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Melbourne Heart Group

Suite 17, Cabrini Hospital, 183 Wattletree Road

MALVERN VIC 3144

Phone : (03) 9500 0296

Fax : (03) 9500 1464

Procedures

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EP study and ablation

PROF PETER M. KISTLER

Electrophysiology study and Catheter ablation

Prof KISTLER has recommended you to have a procedure on your heart called an Electrophysiology study (EPS).
The following information is designed to help you understand what an electrophysiology study is and what to expect during the procedure.

If after reading this information there is any aspect that you do not understand - please do not hesitate to ask Prof Kistler for further information or explanation.

What is an Electrophysiology Study (EPS)?

An EP study is a low risk procedure that has been performed in major medical centres for many years.

The EP study makes it possible to study your abnormal heart rhythm under controlled conditions and diagnose your particular problem.

Who requires EPS?

Patients are referred for EPS for many reasons.

Some of the more common reasons are:

  • rapid or irregular heart beat (often associated with shortness of breath or dizziness).

Common terms used are palpitations, racing heart or missed beats.

  • blackout or dizziness.
  • abnormal findings on an ECG.

Normal heart rhythm.

In order for the heart to do its work (pumping blood throughout the body), it needs a sort of spark plug or electrical impulse to generate a heartbeat. Normally this electrical impulse begins in the upper right chamber of the heart (the right atrium) in a place called the sino-atrial (SA) node. The SA node is the natural pacemaker of the heart.  The SA node gives off electrical impulses to generate a heartbeat in the range of 60 to 100 times per minute.  If you are exercising, doing exertional work or you are under a lot of stress, your heart rate may be faster.  If you take certain medications, your heart rate may be slower.

From the SA node, the electrical impulse is relayed along the heart’s conduction system.  It spreads throughout both the right and left atria causing them to contract evenly.  
Next, the impulse reaches the atrio-ventricular (AV) node.  This special tissue has control over sending the     signal     to the lower chambers or ventricles of the heart.  This causes them to contract and pump blood to the lungs and body.

What happens prior to your procedure?

You will receive a letter outlining the date of your procedure and date and time of your admission to the hospital admission.

In some cases a letter asking you to cease taking your medication is enclosed. This generally refers only to the medication you are taking for your abnormal heart rhythm and this should be stopped 5 days prior to your procedure. If you are taking anti-coagulation (blood thinning)  medication eg Warfarin, Pradaxa, Apixaban or Rivaroxaban then you will be instructed by Prof Kistler as to whether this needs to be stopped. If this is not mentioned in your letter, or if you are unsure please phone Dr Kistler’s secretary with a list of your medication and she will check with Dr Kistler.

You will be required to fast for at least six hours before the study. If your procedure is in the morning, DO NOT EAT OR DRINK AFTER MIDNIGHT, except for sips of water to help you swallow your pills.

What happens during an EP study?

You will be transferred to the Electrophysiology Laboratory (EP lab) from your ward. Usually before leaving your ward your groin will be shaved.
    
The EP lab has a patient table, X-Ray tube, ECG monitors and various state of the art heart mapping equipment. The staff in the lab will all be dressed in hospital theatre clothes. Many ECG monitoring electrodes will be attached to your chest area and patches to your chest and back. These patches may momentarily feel cool on your skin.

A nurse or doctor will insert an intravenous line usually into the back of your hand. This is needed as a reliable way to give you medications during the study without further injections. You will also be given further sedation if and as required. You will also have a blood-pressure cuff attached to your arm, which will automatically inflate at various times throughout the procedure.

The oxygen level of your blood will also be measured during the EP study and a small plastic device will be fitted on your finger for this purpose. Your groin area and possibly your neck or arm will be washed with an antiseptic cleansing liquid and you will be covered with sterile sheets leaving these areas exposed.

The doctor will inject local anaesthetic to the area where the catheters are to be placed. After that, you may feel pressure as the doctor inserts the catheters but let the staff know if there is any discomfort so some more local can be given. Once the catheters are in place you may feel your heart being paced and possibly your abnormal heart rhythm will be induced.

What is radiofrequency ablation (RFA)?

If an abnormal heart rhythm is detected Prof Kistler will proceed to map and ablate the circuit or focus within the heart provided he feels this has been adequately discussed with you and all equipment is available to provide the most successful and safest outcome.

Radiofrequency is a low power, high frequency energy that causes a tiny region of the heart near the tip of the catheter to increase in temperature, thus ablating a small area of tissue.  

Radiofrequency energy has been used for decades by surgeons to cut tissue or to stop bleeding. For the treatment of palpitations, a much lower power of radio-frequency is used.

 

What risks are involved in an EPstudy/RFA?

The EP study is a very low-risk procedure and should a complication arise, it will be dealt with at once.
    
The world wide complication rate for EP/RF studies is less than 0.5%.

Although most people undergoing EP/ RF studies do not experience any complications, you should be aware of the following risks.

Local bleeding or haematoma (blood collection) - this may occur at the catheter insertion site.
Rapid abnormal heart rhythm - this may actually cause you to pass out for a very short period of time and in some cases a small electric shock may be required to restore your normal rhythm.
Perforation or damage - very slight chance that this may occur to either a heart chamber or to the wall of one of the arteries.

Heartblock - depending on the location and type of your abnormal rhythm being ablated, there is a chance of damage occurring to the heart’s normal electrical system. This may be temporary, but permanent damage would result in a pacemaker being inserted.

Major complications - stroke, heart attack, death are very rare.  

Radio-frequency is an effective and safe way to cure patients suffering from palpitations.

Please do not hesitate to discuss any aspect of the procedure including potential complications with your doctor prior to your procedure.

What to expect after your procedure?

After your procedure you will be transferred back to your ward where you will have to lie flat for 4 hours depending on which blood vessels have been punctured. During this time, it is important to keep your legs straight and your head relaxed on the pillow.

Most patients stay in hospital overnight and their heart rhythm may be monitored during this time.

The majority of patients have 2-3 days away from work. Most patients return to driving within 2-3 days.
Gentle exercise such as walking may resume after 7 days provided any bruising has resolved. More vigorous exercise may resume after 14 days

Special note:-

If there is any chance you may be pregnant, please notify Dr Kistler before your procedure.

AF ablation

PROFESSOR PETER M KISTLER
MBBS, FRACP, PhD, FHRS

Catheter Ablation for Atrial Fibrillation 

Patient Information sheet

Professor KISTLER has recommended you to have an ablation procedure for atrial fibrillation.
The following information sheet is designed to help you understand what to expect during the procedure.

If after reading this information sheet there is any aspect that you do not understand - please do not hesitate to ask Dr Kistler for further information or explanation.

Normal heart rhythm

During normal rhythm, an electrical impulse originates from the normal pacemaker of the heart (sinus node) and travels through the upper chambers of the heart (the right and left atria) to cross over a bridge (AV node) to the pumping chambers (ventricles), causing a heartbeat. This is normal sinus rhythm. 
Atrial fibrillation (AF) is a heart rhythm disorder with rapid, irregular, and chaotic electrical activity in the atria. The atrial electrical signals bombard the AV node, and some pass through the AV node to the ventricles, producing a rapid, irregular rate and often causing symptoms of palpitations, shortness of breath, or fatigue. AF affects more than 2 million people in the United States alone; it is seen progressively more frequently as a person ages.

Atrial fibrillation – Treatments options

here are 3 major treatment considerations for AF. 
Firstly stroke protection: in some people, AF promotes formation of blood clots in the atrium that can travel to the brain and cause a stroke. Daily administration of Pradaxa, Apixaban or Xarelto may be used to prevent these clots. Less frequently Warfarin can also be used but requires regular blood monitoring.
Second, medications may be used to slow the heart rate, thus improving symptoms and preventing development of heart failure. 
Third is an attempt to keep the heart in normal rhythm. Medications that alter the electrical properties of the heart often are used to try to maintain sinus rhythm, but they may be ineffective or cause unpleasant side effects.

Catheter ablation

has been used to treat heart rhythm disorders for more than 20 years. A long, thin tube called a catheter is inserted into a blood vessel, typically in the groin, and guided through the blood vessels into the heart. When the tip of the catheter is placed against the part of the heart causing the arrhythmia, radiofrequency electrical current is applied through the catheter to produce a small burn about 6 to 8 mm in diameter. Catheter ablation is very effective when the abnormal area is small, but in AF, there are many electrical waves throughout the atria. However, AF is often “triggered” by rapid electrical activity originating from small areas typically located around the pulmonary veins that drain blood from the lungs back to the left atrium (Figure). Catheter ablation involves encirclement of the pulmonary veins (Figure) to electrically isolate all of the potential triggers around the veins, as well as the electrical “substrate” that allows AF to continue once it starts. With further study, it has become clear that the electrical abnormalities that promote AF can be different for different people and that some people require more ablation lesions than others. 

What happens prior to your procedure?

You will receive a letter outlining the date of your procedure and date and time of your admission to the hospital admission.

MEDICATIONS

In some cases a letter asking you to cease taking your medication is enclosed.  This generally refers only to the medication you are taking for your abnormal heart rhythm and this should be stopped 3- 5 days prior to your procedure.  

If you are taking anti-coagulation (blood thinning) medication such as Warfarin this is generally continued with a blood test (INR) performed the day prior and the result faxed thru to my office (95001464).
The newer anticoagulants such as Pradaxa, Apixaban and Xarelto are often continued including on the morning on the procedure but you will receive individualized instruction.  

You will need to have a CT scan of your chest the day prior to the procedure. Dr Kistler will organize this and uses the scan to guide the catheters around your heart so that the procedure is tailored to your own anatomy. 

You will be required to fast for at least six hours before the study.  
DO NOT EAT OR DRINK AFTER MIDNIGHT, except for sips of water to help you swallow your pills.

 

What happens during the procedure?

You will be transferred to the Electrophysiology Laboratory (EP lab) from your ward. Usually before leaving your ward you will be given a light sedative and your groin will be shaved.
    
The EP lab has a patient table, X-Ray tube, ECG monitors and various equipment. There are constant updates made to the equipment such that the latest in mapping technologies is used to achieve the safest and most successful outcome for you. The staff in the lab will all be dressed in hospital theatre clothes. Many ECG monitoring electrodes will be attached to your chest area and patches to your chest and back. These patches may momentarily feel cool on your skin.

A nurse or doctor will insert an intravenous line usually into the back of your hand. This is needed as a reliable way to give you medications during the study without further injections. You will also be given further sedation if and as required. You will also have a blood-pressure cuff attached to your arm, which will automatically inflate at various times throughout the procedure.

The oxygen level of your blood will also be measured during the procedure and a small plastic device will be fitted on your finger for this purpose. Your groin area and possibly your neck or arm will be washed with an antiseptic cleansing liquid and you will be covered with sterile sheets leaving these areas exposed.

The procedure is performed under general anaesthetic via tubes positioned in the groin and sometimes the neck.  

Most ablation (brown dots in picture) is performed in the left atrium (see picture) which requires 2 tubes to be passed from the groin through the right side of the heart into the left atrium. This is called a transseptal puncture. One tube acts as a port for the ablation catheter and the second is for a circular mapping catheter to map the electrical activity.

What is radiofrequency ablation (RFA)?

Radiofrequency is a low power, high frequency energy that causes a tiny region of the heart near the tip of the catheter to increase in temperature, thus ablating a small area of tissue.  

Radiofrequency energy has been used for decades by surgeons to cut tissue or to stop bleeding.  For the treatment of palpitations, a much lower power of radio-frequency is used.

Are there alternatives to AF ablation?

Before the advent of AF ablation patients had two options to control their palpitations.
1. Life-long medication,which works well in some patients, but requires the patient to take daily medication.  There is also the possibility of side-effects from these drugs. 
2. The alternative is to have a pacemaker implanted and ablation of the AV node which is the main connection between the top (atria) and bottom (ventricles) chambers of the heart. This does not cure the fibrillation but prevents the ventricles from being overstimulated and is very effective at reducing symptoms. As a result the heart relies on the pacemaker for electrical conduction.

What risks are involved in Atrial Fibrillation Ablation?

Although most people undergoing EP/ RF studies do not experience any complications, you should be aware of the following risks.

  • Local bleeding or haematoma (blood collection) - this may occur at the catheter insertion site in the groin or neck.
  • Perforation of the heart wall when gaining access to the left side of the heart (cardiac tamponade). This may require the temporary placement of a drain tube into the sac around the heart and rarely requires open heart surgery.
  • Stroke (1 in 500)
  • Narrowing of the lung veins: now very uncommon with new technology
  • Connection between the back of heart and food pipe (atrio oesophageal fistula) a rare complication estimated at 1 in 1000 – the earliest symptoms are an unexplained fever between 1 week and 6 weeks after the ablation
  • Gastroparesis – rarely the nerve supply to the stomach may be affected by the ablation resulting in paralysis of the stomach with a feeling of abdominal fullness, nausea and weight loss
  • Phrenic nerve injury - rarely the nerve supply to the diaphragm may be affected resulting in breathlessness

The combined risk of a major complication as listed above is between 1 and 2%.

Please do not hesitate to discuss any aspect of the procedure including potential complications with your doctor or Dr Kistler prior to your procedure.

What to expect after your procedure. 

After your procedure you will be transferred back to your ward where you will have to lie flat for 4 hours depending.

Throat discomfort and a sharp chest pain on breathing are common in the first few days

Most patients stay in hospital for one night and their heart rhythm monitored during this time.

The majority of patients have 7 days away from work. You may not drive for 3-5 days following the ablation.

You will be on anti coagulant or blood thinner for at least 2 months following the procedure.

If you develop a fever after discharge from hospital in the first 8 weeks you should present to an emergency department or LMO and ask them to contact Dr Kistler immediately. You should NOT have a gastroscopy.

Palpitations or recurrent AF are NOT uncommon in the first 8 weeks following the ablation and do NOT indicate that the ablation has not been successful. Usually symptoms are controlled with medication and settle.

Valuable websites : 

atrialfibrillation.org.uk

hrsonline.org

 

Melbourne Heart Group

Suite 17, Cabrini Hospital, 183 Wattletree Road

MALVERN VIC 3144

Phone : (03) 9500 0296

Fax : (03) 9500 1464

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