Catheter Ablation: RVOT Ventricular Tachycardia

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Hemodynamically intolerant right ventricular outflow tract (RVOT) ventricular tachycardia (VT)
  • Frequent, symptomatic premature ventricular contractions (PVCs) or sustained or nonsustained VT in patients who have not responded to or do not wish to receive medical therapy
  • PVC-induced cardiomyopathy
CONTRAINDICATIONS
  • Patient refusal
  • Inability to access the heart because of venous obstruction
  • Known intracardiac clot where catheters are to be placed
  • Uncontrolled infection or other acute medical condition
EQUIPMENT
  • Sterile mask, gown, gloves
  • Sterile prep solution for access site
  • Sterile drapes
  • Sterile introducer sheaths, J guidewires, and introducer needles
  • Lidocaine for local anesthesia
  • Syringes and small-gauge (25- or 30-gauge) needles for subcutaneous infiltration of local anesthetic
  • Ultrasound for vascular access (optional)
  • Intracardiac catheters and cables
  • Fluoroscopy system
  • Three-dimensional mapping system (optional)
  • Pacing stimulator
  • ECG and electrogram recording system
  • Radiofrequency generator or cryoablation system
  • Crash cart with intubation equipment, resuscitation drugs, external defibrillator, and pacing equipment
  • Oxygen source and delivery system, if necessary (nasal cannula, mask, etc)
  • Equipment for starting a peripheral IV if necessary:
    • IV catheter (20-gauge)
    • Alcohol or other sterile prep swab
    • Tape or transparent sterile dressing for securing IV
    • Heparin lock for IV
    • Gauze or bandage for IV site
  • Medications for sedation, if necessary (eg, midazolam)
  • Medication for induction of arrhythmia (eg, aminophylline, isoproterenol, atropine)
  • Dressing for femoral IV access site
ANATOMY
  • Electrophysiology studies are used to assess cardiac conduction and rhythm abnormalities. Studies are carried out by insertion of intracardiac catheters via the femoral, subclavian, or internal jugular vein. Catheters for RVOT VT ablation are placed in the right ventricular (RV) apex, and an ablation catheter is placed in the RVOT. Some operators also place diagnostic catheters in the right atrium (RA), coronary sinus, His bundle, or RVOT.
  • Vascular access for catheter ablation via the femoral vein is described here. The femoral vein is located in the femoral triangle just medial to the femoral arterial pulsation, below the inguinal ligament.
  • Relationships of the Heart in the Chest
    • In situ, the right border of the heart is formed by the right atrium (RA) and superior vena cava (SVC) and inferior vena cava (IVC). The left atrium (LA) is the most posterior chamber of the heart and is not visible in the anteroposterior view in the cardiac silhouette.
    • The left and right phrenic nerves are in close proximity to the left atrial (LA) appendage and the SVC, respectively.
  • The right ventricle (RV) extends from the orifice of the tricuspid valve nearly to the cardiac apex, ascends to the left to become the infundibulum (or conus arteriosus), and then reaches the pulmonary orifice, supporting the cusps of the pulmonic valve. The RV is divided into three regions:
    • The inlet, which supports and surrounds the tricuspid valve
    • The apical component, which consists of a coarsely trabeculated region that includes the moderator band
    • The muscular outlet, or infundibulum, surrounding the attachments of the pulmonic valve
  • RVOT anatomy is complex in relation to adjoining structures. The RVOT is anterior and leftward of the aortic root and is shaped like a crescent when viewed from above. The left main and left anterior descending coronary arteries are within a few millimeters of the anterior portion of the RVOT. Although most operators describe a septal side of the RVOT, the adjoining structure is not the LV but is the aortic root. The anterior RVOT, as described in a right anterior oblique projection, is more accurately described as leftward, while the posterior RVOT is rightward. Leftward of the RVOT, in order, are the right and left cusps of the aortic root and the anterior epicardial LVOT, aorto-mitral continuity, and superior mitral annulus.

PROCEDURE
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The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Patients should remain on bed rest for 2 to 6 hours to prevent bleeding at femoral access sites and should refrain from significant physical activity for 5 to 14 days afterward.
  • Patients should be cautioned to watch for swelling or bleeding at the femoral puncture site and to report these immediately to the staff.
  • A recurrence of palpitations or other symptoms should prompt a repeat evaluation.
COMPLICATIONS
  • Risk of vascular injury caused by catheterization is reported to be 1% to 2%.
    • Hematoma
    • Retroperitoneal bleeding
    • Arteriovenous fistula formation
    • Pseudoaneurysm formation
  • Other complications of vascular access:
    • Pneumothorax (internal jugular or subclavian vein access)
    • Brachial plexus injury (subclavian vein access) or femoral nerve damage (femoral vein access)
  • Thromboembolic complications
    • Deep venous thrombosis
    • Pulmonary embolism
    • Stroke or other systemic embolism (especially with left-sided ablation)
  • Right bundle branch block (2%) and complete heart block (rarely) may occur.
  • Coronary artery damage may occur with RVOT ablation but is more likely to occur with aortic cusp ablation.
  • Aortic regurgitation may occur with aortic cusp or LVOT ablation.
  • As with any electrophysiology study and ablation, complications from sedation or anesthesia, ventricular fibrillation, cardiac perforation with pericardial effusion or tamponade, and, rarely, death may occur.
RESULT ANALYSIS
  • Remapping and evaluation may be necessary if the patient has recurrence of palpitations or documented arrhythmia after ablation therapy.
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