Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid...
Transcript of Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid...
![Page 1: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/1.jpg)
Building a Hybrid ProgramS. Patrick Whalen MD FHRS FACC
Director, EP WFUBMC
![Page 2: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/2.jpg)
Wake Forest Baptist Medical Center
Disclosures
• Speaker/consultant- Atricure
• Speaker- Boston Scientific, Medtronic, Biotronik
![Page 3: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/3.jpg)
Building a Hybrid program
• Collaboration between EP
and CTS in not the norm
• Clear advantages for
physicians, patients,
hospitals
• Requires concerted effort
and teamwork
![Page 4: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/4.jpg)
Building a Hybrid program
•Barriers to progress
–EP
–Surgeon
–Administration
•First Steps (Clinic)
• Illustrative Cases
![Page 5: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/5.jpg)
EP Perspective
Interventional EP begain in the operating room
The electrophysiologist is the natural predator of the cardiac surgeon
Fellowship Lessions:
Call the surgeon only when you need to be “bailed out”
![Page 6: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/6.jpg)
Progress
Collaboration is additive: volumes, outcomes (CRT, AF, Extraction, VT), innovation
EP Perspective- Barriers
![Page 7: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/7.jpg)
Wake Forest Baptist Medical Center
• Extends EP toolset (limitations)
• Critical to Sustain an Extraction Program
• Completes AF Program
• Durable PVI, posterior box
• GP Ablation
• LAA isolation/closure
• CAB/Valve +Maze
• CRT, VT
EP Perspective- Advantages
![Page 8: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/8.jpg)
Wake Forest Baptist Medical Center
Surgical Perspective- Barriers
• Time
• Comfort zone
• Training
• EP endpoints
• Communication
and EP
feedback
“Check the Ego at the door”-Steve Hoff, MD
![Page 9: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/9.jpg)
Wake Forest Baptist Medical Center
• Case Mix and Volume
• Better understanding of arrhythmia mgmt
• Wider application of AF therapies to CAB/AVR
• Feedback and validation of surgical ablation
• Veins, box, LAA, outcomes
• Close working relationship improve EP
consultative service
• Post procedure management and follow-up
• Not “bail me out”
Surgical Perspective- Advantages
![Page 10: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/10.jpg)
Wake Forest Baptist Medical Center
Hospital Perspective
• Model already exits (Lung Cancer, Heart
Transplant, TAVR)
• Improved quality, outcomes
• Right intervention at the right time
• Patient experience
• Widen referral network
• Procedural volume with halo effect
• Improved utilization of shared spaces (hybrid labs)
• Case example failed LV lead implant
![Page 11: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/11.jpg)
Wake Forest Baptist Medical Center
Getting Started at Vanderbilt
AF Clinic• EP
• Arrhythmia Surgeon
• EP NP
• Device Clinic
• Shared Space
• Comprehensive service for AF patient
• One stop shop from warfarin to hybrid ablation
![Page 12: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/12.jpg)
Wake Forest Baptist Medical Center
Lead Extraction- Patient Selection
• Collaboration required lead extraction program
• Active Process
• Size of the vegetation
• Left sided endocarditis
• Dwell time of the leads
• Lead Design
• Structural/Congenital Heart Disease
![Page 13: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/13.jpg)
Wake Forest Baptist Medical Center
Case #1 Extraction
• 55 year old with ICM and
primary prevention ICD
• Device ERI
• Riata with exposed
conductors and visible
thrombus
• Normal parameters
• No suggestion of SBE
• On OAC x 2 months with
no change
![Page 14: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/14.jpg)
Wake Forest Baptist Medical Center
Case #1 Extraction
![Page 15: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/15.jpg)
Wake Forest Baptist Medical Center
Case #0 Extraction
![Page 16: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/16.jpg)
Wake Forest Baptist Medical Center
Case #1 Extraction
• Planned hybrid extraction
• Lead liberated with laser
down to SVC/RA junction
• Fem/fem bypass
• Right mini-thoracotomy and
lead removal
• New lead implant and
generator change
![Page 17: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/17.jpg)
Wake Forest Baptist Medical Center
Case #1 Extraction
![Page 18: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/18.jpg)
Wake Forest Baptist Medical Center
Case #1 Extraction
![Page 19: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/19.jpg)
. ATRIAL FIBRILLATION, V-RATE 61-82 . BORDERLINE T ABNORMALITIES, INFERIOR LEADS * NO PRIOR TRACING AVAILABLE FOR COMPARISON
391QTcF
035205251 04-Jan-2013 13:07:34ALMOND, RICHARD
DOB: 06-Jul-1955 57 Years Male Dept: OHO Clinic
Oper: AH
HR 72
PR
QRSD 88
QT 368
QTcB 403
-- AXIS --
P
QRS 11
T -10Requested By: ELLIS
ICD9:427.31
Page 1 of 2
Standard 12- ABNORMAL ECG -
Electronically signed by: Hood, Rob 04-Jan-2013 14:59:24
Edited
VUMC - OHO Clinic (1-91-01)
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
V1
Chest: 10 mm/mVLimb: 10 mm/mVSpeed: 25 mm/secDevice: 100OAKSREMOT> F 60~ 0.5-150 Hz W PH090A b LP?
• 55 yo male
• LSP AF
• ERAF on amio
• LA 5.2cm
• No prior chest
surgery
• Normal LVEF
Case #2
![Page 20: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/20.jpg)
When do I call my surgeon?
• Failed catheter procedures (AF rather than AFL/AT)
• LSP/Chronic AF
– Failed diagnostic DCCV on Amiodarone
• LA >5.5cm
• HCM
• Valvular Heart DZ, surgical CAD
• Prior CVA or strong desire to come off OAC
– LAA Closure
• Morbid obesity
• Exclusions (LA thrombus, prior chest operation, lung
dz)
![Page 21: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/21.jpg)
Wake Forest Baptist Medical Center
21
Hybrid AF: Lesion Set
Lesions mimic Cox-Maze III.
Initial experience was for same day hybrid (n=33).
Can be performed staged.
LAA ligation evolved from GIA staples to Atriclip.
N Contact pericardioscopichybrid ablation (separate data).
![Page 22: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/22.jpg)
Wake Forest Baptist Medical Center
Hybrid LAA
![Page 23: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/23.jpg)
Wake Forest Baptist Medical Center
LAA and AF Triggers
Salzberg et al. Interactive CardioVascular and Thoracic Surgery 0 (2012) 1–3
Benussii et al Circulation. 2011;123:1575-1578.
![Page 24: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/24.jpg)
Wake Forest Baptist Medical Center
Hybrid AF: Lesion Set
![Page 25: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/25.jpg)
Wake Forest Baptist Medical Center
Continuous Monitoring
![Page 26: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/26.jpg)
Wake Forest Baptist Medical Center
ECG
* SINCE PRIOR TRACING * SUPRAVENTRICULAR TACHYCARDIA , ? A FLUTTER . BORDERLINE T ABNORMALITIES, LATERAL LEADS
429
414RR
QTcF
022560718 17-Mar-2010 16:14:15BILLMAN, JAY
DOB: 18-Sep-1951 58 Years Male Race: 9999 Dept: Outpatient
5212Room:
Oper: HR
HR 145
PR 90
QRSD 82
QT 320
QTcB 497
-- AXIS --
P 0
QRS 35
T 98Requested By: WALKER, KRISTIE
Enc ID: 603617020076
Order #: 00033001
ORDERID:1268858807050
ICD.9:427.31
Standard 12- BORDERLINE ECG -
Electronically signed by: Page, Harry 17-Mar-2010 17:13:28
EditedPREVIOUS:11-Mar-2010 17:40:31 - Borderline Confirmed
VUMC - Vanderbilt Hospital (1-10-03)
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
V1
Chest: 10 mm/mVLimb: 10 mm/mVSpeed: 25 mm/secDevice: 2119 F 60~ 0.5-150 Hz W PH090A LP?
![Page 27: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/27.jpg)
Wake Forest Baptist Medical Center
EP LAB
![Page 28: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/28.jpg)
Activation Map
![Page 29: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/29.jpg)
Wake Forest Baptist Medical Center
![Page 30: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/30.jpg)
Wake Forest Baptist Medical Center
Ventricular Tachycardia Support and Access
![Page 31: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/31.jpg)
Wake Forest Baptist Medical Center
Case #3
• 52 y/o with h/o NICM s/p ICD
• Cardiac arrest in Germany in 2006
• Had 2 EP studies and extensive work-up in one
of the most reputed Heart Hospitals in Texas.
Inability to achieve clinical success. ICD
placement for decreased EF.
• Referred to for ICD @ ERI. Continues to have
frequent symptomatic PVCs and reduced EF
despite medical therapy
![Page 32: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/32.jpg)
Wake Forest Baptist Medical Center
ECG
![Page 33: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/33.jpg)
Wake Forest Baptist Medical Center
Clinical PVC
![Page 34: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/34.jpg)
Wake Forest Baptist Medical Center
RCC
![Page 35: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/35.jpg)
Wake Forest Baptist Medical Center
LCC
![Page 36: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/36.jpg)
Wake Forest Baptist Medical Center
LCC
![Page 37: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/37.jpg)
Wake Forest Baptist Medical Center
RF in LCC
![Page 38: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/38.jpg)
Wake Forest Baptist Medical Center
AIV
![Page 39: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/39.jpg)
Wake Forest Baptist Medical Center
Surgical Approach
• Median sternotomy off-pump as patient was a
Jehovah’s Witnes
• Exposure of left main, LAD, left circumflex, and
AIV from epicardial fat.
• Bipolar RF lesions were delivered under the
displaced cardiac vasculature using an Atricure
cool rail
• Subsequent point RF lesions were delivered
with an Atricure pen device
![Page 40: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/40.jpg)
Wake Forest Baptist Medical Center
LA appendage
Left main
AIV and LAD
![Page 41: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/41.jpg)
Wake Forest Baptist Medical Center
AIV and LAD in epicardalfat
![Page 42: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/42.jpg)
Wake Forest Baptist Medical Center
LA appendage
LAD in epicardal fat
Epicardiallesion set
![Page 43: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/43.jpg)
Wake Forest Baptist Medical Center
ECG
![Page 44: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/44.jpg)
Wake Forest Baptist Medical Center
ICD interrogation
![Page 45: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/45.jpg)
Wake Forest Baptist Medical Center
• 66 year-old male with coronary artery disease
with prior inferior myocardial
• infarction (4-vessel CABG and MVR in 1993)
• Pt was transferred in the setting of VT storm.
• Previous endocardial study with identification of
an epicardial VT originating from the inferior
wall of the left ventricle(LV).
• Chronically occluded RCA and SVG to PDA
Case #4-Ventricular Tachycardia
![Page 46: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/46.jpg)
Wake Forest Baptist Medical Center
Ventricular Tachycardia- Access
![Page 47: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/47.jpg)
Wake Forest Baptist Medical Center
Ventricular Tachycardia- Access
• Repeat endo and epi
mapping with surgical
subxiphoid access
• Blunt dissection of
adhesions to expose the
inferior LV wall to the
mitral annulus
• Ablation with EpiSense
surgical ablation catheter
(nContact)
![Page 48: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/48.jpg)
Wake Forest Baptist Medical Center
• Energy was delivered to a
broad region in the inferior
wall substrate with repeat
mapping revealing signal
attenuation and
homogenization of scar in
this region
• One ICD therapy in 3 years
in setting of hypokalemia
(PMVT)
Ventricular Tachycardia- Access
![Page 49: Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest](https://reader033.fdocuments.us/reader033/viewer/2022041919/5e6b632223b347263b3a4e49/html5/thumbnails/49.jpg)
Wake Forest Baptist Medical Center
• Interventional EP began in the operating room
(nothing new under the sun)
• Training an EP surgeon requires work and
effort (just like training fellows)
• Access to the surgical tool set expands what
we can offer to our patients in multiple areas
(CRT, AF, Extraction, VT)
• Collaboration between EP and CTS will
facilitate more progress than we can
accomplish individually
Summary