Queen of the Valley

1000 Trancas Street

Napa, CA 94558

Operative Report

DATE OF OPERATION: 05/10/2017

SURGEON: RICHARD H HONGO, MD

ANESTHESIA: GENERAL

REFERRING CARDIOLOGIST: Sergio M Manubens, M.D.

PROCEDURES PERFORMED:
1. Catheter ablation for the treatment of atrial fibrillation (93656).
2. Additional linear and focal ablation for atrial fibrillation (93657).
3. Secondary discrete arrhythmia ablation (93655).
4. Stimulation pacing after infusion of isoproterenol (93623).
5. 3D mapping (93613).
6. Intracardiac echocardiography (93662).

PREOPERATIVE DIAGNOSES:
1. Persistent atrial fibrillation (I48.1).
2. Atypical flutter (I48.4).

POSTOPERATIVE DIAGNOSES:
1. Persistent atrial fibrillation (I48.1).
2. Atypical atrial flutter (I48.4).
3. Atrial tachycardia (I47.1).

INDICATION FOR PROCEDURE: A 65-year-old woman with palpitations since 2011,

initially thought to be adenosine-sensitive SVT. She was taken to EP lab at Kaiser
Santa Clara in 2014, and went into atrial fibrillation during the procedure and
cardioverted. Formal diagnosis of atrial fibrillation was made at that time
and she was started on sotalol. She had fair suppression with sotalol, but
then, because of breakthrough episodes, was later treated with Multaq, which
was not effective. More recently, rate control with metoprolol, diltiazem, and
digoxin. She was started on Pradaxa, but then switched to Eliquis 5 mg p.o.
b.i.d. She was referred for catheter ablation on 03/30/2017, but a
preprocedural TEE showed left atrial appendage thrombus and the procedure was
postponed. The Eliquis was changed over to Coumadin and she has been
maintained above 2.0 for over 4 weeks. She now presents for a catheter
ablation procedure. The transesophageal echocardiogram was performed by Dr.
Mark Villalon. No left atrial appendage thrombus was observed. Clear
pectinate muscles were observed. There was moderate spontaneous echo contrast
observed throughout the left atrium. Her INR today was 2.6.

DESCRIPTION OF PROCEDURE: The patient was brought to the cardiac

catheterization laboratory in a fasting, nonsedated state. After informed
written consents were obtained, the procedure was initiated. She was placed
under general anesthesia by the anesthesiologist. The patient was prepped and
draped in usual manner. The esophageal temperature probe was placed without
difficulty.

Two 8-French sheaths were placed into the right femoral vein and
an 8-French and a 10.5-French sheaths were placed into the left femoral vein,
using a modified Seldinger technique under direct ultrasonic visualization. A
10-French intracardiac echocardiography catheter was advanced from the left
side and positioned in the right atrium. Throughout the procedure, this was
used to visualize the right atrium, right ventricle, left atrium, left
ventricle, and was utilized for transseptal puncture. A 7-French deflectable
coronary sinus catheter was advanced through the left-sided 8-French sheath and
positioned in the coronary sinus and used for left atrial recording as well as
pacing throughout the case. At this point, 10,000 units of heparin were given
and additional boluses were given throughout the case in order to maintain an
ACT above 350.

Transseptal puncture was then performed using exchanging the 8-French

sheaths on the right side with two 8.5-French long sheaths, a SL0 and a
LAMP sheaths. This was done using a BRK needle and was done without
complication. This was done under direct visualization under intracardiac
echocardiography. A 10 pole 20 mm Lasso was advanced through the LAMP sheath
and was used for mapping. A 7-French SmartTouch SF curve ablation catheter was
advanced through the SL0 sheath and used for mapping and catheter ablation.

Mapping was then performed and a large left atrium was defined. There were 4
pulmonary veins. The right-sided pulmonary veins were both very large with very wide antral
regions. The posterior wall was very low amplitude and discrete regions
of what appeared to be complete scar. There was also very low amplitude
throughout the anterior wall. Pulmonary vein signal was localized
using the Lasso catheter and all 4 veins were successfully isolated. The left
atrial posterior wall was also isolated. With this, the atrial fibrillation
organized into an atrial flutter. This was then mapped and defined to be
perimitral flutter. Highly fragmented signal in the mitral isthmus was
targeted and silenced extensive coronary sinus conduction was noted, but
because of a very small coronary sinus, decision was made not to try to isolate
the coronary sinus. Defragmentation was performed, but the conduction was
still brisk through the coronary sinus and through the mitral isthmus. Mapping
was then performed in the anterior wall region and highly fragmented signal
throughout the roof was observed. Cardioversion was performed in order to
assess the extent of the scarring and in sinus rhythm she was noted to have
near-complete scarring of the roof, except for a highly fragmented area very
anterior and close to mitral valve anulus. During mapping, the patient went
back into a sustained flutter and further mapping and ablation were performed.
An anterior ablation line was then performed, silencing the entire roof, and with
this several cycle lengths of atrial flutter were terminated into a slow
flutter that finally terminated with completion of this anterior catheter line.
Further atrial tach foci were localized in the base of the left atrial
appendage in regions of high fractionation and this was targeted and eliminated
and sequentially, to the point where no further atrial ectopy was noted. A low-
dose Isuprel infusion was given at 4 mcg/minute for about 5 minutes in order to
assess the sinus node function. After initial termination of the flutter,
there was a long sinus pause, but a sinus rhythm between 45 and 50 beats per
minute resumed. With isoproterenol, this went up nicely to about 70 beats per
minute with a normal PR interval.
Post-Ablation Findings:
1. RR interval 1200 milliseconds.
2. PR interval 200 milliseconds.
3. QRS complex 98 milliseconds.
4. QT interval 423 milliseconds.
5. HV interval was 59 milliseconds.
6. AH interval 108 milliseconds.
7. There was no VA conduction in the basal state with no evidence of an accessory pathway
both antegrade and concealed.

At this point, all catheters were withdrawn from the heart. Protamine was
given at 40 mg IV. Figure-of-eight stitches were placed using #0 nylon sutures
to achieve hemostasis in both groin sites. The patient was extubated without
incident. She was noted to have old coagulated blood, mild amount, when the
esophageal temperature probe was pulled out. Suction was performed and no
active bleeding was noted. No bleeding was apparent in the mouth itself. The
patient was extubated without any issue and did not complain of any chest pain.
She had good oxygenation and was transferred to recovery in stable condition.

CONTRAST: Less than 2 cc.

COMPLICATIONS: None.

FLUIDS: Total normal saline infusion of 2500 mL.

CONCLUSIONS:
1. Severe left atrial scarring noted, especially along the left atrial
posterior wall as well as the nearly the entire left atrial roof.
2. Very large right pulmonary veins with antra that extended out into a
funnel like structures.
3. Isolation of all 4 pulmonary veins for the treatment of atrial
fibrillation.
4. Superior vena cava was not isolated because of sinus node dysfunction and
the need to preserve sinus node function.
5. Isolation of left atrial posterior wall.
6. Multiple cycle lengths of atrial tachycardia/microreentry flutters were noted
with slowing and stabilization with isolation of the left atrial roof.
7. The last remaining slow atrial flutter cycle length 400 milliseconds was
determined to be mitral valve annular. Initial attempt was a mitral
isthmus ablation line, but the coronary sinus demonstrated extensive
conduction. Because the coronary sinus was very narrow, decision was made not
to try to isolate the coronary sinus and instead an anterior ablation line
was performed connecting the isolated left atrial roof and mitral valve
anulus with termination of the last flutter.
8. Sinus node dysfunction with very long sinus node recovery time after
termination of the last flutter. Sinus rate of 45 to 50 beats per minute
that picked up with isoproterenol 4 mcg per minute to about 60 to 70 beats
per minute with no atrial ectopy.
9. No retrograde VA conduction was observed with V pacing excluding the
possibility of AVRT.
10.Delay into the left atrial appendage, but this was not isolated.
Isolation of the coronary sinus would probably result in left atrial
appendage isolation because of the extensive anterior wall scarring.

PLAN:
1. Continue warfarin with an INR target of 2.0 to 3.0.
2. Will resume sotalol 80 mg p.o. b.i.d. She had been on this before and
tolerated this well with fair control of her atrial fibrillation prior to
the last few years.
3. We will check EKG in the morning to ensure the corrected QT interval is
less than 500 milliseconds.
4. Hold metoprolol, diltiazem and digoxin for the time being because of her
sinus node slowing and the need to try to restore sotalol.
5. Lasix diuresis overnight.
6. Watch for any further bleeding from either the stomach or the esophagus.
If she complains of chest pain in the morning, we will plan to get a chest
x-ray to make sure no evidence of esophageal injury from either the
catheter ablation or the transesophageal echo is found.