Can someone give me some guidance on this? I’ve only coded the simple av node ablations so this is new to me.

Thank you!

SURGEON:

HW, MD and DR. DH

REFERRING PHYSICIAN:

CLINICAL INDICATION:

The patient is a 78-year-old gentleman with severe cardiomyopathy and

Medtronic BiV-ICD. The patient was noted to have atrial flutter with

recurrent tachycardia and he did have one AV node ablation, but the

patient was noted to have possible recovery with heart rate up to 120s.

The patient also was noted to have heart rate in the 60s. Thus, the

patient came in for EP study with possible ablation redo for AV node.

DESCRIPTION OF PROCEDURE:

The patient was sedated by anesthesiologist using general anesthesia.

Dr. H and I did the procedure together. The patient was prepped

and draped in sterile fashion. Right femoral vein was accessed and 7.0

sheath was placed with ablation. We decided to use a bidirectional ThermoCool

ablation catheter. BiV-ICD was programmed to VVI-40. Dr. H and

I did a detailed mapping of AV node. So far, we have trouble finding

the AV node with his potential, but we did anatomical ablation for presumed

sites for the AV node. In retrospect, the patient could have idioventricular

rhythm and some of the tachycardia could be rate response of slow VT.

We did an anatomical ablation of AV node. Isuprel was started and so

far, the patient is to have heart rate in the 60s to 65 with isoproterenol,

there was no recovery of AV node, but we were not 100% certain. We tried

to attempt cardioversion, but atrial flutter was persistent. We tried

to do atrial pacing. So far, the cycle lines were ranging from 390 to

450 milliseconds. Initially, so we may able to terminate atrial flutter,

then checked through AV conduction, but with multiple attempts, the

patient has persistent atrial flutter ranging from 390 to 450 milliseconds.

I gained isoproterenol changes of cycle lines of the tachycardia. We

did attempt to do the ablation along the isthmus without changing the

cycle lines and then we concluded the study without further ablation.

Hemostasis was obtained by manual pressure. BiV-ICD was reprogrammed

to VVI-80.

CONCLUSION:

1. Attempted ablation redo for AV node, but in retrospect, the patient

could have complete heart block with idioventricular rhythm. We did

an anatomical ablation involving AV node.

2. Isuprel drug testing and the patient has persistent high-grade

complete heart block on isoproterenol.

3. BiV-ICD reprogramming to VVI-80.

4. Attempted cardioversion and atrial pacing, but atrial flutter persisted.

5. Detailed 2D mapping of AV node.

ESTIMATED BLOOD LOSS:

About 10 mL.

CONTRAST USED:

None.

PLAN:

The patient will be kept in ICU overnight and see how he does. At this

moment, we think the patient has complete heart block with idioventricular

rhythm with heart rate in the 60s. We will see how the patient does

with Bi-V pacing of 80.

Dr. H and I performed the procedure together.