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Atrial Fibrillation Ablation: A Community Hospital Experience
Community hospitals play an important role in providing tertiary level cardiovascular care to the elderly population. In this brief case report, we describe atrial fibrillation (AF) ablation in an elderly patient using minimal fluoroscopy at a high-volume community hospital.
Case Presentation
An 83-year-old woman with a history of sinoatrial node dysfunction, paroxysmal AF, and dual-chamber pacemaker implantation 5 years ago presented with persistent AF and new-onset congestive heart failure.
An ejection fraction of 30%-35% was suspected to be due to AF and frequent right ventricle pacing. A coronary angiogram revealed nonobstructive coronary artery disease. The patient reverted to AF after amiodarone load and cardioversion.
Based on the results of the PABA-CHF study, which demonstrated the superiority of pulmonary vein isolation over atrioventricular node ablation with biventricular pacing,1 we chose to proceed with AF ablation instead of cardiac resynchronization therapy (CRT) upgrade. While the median patient age in the PABA-CHF trial was 60 years old, our patient was active for her age. The patient was scheduled for AF ablation under general anesthesia. We used intracardiac echocardiography (ICE) for the groin access, placing an ICE catheter in the right atrium and a decapolar catheter in the coronary sinus using three-dimensional (3D) mapping (Video 1).
Video 1. Insertion of a decapolar catheter using 3D mapping.
We utilized bursts of fluoroscopy to avoid entanglement of catheter or wires into pacemaker leads, keeping fluoro time to <1 minute. We exchanged the 8 French short femoral sheath for a transseptal sheath. After the sheath was a few inches inside the body, the dilator and wire were removed. We inserted an ablation catheter to create a fast anatomical map (FAM), and placed the catheter in the superior vena cava (SVC) (Video 2). We advanced the sheath over the ablation catheter into the SVC and then removed the ablation catheter, placing the dilator and wire back into the sheath. We then inserted the transseptal needle into the sheath, using the ICE catheter to perform transseptal puncture (Video 3). Once left atrial access was obtained, a FAM was made in (3-5 minutes) using a multipolar catheter.
Video 2. Placement of an ablation catheter into the SVC
Video 3. Transseptal catheterization using ICE.
We paid careful attention to stability during catheter ablation. We used frequent apnea and low-volume ventilation to enhance stability for lesion formation. Stability at the left atrial appendage ridge was also important; we defined the ridge using an ablation catheter before starting the ablation (Video 4). Power delivery varied on location and impedance drop, anteriorly 35-50 W for 12-30 seconds and posteriorly 35-50 W for 5-10 seconds. At procedure completion, groin access was closed with a Vascade closure device (Cardiva Medical) for early mobilization. Due to her advanced age and heart failure, the patient was monitored overnight. Postoperatively, the patient has maintained sinus rhythm on low-dose amiodarone.
Video 4. Defining the left atrial appendage ridge.
Discussion
Community hospitals can provide excellent AF ablation outcomes and innovation to the older patient population, with minimal radiation exposure.
Catheter ablation has been shown to be superior to antiarrhythmics in decreasing AF burden. Additionally, the per treatment protocol from the CABANA trial demonstrated potential mortality benefits.2 The recent evidence of cardiovascular and mortality benefit from rhythm control in early AF will further increase ablation volume across the country.3
The electrophysiology program at the Naples Community Hospital (NCH) Heart Institute is a high-volume center, averaging ~400 AF ablations per year with 3 full-time electrophysiologists. Community hospitals play a crucial role in the management of AF in older demographics. AF can have a major impact on the health of elderly patients. With the limited efficacy and potential side effects of antiarrhythmic drugs,2 catheter ablation is an important adjunctive therapy in these communities. Based on the EAST-AFNET trial, ablation in elderly patients can be performed safely, improving symptoms and potentially decreasing mortality.3 In the last 50 consecutive octogenarians at our hospital, only 1 patient (2%) had a major complication of gastroparesis associated with posterior wall isolation, requiring use of a short-term feeding tube.
The complication rate in the elderly has been reported to be as high as 5.3%, the majority of which are driven by vascular complications.4 Use of ultrasonography for femoral venous access could potentially eliminate much of the risk of vascular complications. Limiting the number, duration, and power of lesions in posterior wall isolation could also potentially decrease the risk. Finally, use of pulsed field ablation in the future may potentially help overcome the risk of esophageal or gastric complications.
Disclosures: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Sharma has no conflicts of interest to report regarding the content herein.
References
1. Khan MN, Jaïs P, Cummings J, et al, for the PABA-CHF Investigators. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med. 2008;359(17):1778-1785. doi:10.1056/NEJMoa0708234
2. Packer DL, Mark DB, Robb RA, et al; CABANA Investigators. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA Randomized Clinical Trial. JAMA. 2019;321(13):1261-1274. doi:10.1001/jama.2019.0693
3. Kirchhof P, Camm AJ, Goette A, et al; EAST-AFNET 4 Trial Investigators. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med. 2020;383(14):1305-1316. doi:10.1056/NEJMoa2019422
4. Kautzner J, Peichl P, Sramko M, et al. Catheter ablation of atrial fibrillation in elderly population. J Geriatr Cardiol. 2017;14(9):563-568. doi:10.11909/j.issn.1671-5411.2017.09.008
