# aborted ep ablation



## kmuerth (Feb 6, 2015)

Can I have some opinions on how to code this scenario? Thanks!

1. Complete electrophysiologic study with induction. 
2. Placement of left femoral arterial sheath for pressure monitoring. 
3. Intracardiac echocardiography. 
4. Aborted ablation of left ventricular tachycardia. 
INDICATIONS: The patient is a 63-year-old gentleman with a history of 
atherosclerotic heart disease. Previous inferolateral myocardial 
infarction. Known total occlusion of the right coronary artery. 
Nonobstructive disease involving left anterior descending coronary artery, 
circumflex coronary artery, and ramus intermedius based on cardiac 
catheterization approximately 2 years ago. History of ventricular 
tachycardia. Existing dual-chamber ICD (St. Jude). Recurrent symptomatic 
ventricular tachycardia. Ventricular tachycardia characterized as left 
axis, right bundle branch block morphology consistent with left ventricular 
origin. Resulted in multiple ICD discharges. Recent PET scan positive for 
old infarction. Negative for ischemia. Left ventricular ejection fraction 
0.40-0.45. Planned electrophysiologic testing to determine number of 
inducible ventricular tachycardias with an eye towards VT ablation (left 
ventricular ablation). 
PROCEDURE DESCRIPTION: After informed consent was obtained, the patient 
was transported to the cardiac electrophysiology laboratory in the 
postabsorptive, nonsedated state. He was placed on the table in the supine 
position. The right and left groins were prepped and draped in the usual 
fashion. Local anesthesia of both groins was attained using 1% lidocaine. 
The left femoral artery was percutaneously punctured with an 18-gauge 
thin-wall needle, and a 5.5 French arterial sheath positioned in the 
artery. Left femoral arterial pressure was monitored throughout the case. 
The left femoral vein was percutaneously punctured with an 18-gauge 
thin-wall needle, and an 11 French venous sheath positioned in the vein. A 
10 French intracardiac echo probe was advanced through the 11 French venous 
sheath, and positioned in the right atrium. Intracardiac echocardiography 
was performed. The intracardiac echocardiogram revealed a small 
pericardial effusion that was primarily posterior. Additionally, there was 
evidence of the extensive infarction involving the inferior and part of the 
inferolateral wall of the left ventricle with a transition zone from 
infarcted tissue to healthy tissue in the region of the inferoapical and 
inferoseptal left ventricle. 
Left ventricular ejection fraction is felt to be 0.35-.40 based on 
intracardiac echocardiography. The right femoral vein was percutaneously 
punctured on 3 separate occasions, and 6.5 French and 6 French venous 
sheath positioned in the vein. Three 6 French quadripolar electrode 
catheters advanced through the venous sheath under fluoroscopic guidance, 
and positioned in the high right atrium, His bundle region, and right 
ventricular apex. Complete electrophysiologic testing was performed. 
Basic conduction intervals were recorded. Baseline EKG was recorded. Sinus 
node recovery times were not performed. Incremental atrial pacing was 
performed from the high right atrium until antegrade block occurred. 
Incremental ventricular pacing was performed from the right ventricular 
apex until retrograde block occurred. Antegrade refractory periods 
performed from the high right atrium at drive cycle length of 600 msec. 
Retrograde refractory period was performed from the right ventricular apex 
at a drive cycle length of 600, 500, and 400 msec. 
Double ventricular extrastimuli were introduced at the same drive cycle 
lengths. The patient had reproducible inducible monomorphic sustained 
ventricular tachycardia 2 morphologies. This was inducible at all 3 drive 
cycle lengths using single and double ventricular extrastimuli. The 
slowest ventricular tachycardia was the previously documented clinical 
ventricular tachycardia. This was a left axis, right bundle branch block 
morphology with a cycle length of 412 msec. The second morphology was 
faster and had a northwest axis right bundle branch block cycle length of 
322 msec. Both tachycardias were easily reproducible inducible and were 
noted to be sustained. Both were terminated with ventricular burst pacing. 
It was elected to proceed with left ventricular VT ablation. It was 
elected to proceed with a retrograde approach. The aortic valve had been 
previously noted by transthoracic echocardiography, and was noted by 
intracardiac echocardiography to not be sclerosed or calcified and not 
stenotic. The right femoral artery was percutaneously punctured with an 
18-gauge thin-wall needle, and an 8 French sheath was positioned in the 
artery. 
An 8 French Biosense Webster SF ThermoCool ablation catheter was advanced 
into the 8 French sheath out into the femoral artery. As the catheter was 
being advanced up through the right iliac, it became clear that the iliac 
was fairly heavily calcified, and was at risk for dissection of a plaque. 
Therefore, the catheter was withdrawn. An 8 or 9 French 60 or 90-cm sheath 
was requested. However, neither of these were available. A 9 French, 
30-cm sheath was available. The standard 9 French sheath was exchanged out 
for the 30-cm sheath. This sheath ended at the origin of the right common 
iliac artery. 
The ablation catheter was advanced through the sheath into the distal 
aorta. The aorta was fairly heavily calcified and somewhat tortuous. The 
ablation catheter was advanced into the descending aorta, and navigated 
into what appeared to be the true lumen. The catheter was advanced up into 
the thorax without any difficulty. However, in the descending thoracic 
aorta obstruction was reached. The catheter was withdrawn. A 0.035 
J-tipped guidewire was advanced through the sheath into the aorta. This 
followed the same path as the ablation catheter. Again, it reached a 
terminal point in the descending thoracic aorta distal to the takeoff of 
the left subclavian artery. 
A 6 French JR-4 coronary catheter was advanced over the guidewire. Gentle 
hand injection was performed revealing that the guidewire catheter were in 
a false lumen. Obviously, the ablation catheter resulted in a retrograde 
aortic dissection extending from the abdominal aorta into the thoracic 
aorta. The coronary catheter was withdrawn. Utilizing the coronary 
catheter and the guidewire, the true lumen of the aorta was found. The 
guidewire was advanced through the true lumen of the aorta into the 
ascending aorta across the aortic valve into the left ventricle. The JR-4 
guide catheter was advanced over the guidewire, and positioned in the 
aortic arch. 
Aortic arch angiography was performed. This did not reveal an antegrade 
rent/tear in the thoracic aorta. The catheter was withdrawn into the 
descending thoracic aorta. Hand injection aortography was repeated. Again, 
no antegrade entry into the aortic dissection/false lumen was noted. The 
entire catheter was withdrawn. At this point, it was felt best to abort any 
attempt at ablation of the left ventricular tachycardias. 
Heparin was discontinued and reversed with protamine. All sheaths were 
withdrawn. Firm pressure was applied to both groins for 20 minutes. After 
hemostasis was attained, distal pulses were noted to be baseline. A 
nonpressure dressing was applied to both groins. The patient was 
subsequently transported to his room in stable condition. 
MEDICATIONS ADMINISTERED: Lidocaine 1% local anesthetic. Heparin 14,000 
units IV. Heparin drip up to 1100 units per IV. Versed 6 mg IV. Fentanyl 
125 mcg IV. Nasal oxygen at 3 liters per minute. 
FLUOROSCOPY TIME: Less than 10 minutes. 
CONTRAST: Visipaque 60 mL total. 
ESTIMATED BLOOD LOSS: None. 
COMPLICATIONS: Retrograde dissection of the abdominal aorta extending into 
the thoracic aorta secondary to advancement of the ablation catheter 
through the aorta. No evidence of an antegrade connection to the false 
lumen based on aortic arch and descending thoracic aortography. 
EQUIPMENT MALFUNCTION: None. 
TECHNICAL DIFFICULTIES: As noted above, difficulty occurred with passage 
of the ablation catheter retrograde through the aorta. A 60, 70, or 90-cm 8 
or 9 French sheath was requested. However, no sheath was available for 
use. 
RESULTS: 
I. Basic Conduction Intervals: 
Initial: Sinus cycle length 110 msec. PR interval 186 msec. QRS duration 
176 msec. QT interval 478 msec. PA interval 50 msec. A-H interval 92 
mesc. H-V interval 52 msec. 
Baseline EKG revealed sinus rhythm, normal axis, right bundle branch block, 
old inferior wall myocardial infarction. 
Conclusion: Cycle length 1052 msec. PR interval 178 msec. QRS duration 
168 msec. QT interval 420 msec. PA interval 32 msec. A-H interval 9 msec. 
H-V interval 56 msec. 
Concluding EKG: Normal sinus rhythm, normal axis, right bundle branch 
block, old inferior wall myocardial infarction. 
II. Functional Properties: 
A. Sinus Node - Sinus node function noted tested. 
B. AV node: AV node conduction appears to be normal. 
1. Resting A-H interval 92 msec. 
2. Maximum 1:1 AV node conduction atrial pacing 540 msec. 
4. AV node block cycle length (Wenckebach) 530 msec. 
5. No dual AV node pathways noted. 
6. No dual AV node pathway is noted. 
7. Antegrade refractory period is AV node: Normal. 
Pacing HRA Cycle Length (msec) Effective Refractory Period (msec) 
600 380 
6. There was no retrograde conduction. There was no VA conduction. 
C. Atrial refractory periods: Not performed. 
D. Retrograde refractory periods: Normal. 
Pacing RVA Cycle Length (msec) Effective Refractory Period 
(msec) 
600 260 
500 260 
400 250 
III. Arrhythmias induced. 
A. There was no evidence of an atrioventricular accessory pathway. No 
pathway was observed during sinus rhythm, incremental atrial pacing, or 
retrograde refractory period determination. There was no retrograde 
conduction. There was no VA conduction. 
B. Supraventricular arrhythmias: None induced. 
C. Ventricular arrhythmias: There was reproducible inducible monomorphic 
nonsustained and sustained ventricular tachycardia from the right 
ventricular apex using 1 and 2 ventricular extrastimuli at drive cycle 
lengths of 600, 500, and 400 msec. The reproducible inducible monomorphic 
sustained ventricular tachycardiac at 2 morphologies. One morphology was 
identical to the patient's clinical morphology, and was characterized as a 
left axis, right bundle branch block morphology, cycle length 412 msec. 
The second morphology was characterized as a northwest axis, right bundle 
branch block morphology cycle length 322 msec. Both morphologies of 
sustained ventricular tachycardiac were terminated with ventricular burst 
pacing. 
As noted above, ablation of the 2 morphologies of left ventricular 
tachycardia was aborted secondary to the complication of retrograde aortic 
dissection of the abdominal aorta extending into the thoracic aorta that 
occurred during advancement of the ablation catheter retrograde through the 
abdominal aorta. The aorta was noted to be tortuous and significantly 
atherosclerotic with obvious calcium. 
RECOMMENDATIONS: 
1. The patient's ICD was reprogrammed as desired and as had been noted at 
the time of presentation. During the case, the therapies obviously were 
turned off, and the device had been reprogrammed to the VVI mode at 40 
pulses per minute. 
2. Continue current medical therapy. 
3. The patient will be monitored for an extended period of time in our 
cardiac observation unit. If he develops any abdominal pain or back 
pain, CT angiography will be performed. 
4. The patient will ultimately require readmission and second attempt at 
ablation of the 2 morphologies of ventricular tachycardia that have been 
recurrent, resulting in ICD discharges. There are left ventricular 
tachycardias. The case will be approached from a transseptal approach 
utilizing a Mullins sheath with ablation catheter being advanced through the 
Mullins across the mitral valve for left ventricular ablation. 
However, the retrograde approach must be utilized in backup fashion 
should the ablation not be accomplished with the transseptal approach. 
Therefore, a 90-cm 9 French sheath will be needed. The sheath will be 
needed for passage of the catheter through the aorta in a retrograde 
fashion. This procedure will be performed in 4-6 weeks after the 
current retrograde aortic dissection has healed.


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