Preventable complications-
How to avoid bad outcomes.
Bob West
Mercy Hospital Electrophysiology
Disclosure of
Relationships
Bob West, B.S., RCVT, CEPS
Still employed!!
Disclosure of
Relationships
Participated in TTOP trial ………………Ablation
Frontiers adverse device complications.
Participated...
History of Arrhythmia Ablation
 1969: Surgical division of WPW pathways
 1982: Catheter ablation using DC shock
 1987: ...
RF, standard and irrigated
Radiofrequency energy---resistance heats tissue
4mm,5mm,8mm 10mm deeper and wider lesions
Cryo, standard and balloon
nitrous oxide freezes tissue
Laser, balloon
Cardiofocus 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 access
a 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 cen...
J Am Coll Cardiol 2009;53:1798-1803,1804-1806
32 deaths out of 32,569 patients
tamponade
25%
stroke
16%
other
37%
pneumoni...
Other 12 deaths includes……..
 MI to TEE perforation…………….(Myocardial
infarction, intractable torsades de pointes,
septice...
Monitor the vital signs---old school!
We routinely monitor femoral artery
pressure throughout the PVI procedure
 "It is of the utmost importance that
tamponade...
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 Mapping
Ensite Velocity
 Current improvement include CT or
MRI fusion
 Better understanding of anatomic
variable
 M...
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 afterEsophagus damage after
PV Isolation with the CryoballoonPV Isolation with the Cryoballoon Catheter
P...
To date no esophageal fistula has been seen in cryo
procedures. NOT true anymore!!!!
 Conclusions: This case clearly demo...
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
 P...
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 male
STEMI during Posterior wall accessory pathway ablation
Early recognition of a compl...
Is something important near the ablation
site?.......... Two reported coronary
occlusions in Epstein’s WPW
Incidence of co...
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 ...
RF lesion into Venticle
Steam pops?
 What causes bubbling and popping?
 Local heating causes water
content to vaporize
 High temperature inside...
Typical rupture of intramyocardial structure due to
overheating. Evaporation of tissue liquid led to the
formation of gas ...
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 t...
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, 1188–1194
Direct visualization of the slow
pathway using voltage gradient
mapping:...
It looks like this is a good tool!
AVNRT PW anatomy Voltage guided cryo
Physiologic changes effect
conduction
Preventable complications
of 65

Preventable complications

Published on: Mar 4, 2016
Source: www.slideshare.net


Transcripts - Preventable complications

  • 1. Preventable complications- How to avoid bad outcomes. Bob West Mercy Hospital Electrophysiology
  • 2. Disclosure of Relationships Bob West, B.S., RCVT, CEPS Still employed!!
  • 3. Disclosure of Relationships Participated in TTOP trial ………………Ablation Frontiers adverse device complications. Participated in STOP AF trial …………..Arctic Front balloon CryoCath Briefly participated in ENABLE study …………….Cardiofocus Laser balloon study stopped Participating in Voltage mapping collection for a novel approach to guided therapy
  • 4. 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
  • 5. RF, standard and irrigated Radiofrequency energy---resistance heats tissue 4mm,5mm,8mm 10mm deeper and wider lesions
  • 6. Cryo, standard and balloon nitrous oxide freezes tissue
  • 7. Laser, balloon Cardiofocus diode laser
  • 8. High resolution fluoroscopy
  • 9. EP 120 channel physiology recorder with programmable stimulator
  • 10. PVI goal is to electrically isolate the pulmonary veins
  • 11. Safe and reliable transeptal access a steerable introducer gives added flexibility for achieving good lesions
  • 12. INTRA CARDIAC ECHO imaging for Ablation Pre ablation anatomic orientation
  • 13. Ablation Goals (what is all this stuff for?)  Maximize Success  Reduce Complications
  • 14. 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
  • 15. J Am Coll Cardiol 2009;53:1798-1803,1804-1806 32 deaths out of 32,569 patients tamponade 25% stroke 16% other 37% pneumonia 6% A E fistula 16% avoidable complications
  • 16. 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)
  • 17. Monitor the vital signs---old school!
  • 18. 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
  • 19. Have the vital signs changed? Stable hemodynamics Early recognition
  • 20. Abnormal central Ao pressure  Pulsus paradoxus  Tamponade  COPD  Pulmonary embolism
  • 21. Quick action and calm heads Have equipment for tap available now Critical to act soon!
  • 22. Can recent additions to technology improve outcomes?
  • 23. 3-D Mapping Ensite 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
  • 24. Ensite with fusion on CT
  • 25. 2009 INVESTIGATION PROCEDURES
  • 26. RELEASED IN JANUARY 2011 STOP AF trial Cryo balloon Pulmonary vein isolation
  • 27. Round balloon in an oval/egg shape hole! Some part of the ring will be missed!!
  • 28. To touch up missed area Freezor Max or RF lesions are used or the Balloon repositioned and repeated
  • 29. PVI goal is to electrically isolate the pulmonary veins Pre cryo Post cryo
  • 30. Esophagus damage afterEsophagus 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.
  • 31. 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
  • 32. Fistula causing air embolus to brain
  • 33. TTOP Linear Ablation Ablation Frontiers
  • 34. Linear lesions to the roof and Septum Ablation Frontiers
  • 35. technology to improve outcome
  • 36. 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
  • 37. Location, size, branching and number of pulmonary veins PA CT of Left atrium  Red LA  Green distal PV’s  White esophagus
  • 38. Size and location of atrial appendage
  • 39. Proximity of esophagus to PV antrum
  • 40. Pulmonary vein ostia are not round
  • 41. If you know there is a risk Take every effort to avoid a bad outcome
  • 42. Phrenic nerve proximity to ablation site (A)pre ablation (B)phrenic palsy (C)recovery
  • 43. Sanchez-Quintana found the anterior wall of the RSPV is <2mm from the right phrenic nerve in 32% of their autopsy series
  • 44. Phrenic nerves are independent
  • 45. Coronary artery proximity to isthmus ablation site common atrial flutter 68 yo man
  • 46. Is deeper and wider better? 13 yo male STEMI during Posterior wall accessory pathway ablation Early recognition of a complication is critical ……… emergent coronary stent interrupted this boys MI  Distal RCA occlusion
  • 47. 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
  • 48. 15 year old male Epstein's anomaly with WPW pacing RV- right side posterior Accessory Pathway is common
  • 49. RCA 4mm from right atrial endocardial surface
  • 50. Cryo lesion paint to RCA posterior to Kent bundle No acute or residual symptoms Lower Incident of Thrombus Formation With Cryoenergy Versus Radiofrequency Catheter Ablation Khairy et al. ,Circulation 2003;107
  • 51. RF lesion into Venticle
  • 52. 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
  • 53. 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
  • 54. What is the future?  built in Safety and a quick arrival at the goal  Beautifully engineered
  • 55. Beautiful simplicity "Things should be made as simple as possible, but not simpler." — Albert Einstein (1879–1955)
  • 56. Low voltage bridges occur in both atriums and their veins LSVC LSVC RAA
  • 57. 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
  • 58. 10 patients undergoing AF ablation Cryo lesions
  • 59. The ability to map atrial substrate makes apparent the fundamental structures necessary to maintain and propagate AF
  • 60. In all 10 patients, AF was terminated to sinus rhythm
  • 61. The voltage gradients as well as high voltage areas were dramatically altered Voltage pre ablation Voltage post ablation
  • 62. Published in Europace 19 April 2011 13, 1188–1194 Direct 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
  • 63. It looks like this is a good tool! AVNRT PW anatomy Voltage guided cryo
  • 64. Physiologic changes effect conduction

Related Documents