How to Interpret Your A-Fib Ablation Report

As many of you know, I recently had a second a-fib ablation. In my blog post detailing that ablation, I mentioned the importance of requesting a copy of you’re a-fib ablation report if you have an ablation.

This report is vital to understanding exactly what the EP ablated (or didn’t ablate) during your ablation. It also provides some interesting details about every aspect of the procedure.

The challenge with this report, however, is that it can be difficult to interpret and understand. I reached out to my good friend, Steve Ryan, of a-fib.com, to see if he would be willing to interpret my latest a-fib ablation report as he so generously did for my first report. Steve was more than willing to lend a helping hand.

By the way, Steve’s website is the absolute best source of information about atrial fibrillation and a-fib ablations that you’ll find. It is even better than my website. I can’t recommend his site (or his book) enough!

If you click on the image of the report below, you’ll get the full PDF version of my a-fib report. If you pull the report up (or print it out), you can follow along with Steve’s interpretation of each line of the report below. His comments and interpretation are in bold italics. This should help you interpret your own a-fib ablation report. A heartfelt thanks to Steve for taking the time to do this!

Procedures

Complete EP eval w/attempted arrythm induct
The Electrophysiologist (EP) did an evaluation including attempts to induce arrhythmias.

Intracardiac Echocardiography
A method of visualizing and photographing the interior [intracardiac] of the heart to be ablated. Using sound waves to create moving pictures of your heart.

Programmed stimulation with RX infusion
Using drugs like isoproterenol to try to stimulate A-Fib which is often done after an ablation to make sure all A-Fib-producing spots are ablated.

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

Serial ACTs to achieve ACT 350-500 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.

Three-dimensional Mapping
Using the Carto 3 Biosense Webster mapping system.

Transseptal access x2
To get to the left atrium, Dr. Natale first had to position his catheter(s) in the right atrium, then make a hole in the septum through which he passed the ablation catheters. He made two punctures {x2). He also inserted a catheter through the neck.

Left Atrial / Coro Sinus pace/record
Usually pacing is used to try to stimulate A-Fib/Flutter in the Left Atrium and Coronary Sinus, but there is no mention of this being done in this catheter ablation procedure.

Left ventricular recording
The left ventricle was monitored but they didn’t find anything of note.

Patient History

LVEF is 61% from echo on 11/22/22.
“LVEF” stands for Left ventricular ejection fraction. Travis’ was 61% which is good. A healthy range is 50%-65%. EF, or ejection fraction, measures how much blood is pumped out of the ventricles.

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

Anesthesia Type
General
General anesthesia means you are completely unconscious. Versus “Conscious Sedation” where you are moderately sedated but still conscious. Most centers use general sedation.

Pre Procedure Description

Travis was in sinus when he was brought into the procedure room. With today’s technology one doesn’t have to be in A-Fib/Flutter for an EP to perform a successful ablation. EPs look for and map what are called “potentials.” Like in your car when it isn’t running, you can measure your battery’s 12-volt potential. It’s similar in your heart. EPs map and ablate “potentials” – non-PV triggers to make a patient A-Fib free.

Catheters

The Webster Duo Decapolar catheter is a diagnostic catheter. The distal (far away end) was placed in the Coronary Sinus and the proximal end was placed along the crista terminalis. It’s primarily a mapping catheter. It’s hard to tell from this O.R. report whether this catheter (or the others) was inserted via the right or left femoral (thigh) vein.

A circular mapping catheter (Lasso) was used to map the PVs and other areas.

A Smarttouch (force sensing) catheter was used to perform the RF ablations.

The ultrasound is used primarily to better visualize how to insert catheters in the femoral veins.

Transseptal

LA mean pressure 14/3/8 (mmHg)
Travis is within a normal range (6 to 21 mmHg). Patients with, for example, heart failure or obstructions can have a high left atrial pressure (for example, over 26 mmHg) and need to be put on medications such as furosemide (a diuretic to lower blood pressure).

Post Procedure Description

During mapping, it was noted that all four pulmonary veins and the posterior wall remained electrically silent and isolated due to the previous ablation in 2015.

Vascular closure devices (Vascades Lot #xxxxxx) were deployed to each vascular puncture site achieving hemostasis.
The Vascade vein closure device was used to close off the veins that were punctured in the groin to stop any bleeding (hemostasis). You can read more about the Vascade closure system here.

Hemostasis was achieved with direct manual pressure at the right internal jugular site.
Manual pressure was used to close off the neck puncture site.

Conclusion

Atrial scarring was observed due to the previous ablation.
The quantity of scarring was not measured. This is something Travis should keep an eye on probably for the rest of his life, though it’s currently unlikely to affect his heart functioning.

Successful ablation of electrograms along the floor of the left atrium, left atrial lateral wall and anterior wall of the left atrium.
Electrograms (potentials) were found in the floor of the left atrium, left atrial lateral wall, and anterior wall of the left atrium. Radiofrequency energy (RF) was applied to ablate and eliminate there potentials. These non-PV potentials were found in somewhat unusual locations in the heart. It’s a credit to the EP and the mapping software to be able to find and isolate these areas.

Successful ablation and isolation of the coronary sinus.
Successful ablation and isolation of the left atrial appendage.
Successful ablation of the superior vena cava.
The Left Atrial Appendage (LAA) was ablated and isolated, as well as the Coronary Sinus and Superior Vena Cava. One of the major advances in treating A-Fib today is the recognition that the LAA is often the source of A-Fib signals. After ablating the PVs, EPs now look at the LAA before any other locations in the heart.

A total of 61 minutes of radiofrequency energy lesions were delivered.
61 minutes of RF energy was delivered during the procedure.

Radiation Dosage

Fluoro time: 59.7 minutes
This is a type of X-ray used to see inside the heart.

The RF and fluoro time for this catheter ablation is more than a typical catheter ablation, indicating that this was a complicated procedure. A broad range is 15 minutes to 2 hours. Mapping and ablating the LAA is much more complex than a normal PVI.

Steve’s Further Comments:

We don’t yet fully understand why A-Fib/Flutter potentials develop in non-PV areas of the heart. But advanced, more experienced EPs are able to find, map and isolate these areas, making patients A-Fib free.

If you’ve had an unsuccessful catheter ablation, you need to find an EP who specializes in more complicated cases.

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