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Peri-procedural Management of Patients undergoing Catheter Ablation

Jill Harris, MSN, ACNP-C, CNS Acute Care Nurse Practitioner St. Joseph Heritage Medical Group, Department of Cardiology

Course Objectives • Review the arrhythmias appropriate for treatment by ablation,

as well as associated success rates. • Identify other medical conditions that may increase

procedural risk and/or require additional management. • List necessary peri-procedural diagnostic testing and results

requiring intervention. • Describe appropriate patient education necessary for patient

comfort and obtaining informed consent.

Why catheter ablation? • Patient desire to avoid pharmacologic treatment • Patient unable to tolerate pharmacologic treatment • Pharmacologic treatment ineffective • Highly effective for most SVTs, providing cure

(Ferguson, 2003)

Arrhythmia ID • Supraventricular arrhythmias

-atrial-ventricular reentry tachycardia(AVRT) -atrial-ventricular nodal reentry tachycardia (AVNRT) -atrial tachycardia (AT) -atrial fibrillation (AF) -atrial flutter (AFL) • Ventricular tachycardia (VT)

AVRT

AVRT • Second most common SVT, accounts for approximately 30% • Occurs most often in younger women and children • May occur with WPW • Reentry tachycardia either orthodromic or antidromic through

AV node • Success rate with ablation >95%

(Colluci, 2010)

WPW

WPW • Characteristic EKG finding, does not necessarily have

associated symptoms or arrhythmia • Can be present with AVRT or a-fib • EKG finding present in 0.1-0.3% of the population • 100% success with ablation, though controversy in ablating

asymptomatic patients

(Wellens, 2005 and Pappone, 2005)

AVNRT

AVNRT • Most common SVT, accounts for 50-60% • Mostly in healthy you women • Can occur in pericarditis, previous MI or MVP • Reentry with two pathways, typical and atypical • Success rate with ablation 96%

(Colucci, 2010 and Ferguson, 2003)

AT

AT • Third most common atrial arrhythmia, accounts for

approximately 10% • Occurs most often in middle aged persons or HF or COPD • Reentry tachycardia; AT and multifocal AT • Success rate with ablation somewhat lower than other SVTs

(Colluci, 2010)

AF

AF • Now effects an estimated 33.5 million people worldwide • Occurs most commonly in those aged 65 or older • More commonly in those with HTN, COPD, valvular heart

disease, previous cardiac surgery, thyroid dysfunction, DM, CHF, sleep apnea

• 22-44% of patients return within one year after primary ablation with recurrent arrhythmia

(Chugh, 2013 and Shah, 2012 and hrs.org)

AFL

AFL • 200,000 new cases per year • More common in men, elderly and those with HF, COPD

(Granada, 2000)

VT

VT • Can be idiopathic (younger patients) • Common in patients with cardiomyopathy (ICM, NICM, AVRD)

and CHF • Occur from RVOT, RCC, NCC, deep myocardium or epicardial

(Yamada, 2013 and Killu, 2013)

What is ablation? • Electrophysiology: study of the heart’s electrical conduction

system (EPS) • Ablation: removal of aberrant cardiac tissue • Began as surgical ablation in 1968 • First intracardiac radiofrequency ablation in 1991 • Several different energy sources now available:

radiofrequency,cryothermy and laser

Ching, 2011

Ablation vs. AAD

http://circ.ahajournals.org/content/126/2/223/F2.large.jpg

Mechanics of endocardial ablation • Vascular access similar to angiogram • Several multipolar catheter electrodes placed at various

intracardiac sites through sheath in the groin, sometimes enter through subclavian or jugular

• Sizes range from 5-8 french, capable of pacing and recording or mapping and ablating

• Catheters placed in right atrium, across tricuspid valve annulus to AV node and HIS bundle, RV, coronary sinus and sometimes LV

(Krishnan, 2011 and Murgatroyd, 2011)

http://www.heartrhythmsfla1.com/images/ablation2.jpg

http://www.totalhealth.co.uk/sites/www.totalhealth.co.uk/files/articles/fig2.jpg

Mechanics of endocardial Ablation • EP uses catheters and mapping system to create 3D image of

patient’s anatomy based on activation sequence which identifies arrythmogenic focus (aberrant tissue)

• Focus is stimulated to recreate arrhythmia • Then applies energy source- radiofrequency or cryo to ‘burn’

the arrythmogenic focus

(Kern, 2011)

http://advancingyourhealth.org/heartblog/files/2010/08/apmerge.jpg

Comorbidities Consider when arrhythmias occur: • MI • pericarditis • MVP • COPD • HF • post-CTS

Chronic conditions: • HTN • DM • PVD • RF

Pre-procedure testing • EKG, event monitor if available • LABS: BUN, Cr, electrolytes, PT/INR, pregnancy test • Stress test • Echocardiogram • MRI/CT

Pre-procedure teaching • Informed consent including procedural risks-cardiac and non-

cardiac • Pre-op testing, medication instructions • Expectations during the procedure • Immediate post-procedure course • ‘curative’ statistics for that ablation

Informed consent • Non-delegable duty of cardiologist • Must include:

-why ablation is recommended -benefits of having the ablation -risks associated with ablation -risks of not having ablation -alternatives

(Babb, 2011)

Pre-procedure testing, medication • Indication for labs, echo, ECG, MRI/CT • Need to hold antiarrhythmic meds • When/if to hold anticoagulant medications • When to resume medications • Follow-up lab tests as indicated

Expectations during ablation • General anesthesia • Prolonged supine position for some

Immediate post-procedure • ECG, labs • Frequent monitoring of vital signs, puncture sites • Bed rest • Most can go home same day

(Marijon, 2009)

Intra-procedure monitoring • TEE/ICE • ACT • EKG, vitals • Sedation, anesthesia

Post-procedure testing • EKG, vitals, puncture sites • Labs: ACT, glucose if DM • All other depends on clinical signs of complications

Post-procedure teaching • Puncture site care • Medication instruction • What to do in case of arrhythmia recurrence • Symptoms to be reported

‘curative’ statistics • Ablation not always curative • Speak in terms of success rate • Clearly explain expected timeline for results, need for

medication, resolution of symptoms • Discuss remodeling phase and associated recurrence of

arrhythmia

Follow-up • 1 month, 3 months, every 6 months for two years-more

frequently of complications • ECG at each follow-up • Event monitor before discontinuing anticoagulation and

antiarrhythmic meds

Calkins, 2012

Follow-up testing • ECG • Ultrasound • Labs • After three months-event monitor

Potential complications • Hemorrhage • Venous thromboembolism • Phlebitis • Refractory ventricular

fibrillation • Hematoma • Bradycardia, AV block • Radiation burn • Cardiac perforation • Pneumothorax • Cardiac Tamponade • Stroke

• Esophageal fistula • Mortality • Pulmonary vein stenosis • Aspiration

(Krishnan, 2011 and Altamann, 2011)

Vascular complications • Hemorrhage -3.8% • Hematoma-1.1% • AV fistula-0.3% • Thromboembolic-0.4% • Psuedoaneurysm-0.9%

(Altmann, 2011 and Deshmukh, 2013)

Cardiac Complications • Iatrogenic cardiac complications-1.18% • Pericardial complications-1.52% • Myocardial infarction-0.37%

(Deshmukh, 2013)

Respiratory complications • Pneumothorax-0.39% • Respiratory failure-0.77% • Aspiration-0.2%

(Deshmukh, 2013 and Altmann 2011)

Neurologic complications • Stroke/TIA-1.2% in a-fib, 0.3% in other ablations • Death-0.4%

(Altmann, 2011)

Other complications • Atrial-esophageal fistula-0.2% • Radiation burn-?

(Altmann, 2011)

Risks for complications • Atrial fibrillation ablation-some quote up to 10% • Anticoagulation • Age >75 years • CAD • HTN • Lung disease • DM • Heart failure • Renal disease

(Shah, 2012)

Reducing risk • Clear indication for procedure • Good pre-procedure assessment • Appropriate management of comorbidities • Use of intra-procedure monitoring tools-TEE, ICE

References 1. Collucci RA, Silver MJ, Shubrook J. Common Types of Supraventricular Tachycardia: Diagnosis

and Management. AM Fam Physician 2010; 82,8:942-952 2. Chugh SS, Havmoeller R, Narayan K, et al. Worldwide Epidemiology of Atrial Fibrillation: A

Global Burden of Disease 2010 Study. Circulation 2013;online. 3. Shah RU, Freeman, JV, Shilane, D, et al. Procedural Complications, Rehospitalizations, and

Repeat Procedures After Catheter Ablation for Atrial Fibrillation. J AM Coll Cardiol 2012;59:143-9.

4. Granada J, Uribe W, Chyou PH, et al. Incidence and Predictors of Atrial Flutter in the General Population. J Am Coll Cardiol 2000; 36:2242-2246

5. Altmann D, Hindricks G, Arya A, et al. Management of patients pre-, per, and postcatheter ablation procedures: how to minimize complications? Minerva Cardioangiol 2011; 59:171-86.

6. Marijon E, Albenque JP, Boveda S, et al. Feasibility and Safety of Same-Day Home Discharge After Radiofrequency Catheter Ablation. Am J Cardiol 2009;104:254-258.

7. Pappone C and Santinelli V. Catheter Ablation Should Be Performed in Asymptomatic Patients with Wolff-Parkinson-White Syndrome. Circulation 2005.

8. Wellens HJ. When to Perfom Catheter Ablation in Asymptomatic Patients with Wolff-Parkinson-White Electrocardiogram. Circulation 2005; 112:2201-2216.

9. Murgatroyd FD and Krahn AD. (2011). Patient Instrumentation. In FD Murgatroyd (ed.) Handbook of Cardiac Electrophysiology (pp.6-14) London:Remedica..

10.Yamada T, Lau YR, Litovsky SH, et al. Prevalence and clinical, electrocardiographic and electrophysiological characteristics of ventricular arrhythmias originating from the noncoronary sinus of Valsalva. Heart Rhythm 2013; 10:1605-1612.

11.Killu AM, Friedman PA, Mulpuru SK, et al. Atypical complications encountered with epicardial electrophysiological procedures. Heart Rhythm 2013; 10: 163-1621.

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15.Bunch TJ, May HT, Bair Tl. Atrial fibrillation ablation patients have long-term stroke rates similar to patients without atrial fibrillation regardless of CHADS2 score. Heart Rhythm 2013:10;1272-1279.

16.Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol 2012; 33:171-257.

17.Kinght BP and Jacobson JT. Assessing patients for catheter ablation during hospitalization for acute heart failure. Heart Fail Rev 2011;16:467-476.

18.Eyre-Brook SN and Rajappan K. Catheter ablation for atrial fibrillation: who, why and does it work? Postgrad Med J 2012;88:604-611.

19.Deshmukh A, Patel NJ, Pant S, et al. In-Hospital Complications Associated with Catheter Ablation of Atrial Fibrillation in the United States Between 2000-2010. Circulation 2013;128:2104-2112.

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