preventable complications
TRANSCRIPT
Preventable complications-How to avoid bad outcomes.
Bob WestMercy Hospital Electrophysiology
Disclosure of Relationships
Bob West, B.S., RCVT, CEPS
Still employed!!
Disclosure of RelationshipsParticipated in TTOP trial ………………Ablation Frontiers adverse device complications.Participated in STOP AF trial …………..Arctic Front balloon CryoCathBriefly participated in ENABLE study …………….Cardiofocus Laser balloon study stoppedParticipating in Voltage mapping collection for a novel approach to guided therapy
History of Arrhythmia Ablation
1969: Surgical division of WPW pathways 1982: Catheter ablation using DC shock 1987: Catheter ablation using
radiofrequency energy (RF) ‐ cure of SVT 1992: Catheter RF ablation of atrial flutter 1995: Catheter RF ablation of atrial fibrillation=26 years of RF catheter ablation experience
RF, standard and irrigatedRadiofrequency energy---resistance heats tissue
4mm,5mm,8mm 10mm deeper and wider lesions
Cryo, standard and balloonnitrous oxide freezes tissue
Laser, balloonCardiofocus diode laser
High resolution fluoroscopy
EP 120 channel physiology recorder with programmable stimulator
PVI goal is to electrically isolate the pulmonary veins
Safe and reliable transeptal accessa steerable introducer gives added flexibility for achieving good lesions
INTRA CARDIAC ECHO imaging for Ablation Pre ablation anatomic orientation
Ablation Goals(what is all this stuff for?)
Maximize Success
Reduce Complications
Death as a complication of catheter ablation of atrial fibrillation (AF) occurs in 1 of every 1000 patients
Thirty-one centers reported 32 deaths in 32,569 patients
tamponade (in 8 patients) stroke (5 patients) atrioesophageal fistula (5 patients) massive pneumonia (2 patients).
J Am Coll Cardiol 2009;53:1798-1803,1804-1806
J Am Coll Cardiol 2009;53:1798-1803,1804-1806
32 deaths out of 32,569 patients
tamponade25%
stroke16%
other37%
pneumonia6%
A E fistula16%
avoidable complications
Other 12 deaths includes……..
MI to TEE perforation…………….(Myocardial infarction, intractable torsades de pointes, septicemia, sudden respiratory arrest, extrapericardial pulmonary vein (PV) perforation, occlusion of both lateral PVs, hemothorax, and anaphylaxis caused 1 death each
Asphyxia from tracheal compression secondary to subclavian hematoma, intracranial bleeding, acute respiratory distress syndrome, and esophageal perforation from intraoperative transesophageal echocardiographic probe caused 1 late death each)
Monitor the vital signs---old school!
We routinely monitor femoral artery pressure throughout the PVI procedure
"It is of the utmost importance that tamponade (i.e., the most frequent cause of death in our survey) be recognized promptly, before it is too late."
Dr. Riccardo Cappato from the Policlinico San Donato, Milan, Italy
Have the vital signs changed?Stable hemodynamics Early recognition
Abnormal central Ao pressure
Pulsus paradoxus Tamponade COPD Pulmonary
embolism
Quick action and calm heads
Have equipment for tap available now
Critical to act soon!
Can recent additions to technology improve outcomes?
3-D MappingEnsite Velocity
Current improvement include CT or MRI fusion
Better understanding of anatomic variable
Map arrhythmia real-time and in review
Pinpoint critical path to determine ablation strategy
Ensite with fusion on CT
2009 INVESTIGATION PROCEDURES
RELEASED IN JANUARY 2011 STOP AF trial Cryo balloon Pulmonary vein isolation
Round balloon in an oval/egg shape hole!Some part of the ring will be missed!!
To touch up missed area Freezor Max or RF lesions are used or the Balloon repositioned and repeated
PVI goal is to electrically isolate the pulmonary veins
Pre cryo Post cryo
Esophagus damage after Esophagus damage after PV Isolation with the CryoballoonPV Isolation with the Cryoballoon Catheter
Presented at the Heart Rhythm Society 2008 Scientific Sessions, San Francisco, CA May 14-17.
To date no esophageal fistula has been seen in cryo procedures. NOT true anymore!!!!
Conclusions: This case clearly demonstrates that Cryoballoon ablation can cause esophageal ulceration. Perhaps the absence of atrial-esophageal fistula formation with cryoablation may be related to the post-ablation healing process, rather than an inherent inability of cryoenergy to cause esophageal damage.
Ablation technology by definition causes cellular damage
Fistula causing air embolus to brain
TTOP Linear Ablation Ablation Frontiers
Linear lesions to the roof and Septum Ablation Frontiers
technology to improve outcome
Variation in anatomy
Location, size, branching and number of pulmonary veins
Size and location of atrial appendage Proximity of esophagus to PV antrum Phrenic nerve proximity to ablation site Coronary artery proximity to ablation
site
Location, size, branching and number of pulmonary veins
PA CT of Left atrium Red LA Green distal PV’s White esophagus
Size and location of atrial appendage
Proximity of esophagus to PV antrum
Pulmonary vein ostia are not round
If you know there is a risk
Take every effort to avoid a bad outcome
Phrenic nerve proximity to ablation site
(A)pre ablation (B)phrenic palsy (C)recovery
Sanchez-Quintana found the anterior wall of the RSPV is <2mm from the right phrenic nerve in 32% of their autopsy series
Phrenic nerves are independent
Coronary artery proximity to isthmus ablation site common atrial flutter 68 yo man
Is deeper and wider better? 13 yo maleSTEMI during Posterior wall accessory pathway ablationEarly recognition of a complication is critical ……… emergent coronary stent interrupted this boys MI
Distal RCA occlusion
Is something important near the ablation site?.......... Two reported coronary occlusions in Epstein’s WPW
Incidence of coronary artery injury immediately after catheter ablation for supraventricular tachcardias in infants and children.
Heart Rhythm, Volume 6,Issue 4, Pages 461-467
15 year old male Epstein's anomaly with WPW pacing RV- right side posterior Accessory Pathway is common
RCA 4mm from right atrial endocardial surface
Cryo lesion paint to RCA posterior to Kent bundle
No acute or residual symptoms
Lower Incident of Thrombus Formation With Cryoenergy Versus Radiofrequency Catheter AblationKhairy et al. ,Circulation 2003;107
RF lesion into Venticle
Steam pops?
What causes bubbling and popping? Local heating causes water
content to vaporize High temperature inside tissue causes water vaporization and explosion, which is popping
At high power Inadequate cooling capacity
of irrigation flow High temperature inside tissue, which is not cooled directly by irrigation flow, can cause
popping as well SJM Solution
Controlling the amount of power according to preset temp
Typical rupture of intramyocardial structure due to overheating. Evaporation of tissue liquid led to the formation of gas bubbles that escaped by tearing the endocardium. Visible is a crater discolored by carbonization
What is the future?
built in Safety and a quick arrival at the goal Beautifully engineered
Beautiful simplicity
"Things should be made as simple as possible, but not simpler." — Albert Einstein (1879–1955)
Low voltage bridges occur in both atriums and their veins
LSVC LSVC
RAA
Importance of low voltage bridges
“Ideally, a method to identify abnormal atrial substrate would offer the best chance to understand the underlying atrial disease, as well as, offer the best chance to intervene with ablation.”
Steven J. Bailin, MD Iowa Heart Center
10 patients undergoing AF ablation
Cryo lesions
The ability to map atrial substrate makes apparent the fundamental structures necessary to maintain and propagate AF
In all 10 patients, AF was terminated to sinus rhythm
The voltage gradients as well as high voltage areas were dramatically altered
Voltage pre ablation Voltage post ablation
Published in Europace 19 April 2011 13, 1188–1194Direct visualization of the slow
pathway using voltage gradient mapping: a novel approach for successful ablation of atrioventricular nodal
reentry tachycardia Steven J. Bailin , Matt A. Korthas, Neal
J.Weers, and Craig J. Hoffman
It looks like this is a good tool!AVNRT PW anatomy Voltage guided cryo
Physiologic changes effect conduction