mapping software that will then create a map of the left atrium for which we'll use as a guide to oblate. Um So the first two were the left inferior left superior pulmonary vein. This is the right inferior pulmonary vein. And lastly you'll see the right superior pulmonary vein. So those veins will be our targets for ablation here we are now going from the right side of the heart over to the left side of the heart because atrial fibrillation is a rhythm that generally originates from the left atrium and there you can see in the top right our ultrasound in the bottom, right, our X ray. And now you can see in the top right the catheter across from the right atrium to the left atrium. And we're about to use electro Kateri to go across. You can see that right there And now our sheath is across into the left atrium. On this set of four panels you can see us making our pre map. And so what we're using is a catheter called the pen array catheter, which is a three D electro anatomical mapping catheter, which we can use to create geometry using magnetic patches that are placed on the patient's chest and that is the post. After we've completely finished the map. That's the pre map. Now you can see our ablation catheter which we're currently in this video zeroing so that we can have adequate contact for us and we're beginning to oblate around the pulmonary veins. The goal here is at the end of the case for the pulmonary veins to be red or electrically silent and for the rest of the heart because it's healthy and purple to to stay healthy. One of the things we have to monitor when we do ablation is monitoring for collateral damage, including the esophagus. So, on the right screen you can see actually a temperature probe that was used. So here's us a blading in a different view on the left anterior ridge and it shows an important example for why contact for us is important because there's parts of the heart that are quite slippery. So this is after we finished our ablation, you can see as we kind of spin around the map where all of our ablation lesions were delivered And here we're now mapping afterwards. If you look at the top left screen, you can see that now the left pulmonary veins are red or silent, but we actually still have a gap here on the right because there's still purple. And if you look in the bottom left screen, there's still blue signals that time out with all of our surface signals. So it means that even though it looks like we've done a good pulmonary vein isolation on both sides, there's a gap somewhere. And so where we're gonna find out the gap is is in the carina, the gap between the right and the left or the right, superior and inferior. And so when we did a little bit more ablation. Now, you can see we're putting our catheter in and in the bottom left screen, the yellow um is a surface catheter. And when we put the catheter back into the right, inferior, right superior pulmonary vein, what you'll see is that right here? Now the signal is no longer correlate blue to yellow, they're actually dissociated. And this is a classical finding of a successful pulmonary vein isolation. So, after we've finished with a atrial fibrillation ablation, we want to make sure we're not trading a fib for a cousin rhythm of atrial fibrillation, like atrial tachycardia or atrial flutter. So after we've confirmed our lesion set, we're going to go and look for other arrhythmias here, what we're doing is um pacing from inside the vein and trying to accelerate the heart to the rate at which we're pacing and we can't do that proving that we have electrical block. So we're going around all the poles of the catheter here to prove that what you can see on the bottom left is that the blue and the yellow just march right through one another. If we didn't have electrical block, they would um correlate 1-1. We do that with all four pulmonary veins. So here's the pre and post maps. So now you can see where it was purple in the veins before is now red and we've left the rest of the heart healthy. So here's us inducing an arrhythmia. So we're pacing the heart at 202 103 100 beats per minute. And now on the on the yellow you can see a arrhythmia that's induced. And this is actually a rhythm called typical atrial flutter. So this is an activation map. Not a voltage map where you can see how the electrical activation is breaking out from both the left and the right atrium. What you can see is it's going around in a loop around the trick a spit valve and breaking through to the left atrium. So now we've got our catheter on the right a term of the heart. And in the top right you have a cardiac echo which is showing something called the isthmus and actually seeing the catheter, a blading and as we oblate, what you can see in the bottom left. Is that right there? The rhythm terminates back to normal rhythm. So we've actually identified the circuit and a bladed and terminated back to normal rhythm here. We're now proving block by basically performing something called differential pacing and looking to see where the electrical activity kind of conduct. And here you can see across our line that we've now bladed, it's just colliding. And so as a means of getting patients home on the same day, these are the sheets that all of our catheters are through. We use something called the vast cade device which is a collagen closure device. And here basically we're gonna be taking out this ivy, we do this procedure on full dose blood thinners. So it's really important not just how we get the access with the ultrasound as we showed you at the beginning of the case, but to make sure that we have good hemo stasis or good blood blood control at the end of the case, we're putting this collagen plug in and we're going to deploy the collagen right here. It's a little difficult to see but there's a little green strip there that's the collagen. After about a 32nd wait, we're gonna strip The collagen and then remove the device will hold pressure for about 2-5 minutes depending on the sheet says, and this is what it looks like afterwards. There's no sutures that need to be removed, nothing like that.
Related Presenters
