Can anyone help me with the commanded portion of this EP study please?


Date of Procedure: 01/21/2019

Procedure: Comprehensive EP study with ablation of SVT, ICD evaluation in person with program stimulation from ICD to terminate ventricular tachycardia, pacing and recording from the left atrium, intracardiac echo, intracardiac Three-D mapping, ultrasound assessment and access of right and left common femoral veins

Patient has a history of coronary artery disease and ischemic cardiomyopathy. He has a dual-chamber pacing ICD. He has not had a history of sustained V. tach with rates in the 160 bpm, sometimes faster with very symptomatic episodes, including having chest pain and device discharges. He has undergone a previous A. tach ablation. 3 months ago. He has had no log in of any V. tach since despite being off of antiarrhythmic therapy. He has been found to have atrial flutter and is coming in now for an atrial flutter ablation. He is on chronic anticoagulation with Eliquis.

Patient was brought to the EP lab in a fasting nonsedated state. Sedation was achieved by the anesthesiology service and the patient was placed under general anesthesia.

Both groins were prepped and draped in usual sterile fashion. Under ultrasound guidance axis was obtained into both the left and right femoral veins. 2 separate entries were made into the left and 2 separate entries into the right femoral veins.

A 7 French decapolar catheter was placed into the coronary sinus. A 10 French intracardiac echo probe was used for visualization. This helped monitor contact by the ablating catheter with the atrium. A 7 French 20 pole pent array catheter was used in addition a 7.5 French 3.5 mm tip quadripolar Biosense Webster ThermoCool Smart Touch SF bidirectional FJ catheter was used.

She was seen to have an atrial dysrhythmia with an atrial cycle length of 245 ms. However, there was a ventricular cycle length of approximately 515-520 ms, making me suspicious that he might also have ventricular tachycardia.

His dual-chamber ICD was reprogrammed prior to the start of this procedure to turn off monitoring and therapy. After the radiofrequency delivery. The device was programmed back to monitor and therapy and then we performed an EP evaluation of the device and did anti-tachycardia pacing with commanded therapy, basically to pace terminate his ventricular tachycardia. VT at a rate of about 105 bpm.

Intracardiac Three-D mapping and FAM mapping was performed.

Radiofrequency was delivered at 40 W with a flow rate of 15 mL/m to the tricuspid isthmus region. This was done under intracardiac echo guidance to help ensure tissue contact by the ablating catheter and to help navigate.

Intracardiac echo showed no intracardiac thrombus. We saw the 4 pulmonary veins and they seem to be unremarkable. We used the intracardiac echo to help guide. Radiofrequency catheter placement and delivery and at the end of the procedure to verify that there was no pericardial effusion. LV looked to be dilated have some significant hypokinesis and EF probably in the 30% range.

At the end of the procedure pacing was performed to verify block in the isthmus. Pacing was performed from the coronary sinus and right atrium.

Patient then went into ventricular atrial conduction in V. tach with the same VT cycle length that he had during the presentation into the lab.

I then reprogrammed his device to have detections back on monitoring and therapy on an changed antitachycardia pacing to commanded therapy and pace terminated. His VT. He went back into an atrial paced rhythm with intrinsic conduction.

We then reprogrammed his ICD back to original settings. Although a V. tach rate at 105 bpm will not be detected by the device. He was asymptomatic and hemodynamically stable, so I do not think that this is required to be treated.