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Epicardial Ablation for PVC's
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Epicardial Ablation for PVC's

I'm a 23 year old female and I suffer from PVC's. I was having over 50,000/day, however my EP recently put me on medication (flecainide) which has helped some. I had an enocardial ablation in November 2012, which was unsuccessful. My EP believes that my PVC's are originating on the outside of my heart, so he referred me to another EP who suggested an epicardial ablation. I would love to hear some feedback on anyone who has had an epicardial ablation. I'm interested in the process (patient perspective), and how the recovery was. My biggest concern is missing work, and my doctors were very vague on how long I would be out. I'm scheduled for my next ablation in February, and it's been hard to find a lot of feedback on this type of ablation, so any comments are appreciated!
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1807132_tn?1318747197
That is a high load of pvcs.  I had never heard of an epicardial ablation and nor have I ever heard of anyone talking about it on this site but I looked it up and got a medical study paper that talked a bit about the medial complications.  There seems to be a bigger risk with this type of ablation so I would make sure you get stats from the EP you choose.  The best I can tell from the literature is you would be possibly kept overnight to make sure there isn't any bleeding around the heart.  Anyways hopefully someone pops on who has had the ablation who can give you a patient perspective.  Below is what I found from the NCBI site about possible complications.  I think it would be good to know them.  The fact that this procedure first came out in the late nineties means that it has been around for a little while and I am sure that the complications are being addressed but this was published in 2012 so it is fairly new.  I would go with someone who has some sort of experience with this type of ablation even if you have to travel.  Anyways go by what your gut says.  Best of luck with your next ablation.  Please keep us posted on how you are.


Evaluating complications occurring during an epicardial ablation we have to differentiate between those which can occur during the subxyphoidal puncture, during the ablation procedure and after the procedure.

Among the possible complications that can occur during the puncture, we have to bear in mind that damage of all subdiafragmatic organs can occur. Damage of the liver, stomach or colon may occur particularly in prone subjects. Patients with right heart decompensation or with megacolon, for example, have to be carefully evaluated before the procedure if necessary also with a CT scan. Two cases of abdominal bleeding due to damage of a diaphragmatic vessel are reported in the literature [3]. One [4] of these occurred in our center two years ago and was discovered 3 days after the procedure because of the presence of progressive anemia in the absence of pericardial effusion and without any other significant abdominal symptoms. In both cases abdominal surgery was required to control the bleeding.

Another possible complication occurring during the puncture is the pleural catheterization with guidewire reported in one study population in 1.5% of cases that usually occurs without pneumothorax or complications.

Main cause of epicardial bleeding may be due to damage to the myocardial wall (usually the right ventricle) or to a coronary artery occurring during the puncture or during RF ablation. This complication is reported in 30% of cases in the study population of Sosa and coll [3] and usually doesn't preclude the procedure. In more recent publications [3,4], a lower incidence is reported (between 3.7 and 4.5). The simple puncture of the right ventricle is not usually followed by pericardial blood effusion. This complication called "dry right ventricle puncture" is reported in 4.5% to 17% of cases and will definitely decrease as skill improves. To avoid more important damage to the myocardial wall during the puncture it is really important, in doubtful cases, to check the position of the tip of the needle with a small amount of contrast before inserting the guidewire and in any case to insert it very gently.

A common minor complication is the postprocedure pericarditis with different degrees of severity that usually cause postprocedure chest pain (21% of cases [4]). To reduce the occurrence of this complication it is important to remove the pericardial sheath as soon as possible and the routine pericardial infusion of steroids before removing it.
Coronary arteries

Another important problem that we can encounter during epicardial ablation is due to the presence of the epicardial vessels. Although larger vessels are probably protected by the blood flow [6] it was empirically suggested to consider 12 mm as the minimum optimal distance of the ablating tip catheter from the coronary vessel. Nevertheless average distance reported in the study of Della Bella [4] is 8.6±7.8 mm and in the last guidelines is strictly suggested to deliver RF energy maintaining a minimum distance > 5 mm from the coronary artery [1].

It is always stronglyrecommended to perform a coronary angiography to clarify the position of the tip of the ablating catheter compared to the vessel. For the difficulty to visualize in a 3D way an object of which we have only two-dimensional images, the concurrent use of a 3D electro-anatomical map may be a useful tool with which we can annotate over the map tags displaying the course and position of the coronary artery.

Another helpful possibility is provided by the use of merge capabilities of the mapping system that allows the superimposition over the electro-anatomical map of the anatomical images obtained with a CT (Figure 3). In frequent cases, with the surface rendering tools included in the system, a clear visualization of the major coronary arteries can be obtained.
Figure 3
Figure 3
A: Coronary angiography performed with the ablating catheter in a site where, during VT, a diastolic potential was registered. The tip of the catheter is close to the LAD artery. B: Carto bipolar map merged with the epicardial anatomy obtained with a ...

In the most important published experiences damage to a coronary artery is reported in one case by Sosa [3] and in one by Sacher [5]. No damage was reported in Della Bella's survey [4]. Although all recommend the use of coronary angiography it is interesting to note that in the last paper it was only performed in 43% of cases, with a wide variation among centers (15% - 87%). Maybe this is due to the fact that in some cases, particularly in the lateral wall of the right ventricle or in big true scar areas, there are regions where the likelihood to find major coronary arteries is very low and if the operators feel sure of themselves the coronary angiography can be avoided.

In addition, the use of anatomical images obtained with CT scan and the merge process available with the CARTO technology could explain the reduced recourse to the angiography.
Phrenic nerve

The position and the course of the phrenic nerve may in some cases be an important obstacle to the delivery of RF energy. While the damage to the right phrenic nerve that usually descends along the superior vena cava and along the right atrium is described occurring during ablations of atrial arrhythmias [7,8], the left may be damaged during the ablation of VT. This nerve usually runs along the lateral wall of the left ventricle but many different positions have been described [9]. Different strategies have been proposed over the years to localize the course of the nerve and to avoid damage during RF delivery in site near the nerve. The latter are usually described as a case report or in small groups of patients but none has been systematically evaluated in big populations. Even if the course of the phrenic nerve could be identified with imaging technique, the only easily feasible way to detect the presence of the nerve is the use of high intensity pacing that must be performed checking the presence of the diaphragmatic capture also with X-Ray [10]. Care must be taken to perform this test, in case of intubated patients, after antagonization of any muscle relaxants.
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Thank you for finding and posting that study. I hadn't read that particular one. It's always good to know the risks and complications of a surgery. I was given a pretty good overview of the risks by my EP. I am glad you found that article, It was very interesting. I am going to ask my doctor if they are going to do a coronary angiography before they ablate, because the origin appears to be near a coronary artery. They did tell me that there's a chance they may get in and realize it's too risky to ablate. And I'm having mine done at the University of Virginia Hospital. They specialize in these types of ablations. I also did alot of research, so I feel like I'm in safe hands. Thank you again for responding. I will let you know how my procedure goes.
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1807132_tn?1318747197
I am god to hear of the expertise of the hospital you are going to.  Do let us know where it is and I will send prayers your way that day.  I wish you great success getting this fixed. Take care
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Avatar_f_tn
I thought I was post an update of how my ablation went. I was under general anesthesia for the surgery. They went in with catheters in both groin sites and through a small incision under my collarbone. The epicardial site they were trying to reach ended up being too close to my coronary artery and my phrenic nerve.. Before we went under my EP and I discussed how aggressive I wanted him to be, and for this site, the risk of damage was high, so my EP decided against ablating there.

He did find another area inside my heart, in the left ventricle, that was producing pvcs, so they did some ablating there. They monitored me for over an hour while trying to induce the pvcs, and I had none. Well as soon and they woke me up on the table, I was having excruciating chest pain and  sob, and almost immediately my pvc's came back. Between 6 and 10 pvc's every other beat. They moved me to recovery for 3 hours and continued to watch me and gave me some much needed pain medicine. After a couple of hours, as the pain subsided some, my pvc's decreased to about 3-4 every other beat. But they were still quite frequent, and not what my EP was expecting after he seemingly eliminated them completely.

I stayed overnight, and by the time I was discharged the following morning, I was having couplets every other beat. My EP came in and spoke with me before I left, and said he was very disappointed with the outcome, and he had never seen a patient go from zero pvc's to that many so quickly. He said that the area he ablated was pretty deep, and he had to do alot of burning, and that it was possible he didn't do enough burning to completely eliminate the area. So he raised my dosage of flecainide to 100mg twice a day, and scheduled me for a followup in 3 months to decide whether I would want to try another ablation of the same area, and hopefully fix it this next time around.

Needless to say, I'm a little frustrated and disappointed. But I'm trying to stay positive, and ride it out until my followup in May.
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Avatar_f_tn
Interested to see how & what you are doing. Sorry it's so rough!!! I have a similar thing with frequent PVCs, passing out, & on & on. Athletic 64 yo, no heart disease. Anesthesia suppresses the PVCs, only to have them return with a vengeance when I wake up, so my last ablation done completely awake. They found that the focus is in the left ventricle right on top of a main artery (LAD) & they are thinking of stenting the vessel prior to epicardial ablation & trying again. Flecainide 300 per day plus diltiazem 240 a day is required to keep the pvcs lower but I get so dizzy & symptomatic from the medicine it's hard to function.
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Avatar_f_tn
Right now I am just trying to ride out the next 3 weeks until my next appointment. I stay exhausted, but I am forcing myself to exercise at least a few minutes a day. I really hope they will lower my dose of flecainide. I had an appointment in March with the EP who did my first ablation, and he said that other surgical options included trying the epicardial ablation (low chance of success), or doing an open heart procedure. Not exactly promising news, but I'm glad they are still looking for solutions other than medicine.

My first ablation was done under light sedation, and it was rough. I'm not sure that I could handle being completely awake! When is your next ablation scheduled for? I hope it all goes well.
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