My Official Catheter Ablation Report

When you have a catheter ablation done for the treatment of atrial fibrillation, you can request an official ablation report (or called the operating room report or EP study report). Depending how efficient your hospital is at processing reports and paperwork, you might be able to get one within a few days of your procedure if you request one immediately.

I had my ablation done on March 5, 2015 at St. David’s in Austin, TX and my report was available for me to pick up just four days after the procedure so they were pretty efficient.

This report is a technical document that details what the electrophysiologist (EP) did during the ablation.

This is an extremely important document to make sure you get your hands on. In the event you need another procedure down the road or you develop other heart conditions, future doctors will want to know exactly what was done and this document will tell them.

I have provided copies of my report here in case you’re curious what they did during my ablation.

Please note, these reports are very technical and difficult to understand. Unless your EP walks you through it or you know someone that can translate what it says, these reports can really make your head spin!

I didn’t have a clue what mine said until I enlisted the help of my good friend, Steve Ryan of a-fib.com. He was kind enough to take the time to translate my report into plain English. Shannon Dickson, the Editor of Afibbers.org also contributed. A heartfelt thanks goes out to both of them for helping me out with this!

Steve’s explanations for each point in the report are highlighted in blue italics.

(click on the thumbnail images to see the full size images)

Procedures

Three-dimensional mapping

Programmed stimulation with RX infusion
Using drugs like isoproterenol to try to stimulate atrial fibrillation which is often done after an ablation to make sure all afib-producing spots are ablated and no longer firing.

Transseptal access x2
To get to the left atrium where most afib originates, doctors have to go through the transseptal wall between the right and left atrium. “2x” means they made two punctures and used two catheters.

RF ablation for PVST (AF)
“RF” stands for Radio Frequency ablation which uses heat to make an ablation, as compared to CryoBalloon ablation which uses cold. “PVST” stands for “Paroxysmal Supraventricular (above the ventricles) Tachycardia (faster-than-normal heart beat rate) which usually includes atrial fibrillation.

Left atrial pacing/recording
“Pacing” means they used some form of cardiac pacemaker to control the rate of contraction of the heart and in particular to try to stimulate the heart into afib.

Intracardiac echocardiography
Intracardiac means “inside the heart” and an echocardiograph is using sound waves to create moving pictures of your heart.

Left atrial angiogram
Using X-ray to image the left atrium

Serial ACTs to achieve ACT 300-500 seconds
“ACT” stands for Activated Clotting Time which is a measurement of how fast blood coagulates. Above 300 seconds is what is usually recommended during an ablation. “Serial” means ACT measurements were taken frequently during the ablation.

Complete EP evaluation with attempted induction of arrhythmia
As with drugs like isoproterenol mentioned above or with pacing.

Left ventricular visualization
In addition to studying the left and right atria, they also viewed the ventricles – the parts of the heart below the atria which pump blood throughout the body.

Pre-Procedure Diagnoses
Atrial fibrillation that is most likely paroxysmal. The patient typically pursues early cardioversion with Flecainide as a pill-in-the-pocket approach or DCCV. His episodes have increased in frequency and duration over the last year.
Pill-in-the-pocket refers to a strategy where one takes an antiarrhythmic only when one has an attack of afib. It’s used when someone can’t tolerate an antiarrhythmic drug on a regular basis. In general, like a fire, it’s better to keep an afib attack from starting rather than trying to put it out once it has started. DCCV is short for direct current cardioversion and refers to Electrocardioversion where one’s heart is shocked to return it to normal sinus rhythm.

Patient History
Atrial Fibrillation, as described above. Preserved LVEF. Anxiety.
Left Ventricular Ejection Fraction—how much blood is being pumped out of the left ventricle of the heart (the main pumping chamber) with each contraction. “Preserved” means the patient has a within normal range LVEF. Afib over time often damages and reduces LVEF. Afib often causes anxiety, fear, depression, frustration, and anger. Although in my case I have suffered bouts of anxiety even before I was diagnosed with afib.

ASA Score
ASA Classification II provided by anesthesia service.
The American Society of Anesthesiologists (ASA) physical status classification. “II” refers to patients with mild systemic disease and is of minimal interest from a patient’s perspective.

Anesthesia Type
General
You are completely unconscious versus “conscious sedation” where you are moderately sedated but still conscious. Most centers now use general anesthesia.

Patient Allergies
NKDA
No Known Drug Allergies.

Procedure Description
The patient was brought to the Electrophysiology lab in the fasting, post absorptive state (3-5 hours after a meal has been completely digested and absorbed). Risks, benefits and alternatives of the procedure and general anesthesia were explained to the patient and a written informed consent was obtained. The patient was prepped and draped in the usual sterile fashion. (Before the ablation a nurse will usually shave the groin area but in my case I shaved ahead of time).

Both right and left groins and the right neck were anesthetized with 1% Lidocaine and 0.5% Bupivacaine and vascular access was obtained (puncturing the groin veins and inserting the catheter needles) by the modified Seldinger technique (a standard technique of using a hollow needle and guide wire to insert the catheters) and ultrasound guidance. Surface ECG (Electrocardiogram) leads 1 aVF and V1 (like getting an ECG in your doctor’s office) and intracardiac electrograms from the CS (Coronary Sinus), HIS bundle (the heart muscle cells which transmit the electrical impulses from the AV Node to the ventricles), and the RVA (Right Ventricular Apex).

Heparin (an anticoagulant used during ablations) boluses (singles doses) 13,000 units initially were given to maintain an ACT (Activated Clotting Time-see above) 300-500 sec (seconds). An esophageal temperature probe was inserted and maneuvered under fluoroscopy (X-ray) to monitor esophageal temperatures throughout the case. (The esophagus lies just behind the left atrium. Doctors monitor esophageal temperature and will stop an ablation if the temperature goes too high in order to prevent damaging the esophagus.)

At the end of the procedure, Protamine (a drug that reverses the anticoagulant effects of heperin) was given, sheaths and catheters were removed and hemostasis (stopping bleeding) was achieved with direct manual pressure. The patient tolerated the procedure well and was transferred in stable condition.

(O.R. reports will usually list the various sheaths and catheters used during the ablation. But this information isn’t important for most patients, with the exception of the new contact force catheters which significantly improve ablation effectiveness.)

Ice and Three-Dimensional Mapping
A three-dimensional reconstruction of the left atrium was created with the use of the Carto system (Biosense Webster). The following structures were visualized with ICE (Intracardiac Echocardiography). The right atrium, fossa ovale, tricuspid valve, coronary sinus, crista terminalis, RA appendage, LA, mitral valve, left atrial appendage, left superior pulmonary vein (opening), left inferior pulmonary vein, right superior pulmonary vein, right inferior pulmonary vein, aortic valve, left ventricular outflow tract, ascending aorta, pulmonic valve, right ventricular outflow trace and pulmonary artery. ICE was also used to guide transseptal catheterization (passing the catheter from the right atrium through the septum into the left atrium).

Transseptal
Left atrial instrumentation was achieved by double transseptal punctures. The Baylis transseptal system was used to facilitate the transseptal punctures. Proper placement was confirmed by fluoroscopy, intracardiac echocardiography, contrast injection, left atrial pressure tracings and left atrial pressure. (Elevated LA pressure might indicate an increased volume of blood entering the left atrium. Doctors take multiple precautions to make sure when they do a transseptal puncture that they do wind up in the left atrium).

LA mean pressure 14/5 (mmHG) (“mmHG” stands for millimeters of mercury, a unit of pressure measurement)

Procedure Description

(For a patient this is the most important part of the O.R. report.)

The patient arrived to the Electrophysiology laboratory in sinus rhythm. (This is generally considered a good thing and makes the ablation easier. Often doctors will Electrocardiovert someone in afib a few days before the ablation in order to get them in sinus before the ablation. It’s easier to find “potentials” if there aren’t a lot of afib signals swirling around the atrium).

After left atrial instrumentation was achieved by double transseptal punctures, the circular mapping catheter was placed in all four pulmonary veins, antrums and along the posterior wall of the left atrium. During mapping, pulmonary vein potentials were noted in all pulmonary veins except for the RIPV (Right Inferior Pulmonary Vein—often the smallest of the PVs), which was silent. (“Pulmonary Vein Potentials” are kind of like the battery in your car. Even if your car isn’t running, you can still measure 12 Volts “potential” from it. PV potentials are what EPs map and ablate, even though these potentials may not be firing and producing A-Fib signals at the time.)

Otherwise, mild atrial scarring was observed. (“Scarring” usually refers to fibrosis—a fibrotic hardening of the atrial wall often caused by afib and is part of the overall remodeling effect of afib. Scarring/fibrosis is usually considered irreversible. It would be good to do an MRI on Travis to determine exactly how much actual scarring/fibrosis there is and to keep track of its possible progression. A successful catheter ablation which returns the heart to normal sinus rhythm usually stops this progression).

The pulmonary veins were isolated at the level of the antrum (well outside the PV openings to prevent stenosis/swelling of the PVs) using radiofrequency energy (RF) (heating/burning). With ablation of the LSPV (Left Superior Pulmonary Vein), there was spontaneous atrial fibrillation with rapid ventricular response. Despite isolation of the pulmonary veins, the patient remained in atrial fibrillation. A roof line and an infero-posterior line were created with radiofrequency ablation for the purpose of isolating the posterior wall of the left atrium. Despite isolation of the posterior wall of the left atrium, the patient remained in atrial fibrillation. Electrograms were mapped to the left atrial septum (the septum is the wall that separates the left and right atrium), floor of the left atrium, and anterior roof of the left atrium. Radiofrequency was applied with elimination of the potentials.

Despite ablation in these areas, the patient remained in atrial fibrillation. The coronary sinus was ablated and debulked. Ablation along the right atrial septum to eliminate potentials was done. Despite extensive ablation in the left atrium, external cardioversion (at 200 Joules) restored sinus rhythm. (This was a more difficult case. The ideal goal of an ablation is to “terminate” afib into sinus rhythm (or a mild tachycardia). But despite finding and ablating non-PV potentials in many different parts of the heart and creating blocking ablation lines, they couldn’t terminate the afib and had to shock Travis back into sinus rhythm. Sometimes in difficult cases, that’s the best that can be done. And frequently that’s all that needs to be done. What’s most important is the permanence and thoroughness of the ablations. In Travis’ case, the ablation worked because of all the potentials that were ablated/eliminated. Three months after his ablation, Travis hasn’t had a single episode of atrial fibrillation.

Radiofrequency power was titrated if overheating was observed by intracardiac echocardiography and/or elevation of esophageal temperature. (Most experienced EPs and centers are very careful to avoid overheating and damaging the esophagus which lies behind the left atrium.)
Isuprel (isoproterenol) was infused up to 20 mcg/min for 10 minutes to illicit right or left atrial arrhythmias and to assess pulmonary vein reconnections. (Isuprel is like adrenaline and is used to try to stimulate the heart to go into afib). Following infusion of isuprel, there were sporadic PACs (Premature Atrial Contractions) from the left atrial appendage that were not targeted for ablation.

(Once Travis’ heart heals from all the ablation burns, it may be necessary to do a second ablation in order to isolate his left atrial appendage, or known as the LAA. But one has to be careful too, if possible, not completely electrically isolate the LAA so that it no longer contracts sufficiently which would create clots. When isolating the LAA, there is about a 70% chance of significantly reducing its emptying volume. If the LAA emptying volume is reduced to less than 40 milliliters/sec, the patient would have to be on blood thinners for life or their LAA would have to be removed or closed off. Otherwise clots would form in the LAA because of low blood flow. Strokes are associated with increased age. But it might be more accurate to associate clots and strokes with reduced physical activity and blood flow which often go along with aging).

The circular mapping catheter was then placed in the superior vena cava and the superior vena cava was isolated using radiofrequency energy. No phrenic nerve stimulation was present at 20 mA at sites of radiofrequency ablation in the superior vena cava. (They made sure the ablation didn’t harm or affect the phrenic nerve which is located near the superior vena cava. The phrenic nerve controls the diaphragm and breathing.)

A total of 58.5 minutes of radiofrequency was delivered. (This was a very extensive ablation compared to most.)

At the end of the procedure, Protamine (which reverses the anticoagulant effect of heparin) was given, sheaths and catheters were removed and hemostasis (stopping bleeding) was achieved with direct manual pressure. The patient tolerated the procedure well and was transferred in stable condition.

Plan

Continue long-term anti-coagulation with apixaban (Apixaban is marketed as the brand Eliquis. Travis did so well that he was taken off of Eliquis two months after his ablation.)

Discontinue antiarrhythmic therapy with flecainide (Many centers have a patient continue taking antiarrhythmics during the three-month blanking period but in this case they were not continued).

Follow-up in 6-12 weeks

Event recorder upon discharge

Conclusion (This repeats the main points of the “Procedure Description” above.)

1. Successful isolation of all the pulmonary veins. The RIPV was silent at baseline. With ablation of the LSVP, spontaneoous atrial fibrillation with rapid ventricular response was documented.

2. Mild atrial scarring was observed.

3. Successful isolation of the posterior wall of the left atrium utilizing roof and infero-posterior lines.

4. Successful ablation of electrograms along the roof, septum and floor of the left atrium.

5. Successful ablation of the coronary sinus to debulk and eliminate potentials.

6. On high-dose isoproterenol (20- mcg/min) there were sporadic PACs from the LAA not targeted for ablation.

7. Successful isolation of the superior vena cava.

Complications
None

Estimated Blood Loss
<10mls (< means less than, “mls” stands for milliliters)

Post Procedure Diagnosis
Paroxysmal atrial fibrillation s/p PVAI (“s/p” means “status post” or what condition the patient was in after the ablation. “PVAI” stands for the “Pulmonary Vein Antrum Isolation” ablation procedure. This is a shorthand for doctors indicating that Travis did have paroxysmal A-Fib, but then he had a PVAI. After his ablation, Travis was in normal sinus rhythm.)

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