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Cryoablation of atrial fibrillation

RF and cold ablation procedures

Basic electrophysiology study

Complete electrophysiology study

Pacemaker insertion

Insertion of dual chamber pacemakers (AV sequential)

Insertion of single chamber defibrillators

Insertion of AV sequential defibrillators (dual chamber)

Insertion of biventricular resynchronisation defibrillators

Electrophysiology study therapeutic transcatheter RF ablation of supraventricular tachycardia

Syncope Study. Tilt test

Insertion of subcutaneous recorder for idiopathic syncope

Atrial fibrillation has enormous impact on society and is one of the most common type of cardiac arrhythmias for people over 50 years.

In Spain, atrial fibrillation is the cause of approximately 25% of all out-patient cardiology consultations.

¿Qué es la Fibrilación Auricular?

Pronóstico y Tratamientos Fibrilación Auricular

Contraindicaciones Crioablación Fibrilación Auricular

Crioablación Fibrilación Auricular Procedimiento comentado por el Dr. Paylos

Presentacion Unidad de Arritmias HLA Universitario Moncloa-Madrid, España

  • Estudios previos al procedimiento
  • Ecocardiograma transtorácico.
  • Transesofágico al menos 48 horas antes del procedimiento.
  • TAC / alta resolución (64 cortes) (Toshiba Aquilion 64, TSX-101A).
  • RMN (1.5 T / Magnetom Symphony, Siemens) Tipificación Anatomía / Número y Calibre / VVPP.

We use ablation procedures to scar or destroy tissue that causes an abnormal heart rhythm. This prevents abnormal electrical signals from passing through the heart.

What is RF ablation? RF ablation is usually performed under conscious sedation (to reduce anxiety). Vital constants (heart rate, blood pressure) are monitored. Catheters are introduced into the cardiac cavity via the femoral vein, in the groin.

The procedure lasts a few hours. The first part consists of an electrophysiology study (arrhythmia study), stimulating the atrium and the ventricle to induce arrhythmia (establishing the mechanism by which it is caused). Immediately afterwards, the ablation is performed, mapping the ideal site for the procedure. After ablation, we verify that there is no further production of arrhythmia, and finish the procedure.

Patients are then ordered bed rest for at least four hours, after which time, providing no complications arise, they are sent home.

When is it indicated? Catheter ablation evolved from arrhythmia surgery and has transformed the treatment of tachyarrhythmias. It was initially performed using high voltage direct current (DC). However, in the 1980s, due to the high rate of complications, DC was replaced by radio frequency (RF), making catheter ablation the treatment of choice for many types of tachycardia.

It is considered the first-line treatment for certain types of arrhythmia (Wolff-Parkinson-White syndrome), as well as an important technique for handling other types of arrhythmia which do not respond to medical treatment or where it is contraindicated (atrial tachycardia, atrial fibrillation or flutters, AV nodal reentrant tachycardia, idiopathic ventricular tachycardia).

Two methods RF ablation Cryoablation or cold ablation

  • Mediante dos métodos
  • Ablación por radiofrecuencia
  • Crioblación o el suo del frio

Electrophysiology studies are performed to diagnose patients with heart rhythm disorders (arrhythmias). They tell us the type and severity of the arrhythmia and also help to better define the treatment to be applied.

What happens during the electrophysiology study? The heart is a muscle that pumps blood through a series of vessels (arteries and veins). The function of the heart valves is to move the blood in the right direction. The heart also has an electrical system, which issues the impulses that mark the cardiac rhythm and adapt it to the needs of the body. Disorders in the heart's electrical system cause disturbances in the cardiac rhythm, known as arrhythmias. Bradycardia is a slower than normal heart rate, and tachycardia is a faster than normal heart rate. Electrophysiology studies are tests that help to diagnose abnormal arrhythmias and define the best course of treatment.

Medical protocol Variable number of electrode catheters ADA (4P / 6F) AV Node / His (3P / 7F) Right ventricle apex (4P / 6F) Coronary sinus (10P / 6F) 4-Pole 7F (mapping) Access pathways Right / left femoral vein and artery Left antecubital / median cubital veins (coronary sinus) Left / right subclavian vein Right jugular vein (exceptional cases)

Estudio Electrofisiológico Básico. Diagnóstico

  • Protocolo Médico
  • Número variable de electrocatéteres
  • ADA (4P / 6F)
  • Nodo AV / His (3P / 7F)
  • Ápex ventrículo derecho (4P / 6F)
  • Seno coronario (10P / 6F)
  • Cuatripolar 7F (mapeo)
  • Vías de acceso
  • Arteria y Vena femoral derecha / izquierda
  • Venas antecubitales (seno coronario) / medianas izquierda
  • Vena subclavia derecha / izquierda
  • Vena yugular derecha (Excepcional)

Electrophysiology studies are performed to diagnose patients with heart rhythm disorders (arrhythmias). They tell us the type and severity of the arrhythmia. Additionally, they help to better define the treatment to be applied.

How are electrophysiology studies performed? First of all, patients are required to be fasting.

They remove their clothes and lie down on a special bed in the electrophysiology lab. In general, patients are first sedated.

Local anaesthesia is applied at the site where the needle is inserted (veins and/or arteries of the groin, arm or neck) to ensure that patients feel no pain. Afterwards, the catheters, which are long, fine, flexible wires, are inserted and directed towards the heart using X-ray or other localisation systems that do not require radiation.

The catheters give a permanent picture of the heart's electrical activity from the inside, defining the type of arrhythmia and pinpointing its location.

Electrical activity is shown on monitors. They can also be used as pacemakers if they are connected to an external stimulator device.

It is sometimes necessary to administer drugs during the test, to refine the diagnosis. Occasionally, electrical shocks need to be administered. If this is necessary, the patient is anaesthetised.

The time of the procedure may vary from 30 minutes to several hours.

When it is over, patients are advised to rest for several hours, to prevent complications arising at the puncture site.

Medical protocol Right / left femoral vein and artery Left antecubital / median cubital veins (coronary sinus). Left / right subclavian vein Right jugular vein (exceptional cases)

Estudio Electrofisiológico Completo. Diagnóstico

  • Protocolo Médico
  • Arteria y Vena femoral derecha / izquierda
  • Venas antecubitales (seno coronario) / medianas izquierda
  • Vena subclavia derecha / izquierda
  • Vena yugular derecha (Excepcional)

Pacemakers are electrical devices, like mini-computers, that can detect the heartbeat and issue small electric shocks that make the heart beat when the patient's own impulses are absent or too slow.

They consist of a small device, known as the generator, which is about four centimetres around and just a few millimetres thick, and contains a small electrical circuit and a battery to supply power. This is connected to one, two or, sometimes, three very fine wires, known as electrodes, inserted into the cavities of the heart. The electrodes can ‘feel’ or detect the heartbeat and transmit shocks from the generator to stimulate the heart when needed.

Pacemakers are inserted during surgery under local anaesthesia, while the patient is conscious. The operation can last up to a couple of hours, the time varying from case to case. As in any surgical procedure, complications may arise. However, these are very infrequent.

Medical protocol Single puncture (Seldinger technique) Left / right subclavian vein Jugular vein, in exceptional cases Local anaesthesia General anaesthesia in specific cases

Implante de Marcapasos Monocameral

  • Protocolo Médico
  • Simple punción percutánea (Técnica de Seldinger)
  • Vena subclavia derecha / izquierda
  • Excepcionalmente yugular
  • Anestesia local
  • Casos puntuales anestesia general

Artificial pacemakers are electronic devices that issue electrical impulses to stimulate the heart when normal physiological stimulation fails. Once these impulses are generated, they need a conductor wire (or electrode catheter) between them to work. By this means, the cardiac stimulation system consists of an electrical impulse generator, or pacemaker, and a wire.

Medical protocol Double puncture (Seldinger technique) Left / right subclavian vein Jugular vein, in exceptional cases Local anaesthesia General anaesthesia in specific cases

Implante de Marcapasos Bicameral Secuencia AV

  • Protocolo Médico
  • Doble punción percutánea (Técnica de Seldinger)
  • Vena subclavia derecha / izquierda
  • Excepcionalmente yugular
  • Anestesia local
  • Casos puntuales anestesia general

This procedure re-establishes normal cardiac rhythm by means of an electric shock. They may be external (on the skin) or implantable (definitive); the latter are only indicated in certain specific situations.

Defibrillation is based on applying a short, sharp shock of high-voltage electricity to stop and reverse a faster than normal heart rate (sustained ventricular tachycardia, ventricular fibrillation); situations when the heart beats too fast or electrical activity is chaotic, due to a certain area of the heart triggering uncontrolled or ineffective impulses or impulses that cause haemodynamic instability (deterioration of vital signs), all of which may provoke cardiac arrest. The electric shock stops the arrhythmia, allowing doctors to identify and eliminate the causes.

Medical protocol Single puncture (Seldinger technique) Left / right subclavian vein Jugular vein, in exceptional cases Local anaesthesia General anaesthesia in specific cases

Implante de Desfibriladores Monocameral

  • Protocolo Médico
  • Simple punción percutánea (Técnica de Seldinger)
  • Vena subclavia derecha / izquierda
  • Excepcionalmente yugular
  • Anestesia local
  • Casos puntuales anestesia general

This procedure re-establishes normal cardiac rhythm by means of an electric shock. They may be external (on the skin) or implantable (definitive); the latter are only indicated in certain specific situations.

Medical protocol Double puncture (Seldinger technique) Left / right subclavian vein Jugular vein, in exceptional cases Local anaesthesia General anaesthesia in specific cases

Implante de Desfibrilador Secuencial AV Bicameral

  • Protocolo Médico
  • Doble punción percutánea (Técnica de Seldinger)
  • Vena subclavia derecha / izquierda
  • Excepcionalmente yugular
  • Anestesia local
  • Casos puntuales anestesia general

Cardiac resynchronisation therapy may be indicated in certain patients with refractory congestive heart failure

OBJECTIVES: To improve the quality of life of patients in extreme situations, mainly with coronary artery disease (ischemic)

INCLUDES PATIENTS: Excluded / Heart transplant Refractory heart failure (NYHA functional class III / IV) E.F. Left ventricle ≤ 30 – 35% BCRI (QRS ≥ 150 mS) ECG diagnosis (myocardial contractility / intraventricular and interventricular AV synchronism) ACCESS PATHWAYS Triple punction of left subclavian vein Electrode right atrial (appendage) Electrode right ventricular (apex) Electrode right ventricular (epicardium) Pathway to coronary sinus Phlebogram (coronary sinus and coronary veins) Selecting the right vein Correct synchronisation RV / LV - Activation times

IMPLANTABLE AUTOMATIC STIMULATION DEVICES / CARDIOVERTERS / DEFIBRILLATORS / Resynchronisers (ICD + CRT)

Single chamber (most frequently used) Dual chamber: normally used if: AV synchronisation required Atrial contraction Adjuvant therapy / I.C. Triple chamber (more frequent / with biventricular resynchronisation therapy)

Procedure used in cases of:

Nodal re-entrant tachycardia Tachycardia in association with concealed or manifest accessory pathways (Wolff-Parkinson-White syndrome) Ablation of common atrial flutter THERAPEUTIC: VARIABLE NUMBER OF ELECTRODE CATHETERS (3-7)

ADA AV node / His Right ventricular apex Coronary sinus (LA, LV / Epicardium) 4-Pole 7F (mapping / ablation): right ventricle and left ventricle Left atrium, Endocardium: Transeptal

Access pathways Right / left femoral vein and artery Left antecubital / median cubital veins (coronary sinus) Left / right subclavian vein Right jugular vein (exceptional cases)

  • Vías de acceso
  • Arteria y Vena femoral derecha / izquierda
  • Venas antecubitales (seno coronario) / medianas izquierda
  • Vena subclavia derecha / izquierda
  • Vena yugular derecha (Excepcional)

The tilt-table test is performed on a table that is inclined slowly upwards to evaluate the causes of syncope, when patients have suffered repeated fainting fits (syncopes)

MEDICAL PROTOCOL

Tilt table 70º tilt (most usual protocol) Continuous monitoring (ECG and blood pressure) Crash trolley (stand-by) Manoeuvres / Cardiopulmonary resuscitation Assessment of neurally mediated response (vagal and sympathetic reflex action) CARDIOINHIBITORY / VASODEPRESSOR

Estudio Electrofisiológico Terapéutico Ablación Transcateter por Radiofrecuencia de Taquicardia S

The causes of syncope are difficult to ascertain in up to 38% of cases.3 The leading obstacle in ascertaining the cause of syncope lies in the unpredictable frequency of episodes. Implantable recorders make long-term ECG monitoring possible.

SUBCUTANEOUSLY IMPLANTABLE RECORDERS

Activation: Manual (patient) Automatic (programmable) Heart rate limits Bradycardia Tachycardia Asystole Record possibility (1-4 minutes) before/after EVENT

Medical protocol ADA (4P / 6F) AV Node / His (3P / 7F) Right ventricle apex (4P / 6F) Coronary sinus (10P / 6F) 4-Pole 7F (mapping)

  • Protocolo Médico
  • ADA (4P / 6F)
  • Nodo AV / His (3P / 7F)
  • Ápex ventrículo derecho (4P / 6F)
  • Seno coronario (10P / 6F)
  • Cuatripolar 7F (mapeo)