Electrophysiology study and Cardiac Ablation (4).pptx

For cardiovascular nursing masters students

1. GROUP ASSIGNMENT ON EP STUDY AND CATHETER ABLATION BY; MAHLET ADISS MULUBRHANGEBRU MELESE ADANE TEWODROS AYELE MENBER YILMA

2. Electrophysiology study and Cardiac Ablation

3. Outline Identify what is electrophysiology study/ cardiac ablation Their indications, pre-procedure preparation Risk of each procedures and contraindications Techniques used during procedure and post procedure care Nursing interventions Sheath removal technique

4. Introduction Anatomy & physiology of the heart's conduction system: Comprises specialized cardiac muscle cells and conducting fibers (SA, AV nodes, HIS bundle, and Purkinje fibers) Conduct impulses through the heart and initiate the cardiac cycle and coordinate the synchronized contractions of the four cardiac chambers. Bundle of his

5. Arrhythmia mechanism Three distinct mechanisms are described: • enhanced automaticity • re-entry • triggered activity. The first two account for nearly all clinical tachycardias,

6. SVT Atrioventricular nodal re-entry tachycardia (AVNRT) In AVNRT, there are two functionally and anatomically different pathways within the AV node: one is characterized by a short effective refractory period and slow conduction, and the other has a longer effective refractory period and conducts faster.

7. ECG…. The rhythm is recognized on ECG by normal regular QRS complexes, usually at a rate of 140-240 per minute. Sometimes the QRS complexes will show typical bundle branch block. P waves are either not visible or are seen immediately before or after the QRS complex because of simultaneous atrial and ventricular activation.

8. Atrioventricular reciprocating tachycardia (AVRT) T here is a large circuit comprising the AV node, the His bundle, the ventricle and an abnormal connection from the ventricle back to the atrium= an accessory pathway or bypass tract. R esult from incomplete separation of the atria and the ventricles during fetal development. Atrial activation occurs after ventricular activation and the P wave is usually clearly seen between the QRS and T complexes

9. The Wolf Parkinson White Syndrome (WPW) An abnormal band of atrial tissue connects the atria and ventricles and can electrically bypass the normal pathways of conduction; a re-entry circuit can develop causing paroxysms of tachycardia. ECG shows: - Short PR interval - Delta wave on the upstroke of the QRS complex

10. Atrial flutter (HR200-350/min)   A condition in which the electrical signals come from the atria at a fast but even rate, often causing the ventricles to contract faster and increase the heart rate. When the signals from the atria are coming at a faster rate than the ventricles can respond to, the ECG pattern develops a signature "sawtooth" pattern, showing two or more flutter waves between each QRS complex

11. Atrial fibrillation (AF) A condition in which the electrical signals come from the atria at a very fast and erratic rate. The ventricles contract in an irregular manner because of the erratic signals coming from the atria. The ECG shows normal but irregular QRS complexes, fine oscillations of the baseline (so-called fibrillation or f waves) and no P waves. Common causes include CAD, valvular heart disease, hypertension, hyperthyroidism and others. In some patients no cause can be found 'lone

12. Ventricular Tachyarrhythmias life-threatening ventricular tachyarrhythmia's (Sustained ventricular tachycardia and ventricular fibrillation) Torsades de pointes

13. Ventricular tachycardia (VT) A condition in which an electrical signal is sent from the ventricles at a very fast but often regular rate. The ECG shows a rapid ventricular rhythm with broad (often 0.14 s or more), abnormal QRS complexes. AV dissociation may result in visible P waves

14. Ventricular fibrillation (VF)  A condition in which many electrical signals are sent from the ventricles at a very fast and erratic rate. As a result, the ventricles are unable to fill with blood and pump. This rhythm is life-threatening because there is no pulse and complete loss of consciousness. The ECG shows shapeless, rapid oscillations and there is no hint of organized complexes

15. Torsades de pointes  This is a type of short duration tachycardia that reverts to sinus rhythm spontaneously. It may be due to: - Congenital - Electrolyte disorders e.g. hypokalemia, hypomagnesemia , hypocalcemia . QRS complexes are irregular and rapid that twist around the baseline. In between the spells of tachycardia the ECG show prolonged QT interval

16. Electrophysiology study EP study is a test performed to assess the heart's electrical system or activity in order to diagnose abnormal heartbeats. During an EP study, a thin tube called a catheter is inserted into a blood vessel that leads to heart. Then specialized electrodes are placed in the heart to send electrical signals and measure electrical activities of heart.

17. Purpose Identify location of arrhythmia How well certain medicines work to treat arrhythmia. Indication of cardiac ablation Indication for pacemaker or ICD To identify potential risk for heart problems such as: fainting or sudden cardiac death due to cardiac arrest

18. Pre-procedure Take full history and physical examination Counsel alleviate fear and anxiety NPO patient for 6 to 8 hours before the test Keep IV line open and put on parenteral fluid Mostly Anti-arrhythmic stop 3 days earlier before the procedure Ensure patient sign consent

19. Cont.… Collect pre procedure investigation such as CBC, renal function, serology test, patient weight and height, ECG, Echo Removed patient jewelry Put patient on monitor Prepare emergency drugs

20. Cont... Emergency drugs Atropine1mL=1mg no dilution. Adrenaline 1mg /1mL will be dilute with 9ml N/S. NTG 10mg/10ml (1mg/1ml) Amiodarone150mg/3ml loading dose 300mg (2amp) dilute with 20_30ml of D5W push over a minimum of 3 mints.

21. Risk of the procedure Abnormal heart rhythms that make dizzy. Heart attack (myocardial infarction) and stroke Heart valve damage Blood clots Infection, bleeding and bruising at the site where the catheter went in

22. During the procedure Only slight sedation, fully sedation forbidden Lie on a table near an X-ray camera and other equipment. Local anesthetics give on puncture area Puncture then insert thin tubes, or catheters, into your veins in those areas Mostly two catheters inserted, one is for to help guide the procedure and other for electrophysiology study. The catheters will thread through vein to heart. Small electric pulses will be sent through the catheters to make heart beat at different speeds.

23. Cont.… The patient may feel his heart beat stronger or fast. The catheter then record the electrical activity of the heart. This allow to locate the problem area of the heart. If the type and location of the abnormal heart rhythm is found, the treatment decided. Cardiac ablation or insertion of a pacemaker or ICD may be done during or right after the EP study

24. Post-procedure The catheters and IV will be taken out. Direct pressure applied to stop the bleeding. Transfer the patient to recovery unit. Order to lie supine for few hours. Keep the arm or leg used for the test straight. Keep NPO/parenteral fluid 4-6hrs.  

25. Cardiac Ablation Catheter ablation is a procedure that uses radiofrequency energy (similar to microwave heat) to destroy a small area of heart tissue that is causing rapid and irregular heartbeats. The procedure is also called radiofrequency ablation. Destroying this tissue helps restore heart’s regular rhythm. Catheter ablation destroys the abnormal tissue without damaging the rest of the heart. 

26. Indications Arrhythmias symptomatic recurrent supraventricular tachycardia due to atrioventricular (AV) nodal reentrant tachycardia (AVNRT), Wolff-Parkinson-White (WPW) syndrome Ventricular tachycardia Unifocal atrial tachycardia Atrial flutter and Atrial fibrillation Arrhythmia don’t respond to pharmacological management or cause severe side effect

27. contraindications Left atrial ablation and ablation for persistent atrial flutter should not be performed in the presence of known atrial thrombus. Similarly, mobile left ventricular thrombus would be a contraindication to left ventricular ablation. Mechanical prosthetic heart valves are generally not crossed with ablation catheters. Women of reproductive age should not be exposed to fluoroscopy if any possibility exists that they are pregnant.

28. Risk of the procedure Arrhythmias Bleeding where the catheter is inserted Infection Blood clots Heart or blood vessel damage Damage to the vessel where the catheter was inserted Heart attack/stroke

29. Pre-procedure Take full history and physical examination Do investigations and collect, mentioned above Shave the groin area Don’t take Anti-arrhythmic drug for 6-8hrs. NPO for 6-8hrs, keep IV line open and hydrate with parenteral fluids Prepare emergency drugs, mentioned above

30. During procedure Maintain sterile area Attach patient with monitor and strictly follow Draping patient with sterile drape while exposing puncture area Clean puncture area by using iodized solution Give local anesthetic on puncture site 3 puncture site used

31. Cont.… Insert sheath by using puncture needle through the blood vessel Inserts electrode catheters, through the sheath and feeds these tubes into heart. To locate the abnormal tissue causing arrhythmia, sends a small electrical impulse through the electrode catheter. This activates the abnormal tissue that is causing arrhythmia. Other catheters record the heart’s electrical signals to locate the abnormal sites.

32. Cont.… Places the catheter at the exact site inside heart where the abnormal cells are and then, a mild, painless, radiofrequency energy (similar to microwave heat) is sent to the tissue. This destroys heart muscle cells in a very small area that are responsible for the extra impulses that caused arrhythmia. After the procedure ended remove the catheter Dress the puncture site with out removing the sheath

33. Post-procedure Transfer patient to a recovery room Counsel patient don’t bend his leg, if the puncture is femoral Put on monitor and follow v/s and cardiac rhythm Watch for any swelling, pain or bleeding at the puncture site Announce patient to inform early if has chest pain Counsel to well complied with medication and follow up time Give instruction about what to do at home

34. Nursing intervention Watch for any symptoms of pain or tightness in the chest or signs of stroke (face drooping, arm weakness, speech difficulties).  Check for bleeding or swelling at the puncture site Monitor heart rhythm Talk to patient about test result, treatment options and plans for follow up Counsel about what he/she do at home

35. Instructions include Don’t drive at least 24hrs or until feel healthy. Avoid heavy physical activity until at least for a week Don’t lift anything weighing more than 10 pounds. Don’t take a bath, swim or otherwise submerge the incision site in water for one week Keep the incision site clean and dry

36. Cont.… Call your health care professional if you notice any signs of infection Announce the puncture site may be sore for several days. A small bruise at the puncture site is normal. If the site starts to bleed, lie flat and press firmly on top of it Have someone call the doctor or hospital

37. Consult immediately Catheter insertion site feeling numb or tingling. Affected hand or foot feeling very cold or changing color. The puncture site looking more and more bruised. The puncture site beginning to swell or fluids coming from it. Have a fast or irregular heartbeat, SOB, fever Feel sick to stomach or sweat a lot

38. Femoral puncture site care and sheath removal Before removing a femoral artery sheath, make sure : To check the type and time of procedure performed, size of sheath inserted, amount of heparin administered and operator’s orders. Heparin is stopped or, if available, ACT is < 150 sec. Vital signs are stable, patient is on monitor and there is no active chest pain. There is a functioning iv line. Atropine is ready and with in reach, if needed.

39. Removing the sheath Stand on the side of puncture, adjust bed height or use foot sole (allows adequate compression without fatigue). Put on surgical glove, Clean the area (including the sheath) with antiseptics. Give 10ml of local anesthetic (1% lidocaine ) to the skin around the puncture site. Aspirate 5ml blood through the side arm of the sheath and discard but never flush back! If no blood comes out on aspiration, just proceed with the removal.

40. Cont.… Put three fingers of the left hand 2-3cm above the site of arterial puncture (not directly over the puncture site!) For venous compression: put one finger distal to, one directly over and the other proximal to the puncture site. Pull the sheath slowly (at similar angle of insertion) and take it out, check for clot in the sheath and completeness of parts of the sheath. As soon as the tip comes out, gently release the pressure of your fingers and deliberately allow a little spurt of bleeding (to wash out any clot).

41. Cont.… Then, put your other hand on your fingers and apply constant gentle pressure and don’t interrupt to check for bleeding or change of hands (especially first 5 minutes)! Completely obliterate the distal pulse for 5 minutes, then gradually ease the pressure Check distal pulse after 5 minutes (by assistant) while still compressing (ease the pressure so that dorsalis pedis becomes faintly palpable during this period), and watch for change in color of the limb. Decrease pressure further every 5 minutes.

42. Cont.… After releasing the pressure at the end, check for any oozing, hematoma; cover the area with palm and ask the patient to cough gently. Apply bandage over the site Tell the patient to report if he/she feels any warmth, wetting or swelling of the site. Inform the patient to hold the site during coughing, sneezing, laughter and to keep the punctured leg straight.

43. dilemmas During electrophysiology (EP) studies and catheter ablation procedures, several dilemmas or challenges may arise, requiring careful consideration and decision-making by the healthcare team. Some of the common dilemmas encountered include: 1. Patient Selection: Determining the appropriateness of EP study and catheter ablation for individual patients can be challenging, particularly in cases where the benefits and risks are less clear. Balancing the potential benefits of symptom relief and arrhythmia control with the risks of procedural complications and the burden of invasive therapy is crucial.

44. Cont.… 2. Risk-Benefit Assessment:  Assessing the risks and benefits of EP study and ablation procedures requires consideration of various factors, including the patient's comorbidities, arrhythmia severity, procedural complexity, and expected outcomes. Balancing the potential benefits of arrhythmia control and improved quality of life with the risks of procedural complications, recurrence of arrhythmias, and the need for additional interventions is essential.

45. Cont … 3 . Resource Allocation:  EP studies and catheter ablation procedures require specialized equipment, skilled personnel, and dedicated facilities, posing challenges related to resource allocation and healthcare delivery. Optimizing procedural efficiency, prioritizing patient access to care, and balancing healthcare costs with clinical benefits are important considerations

46. Reference 1. https://www.heart.org/en/health-topics/arrhythmia/symptoms-diagnosis--monitoring-of-arrhythmia/electrophysiology-studies-eps 2. https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/ablation-for-arrhythmias