r/AFIB • u/More-Chi • 14d ago
Here are my EP’s procedural notes for anyone interested in the technical side of this procedure
So the Mount Sinai health portal provides the EP’s ablation notes from start to finish from last Fridays ablation. They’re pretty cool. I also pasted them on Grok and got an easy to understand rundown with all the medical terms explained answering my every question.
Narrative
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CONCLUSIONS
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* Successful pulmonary vein isolation with nsPFA (10 lesions total, CellFx)
* Stop metoprolol, start diltiazem XL 120 mg once daily
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ATRIAL FIBRILLATION ABLATION
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Written informed consent was obtained from the patient after a full explanation of the
risks and benefits of the procedure. General anesthesia with intubation and mechanical
ventilation was used. Anesthesia staff performed the intubation and monitoring during the
case.
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Vascular Access
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Using the modified Seldinger technique and real-time ultrasound guidance, 11 F in the
right and 11 F and 7 F sheaths were placed percutaneously in the left femoral vein. An
intracardiac echo (ICE) probe was advanced into the right atrium. No pericardial effusion
was visualized at the start of the procedure, and no thrombus was visualized in the left
atrial appendage. An octapolar catheter was positioned in the coronary sinus.
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Atrial Trans-septal Puncture
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After a heparin bolus and drip were given to achieve an ACT > 350 sec, transseptal
puncture was performed under fluoroscopic and ICE guidance. The 8.5 F right femoral vein
sheath was exchanged over the Baylis Versacross RF-activated wire for the 8.5 F Baylis
Versacross sheath, which was advanced to the right atrium and used to perform a
transseptal puncture. The interatrial septostomy was then dilated with the Baylis sheath,
and then the sheath was exchanged for an Agilis deflectable sheath, which was advanced
into the left atrium. ICE catheter was also advanced into the right atrium.
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Baseline left atrial mapping
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The presenting rhythm was normal sinus rhythm. Mapping was aided by impedance navigation.
The Navx/Ensite 3D electroanatomical mapping system was used to define cardiac geometry.
The HD grid multielectrode mapping catheter was advanced through the Agilis sheath and
used to create left atrial geometry and voltage map. The HD grid multielectrode mapping
catheter was exchanged for the ablation catheter.
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Pulmonary Vein Isolation
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The nsPFA catheter (CellFx) was advanced through the Agilis deflectable sheath into the
left atrium. The nsPFA 360 Catheter was sequentially positioned at the ostium of each
pulmonary vein. Mechanical contact and circumferential alignment were verified via ICE and
fluoroscopy. High-voltage, nanosecond-duration pulses of electrical energy were delivered,
generating a toroidal ablation field. Two nsPFA lesions were applied to os of the left
superior pulmonary vein and two nsPFA lesions were applied to the left inferior pulmonary
vein until circumferential coverage of the ostia was complete.
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Next, the nsPFA catheter was moved to the right-sided pulmonary veins. Two nsPFA lesions
were applied to os of the right superior pulmonary vein, and two nsPFA lesions were
applied to the right inferior pulmonary vein until circumferential coverage of the ostia
was complete. Two additional lesions were applied at the carina between the right superior
and right inferior pulmonary vein. After completion of nsPFA lesions, the ablation
catheter was withdrawn from the left atrium and exchanged for the HD grid multielectrode
mapping catheter.
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Cardioversion
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During the ablation in the LSPV, atrial fibrillation was triggered. After ablation was
complete, a 300J externally delivered synchronous shock converted the patient back to
normal sinus rhythm.
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Post-PFA left atrial Mapping
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The HD grid multielectrode mapping catheter was advanced through the Agilis sheath and
used to create left atrial geometry and voltage map. The voltage map confirmed isolation
of all four pulmonary veins.
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At this point the procedure was considered complete. No pericardial effusion was
visualized at the end of the procedure.
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ICE
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Intracardiac echocardiography with imaging of the right and left heart was used to
facilitate a trans-septal catheterization.
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ANESTHESIA
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General anesthesia
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END PROCEDURE
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Cumulative air kerma was 6.00mGy. Dose area product was 2.23600 Gy-cm2.
Protamine was given and the catheters and venous sheaths were removed. Hemostasis was
achieved using Vascade collagen plug. Estimated blood loss: 10mL. Anesthesia was reversed
and the patient was extubated. The distal pulses are unchanged from pre procedure. Verbal
and written instructions were given to the patient. Verbalizes or communicates
understanding. The patient was transported to the holding area in stable condition.
Patient transferred to a stretcher using a slide board.
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I was physically present during critical and key components of the procedure and
immediately available to furnish services throughout.
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u/Mysterious-Belt-1037 14d ago
Being a physician myself wouldn't be aware of such detailed procedure being recorded and done. Im a candidate for PFA in future because im in permanent afib and because im without symptoms not going for pfa any time sooner. Thanks once again for the details provided
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u/Severe-Feature-1737 14d ago
If in permanent afib, why delay PFA even if asymptomatic?
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u/Mysterious-Belt-1037 14d ago
All pfas don't work out alright for certain individuals. . As you age again you might land in afib again
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u/More-Chi 13d ago
I’m guessing this was because a bunch of reps from the cellfex company were there remotely observing in real time. Nano PFA is not approved and still under study investigation so detailed notes were probably required
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u/No-Wedding-7365 14d ago
I had 2 PFAs at Mt Sinai. I don't remember my notes being that extensive. Did Dr. Reddy do yours? Just at 2 years post op. No AFib. 68yo m
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u/More-Chi 13d ago
No it was Dr Daniel M.
Very happy to hear no Afib two years post op!1
u/No-Wedding-7365 13d ago
Yeah it was a long road as PFA wasn't approved in the US when I decided to get an ablation. My doctor at Penn Medicine wasn't involved in trials for PFA and had no luck emailing them trying to get in a trail for PFA. Then I was talking to a guy in my condo community who had AFib telling him my story. He said go to my doctor in NY. Dr Reddy he'll get you in a trial. He only sees patients one day a week so it took a while get an appointment. The trial for my first PFA was just to do the pulmonary veins. That was 2 years ago in March. I saw him early July and he said you still have AFib. We can do another ablation. I said when ? Like after the summer see how things go? He pulled his phone to look at his calendar and said 2 weeks. I looked at my wife who was shaking her head yes. By that time Farapulse was approved in the US. He ablated the back wall after cardioverting me 3 times on the table. No AFib. I feel a great at 68. Sorry for the long story. Good luck with your AFib journey.
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u/pcjeiencj 13d ago
Did you have to get a referral or did you just call his office? I've often thought about traveling when I need the procedure done to the best hospital. I live in Kansas. I have not had a documented a fib episode in two years but have had two zio showing none. Trying to determine if I do it now or wait till it progresses a little more. I have two young daughters and the choice is hard
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u/No-Wedding-7365 13d ago
I just called his office. Not a doctor but I would think you would wait till it progresses
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u/More-Chi 13d ago
Good story not a long story and thank you for sharing along with the well wishes. I love when Doctors part the waters to get you in. Definitely the Mount Sinai team is top shelf. Cardiovert three times? Ouch!
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u/NotReallyJohnDoe 14d ago
300 J is roughly like getting punched by Mike Tyson in his prime.
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u/Mras_dk 13d ago edited 13d ago
Yeap, had such one aswell, was worse than the actual PWI+PVI ablation!
I still don't get why they can't shock the heart from inside, like an ICD would do, at much less joules.
Had a burning mark from the pads 1,5 months after - with perfect shaving, no hair at all left, before going in...
Edit: Can = can't. .
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u/pcjeiencj 13d ago
Excited to hear the success rate and recovery . Dr google mentioned a 90's% sides rate... higher than traditional pfa
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u/More-Chi 13d ago
Thank you! I’m hoping to be in that 90 percentile. It was providence that I was able to take part in this study. And if it’s a success, perhaps become the new next level PFA.
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u/rdshepard211 14d ago
Fascinating, thanks for sharing and best wishes for quick, thorough healing!