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Dr. Sidney Peykar

Visiting the EP Labs as an Observer Instead of as a Patient

SSR at BAFS 2014by Steve S. Ryan, PhD

Every year I attend the Boston A-Fib Symposium to learn the state of the art in Atrial Fibrillation research and development. This year it was held in Orlando, Florida. (See my reports at 2014 BAFS.)
I traveled to Florida a few days early so I could make a couple of side trips. I was privileged to visit with two of the best Electrophysiologists (EPs) in Florida, Dr. Robert Fishel of Florida Electrophysiology Associates in Atlantis, FL,  and Dr. Sidney Peykar of Cardiac Arrhythmia Institute in Port Charlotte, FL.
I visited their EP labs and observed each doctor as he treated A-Fib patients with Pulmonary Vein Ablation/Isolation (PVI) and other procedures. It was a great learning experience for me.

Day 1: Dr. Robert Fishel in Atlantis, FL

Dr. Robert Fishel graciously allowed me to observe him performing ablations at JFK Medical Center in Atlantis, FL. I had to wear scrubs, a mask, radiation vest, booties and a hair cap. (And I had to keep out of the way.)

Dr Robert Fishel and Steve S. Ryan. PhD

Dr. Fishel would do one ablation, then move to another EP lab where the patient was already anesthetized and everything was already set up for him to do another ablation. Then he moved to an operating room where he replaced a pacemaker. He continued these tightly schedules procedures all day long. (He never seemed to get tired. I’m fairly athletic, but had trouble keeping up with him.)

Video Dr Fishel - Treatments of Afib

VIDEO: “Inside the EP Lab During a Catheter Ablation Procedure with Dr. Robert S. Fishel.”

One of his patients was in persistent A-Fib which is usually harder to cure. Dr. Fishel had to make extra ablation lines, but still made the patient A-Fib free in around two hours.

After observing 2-3 procedures, I couldn’t figure out how he was doing the transseptal punctures without using monitors. Only after I was back in the rental car, did it dawn on me that he was doing the transseptal punctures by feel and from his years of experience.

VIDEO: We have a video of Dr. Fishel in our A-Fib Video Library, see “Inside the EP Lab During a Catheter Ablation Procedure with Dr. Robert S. Fishel.”

Day 2: Dr. Sidney Peykar in Port Charlotte, FL

The next day I drove to Fawcett Memorial Hospital in Port Charlotte, FL, where Dr. Sidney Peykar kindly hosted me and allowed me to observe him during several PVI procedures.

He used slightly different equipment and mapping technology than Dr. Fishel. He used a vascular ultrasound probe to insert the catheter in a vein in the groin and Transesophageal Echocardiogram (TEE) for transseptal guidance and to rule out a left atrial appendage clot.

(With the help of Drs. Peykar and Fishel, I will write an extensive description of the stages of an ablation and all the equipment and personnel involved, so that patients can better understand and not be fearful of a PVI procedure.)

Steve S. Ryan, PhD and Dr Sidney PeykarAfter several PVIs, he moved to another procedure room and did an electrical cardioversion on a patient. He returned him to normal sinus rhythm after only one shock.

Dr. Peykar and I also talked about a particular area of concern: A-Fib patients with Sleep Apnea. Obstructive sleep apnea (OSA) is prevalent among patients with A-Fib and has prompted significant research to understand the relationship. Because Sleep Apnea can easily cause a recurrence of A-Fib after a successful PVI, Dr. Peykar insists his patients with Sleep Apnea receive treatment (like using a CPAP machine at bedtime). (BTW: He’s quite informed on the topic and had all the relevant research articles on his smart phone which he emailed to me with a few key strokes.)


What impressed me most about both doctors was how relatively easy and uncomplicated it is for good EPs to make patients A-Fib free by the end of the procedure (with no apparent complications, at least not while I was there.)

I’m grateful to both Dr. Peykar and Dr. Fishel for letting me experience several PVI procedures from the doctor’s perspective (my only previous experience was years ago as an A-Fib patient).GFX TV set Lights Camera Action

BTW: This first hand experience in the EP lab better prepared me for first day of the 2014 Boston A-Fib Symposium when seven procedures were performed LIVE via satellite. See my report: Live via Satellite: Seven Ablation Cases from The Netherlands, France, Italy, Germany, Russia, Boston & Michigan, USA.

References for this article
Dr. Robert Fishel, Florida Electrophysiology Associates/Palm Beach Heart Associates, West Palm Beach/Atlantis, FL 33462 Toll Free: 888-VTACHMD, (561)-434-0353 Web site:

Dr. Sidney Peykar, Cardiac Arrhythmia Institute, Port Charlotte, FL, 33952 & Sarasota, FL 34239 (800) 771-7164 Web Site:

Goyal SK, Sharma A. Atrial fibrillation in obstructive sleep apnea. World J Cardiol. 2013 Jun 26;5(6):157-63. doi: 10.4330/wjc.v5.i6.157. PubMed PMID: 23802045; PubMed Central PMCID: PMC3691496.

Posted February 2014

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Last updated: Saturday, February 14, 2015

The Evolving Terminology of Catheter Ablation

The Evolving Terminology of Catheter Ablation;

The Evolving Terminology of Catheter Ablation

By Steve S. Ryan, PhD

Pulmonary Vein Ablation of A-Fib is a relatively new procedure whose techniques and language are evolving. What follows is perhaps an oversimplified, somewhat biased attempt at explaining the catheter ablation procedures from a patient’s perspective. (Pulmonary Vein Ablation differs from other types of Catheter Ablation used in treating A-Fib, such as ‘Ablation of the AV Node’.)

Ablation Terminology

‘Focal Catheter Ablation’ or ’Focal Point Catheter Ablation’

In this early procedure doctors mapped the sources of ectopic beats (beats that come from any region of the heart that ordinarily should not produce heart beat signals), then used a Radiofrequency (RF) catheter to “ablate” or burn off areas or points within the heart producing these ectopic beats. But if you weren’t in A-Fib at the time, it was difficult to identify the Focal Points or areas of the heart producing ectopic beats.

‘Segmental Ablation’

Doctors discovered that when a patient was not in A-Fib, the Focal Points producing A-Fib signals could still be found by identifying and mapping electrical potentials coming from these points. A potential is an electrical charge or energy—like the battery energy in your car. Even if your car isn’t running, you can still measure 12 volts “potential” at the battery. Similarly, in your heart any potential can be measured and pinpointed, even if you aren’t in A-Fib. When the area is ablated, the potential disappears. Like taking the battery out of your car, removing this potential eliminates your A-Fib. (Doctors today do not usually ablate within the Pulmonary Veins because of the risk of causing Stenosis (swelling). Instead they determine where the A-Fib signal(s) exits the Pulmonary Vein opening and ablate there to “Isolate” the A-Fib signal.)

‘Circumferential Ablation ‘or ‘Circumferential Pulmonary Vein Ablation’ (CPVA)

A circular catheter is used to make Circular Radiofrequency Ablation lines around each of the four Pulmonary Vein openings (ostia) in the left atrium of the heart. This procedure isolates the Pulmonary Veins from the rest of the heart and prevents any A-Fib signals from these veins from getting into the rest of the heart.

‘Anatomically-Based Circumferential PV Ablation’ or ‘Wide Area Circumferential Ablation’ (WACA)

Instead of trying to make continuous, perfect linear lesions around the Pulmonary Viens which can be difficult and time consuming, doctors use a “drop and drag” technique with a larger tip catheter which leaves gaps that are usually closed over time with scar tissue. This procedure originated in Italy. It has a good success rate with very few side effects both for Paroxysmal and for Chronic A-Fib.

The ‘Anatomically Based Circumferential PV Ablation’ procedure is faster, easier, requires less operator’s skill, and is more cost effective for doctors. But from a patient’s perspective it involves a lot of scarring of the heart by high wattage wide tipped catheters. And 20% of patients have atrial flutter after the procedure because of all the gaps in the lesion lines, though most of this flutter eventually disappears as these gaps fill in with scar tissue. Probably because of the gaps which caused patients a lot of problems, WACA doesn’t seem to be used much any more.

‘Pulmonary Vein (Wide Area) Antrum Isolation’(PVAI)

Instead on encircling each of the four Pulmonary Vein openings, one large encircling set of lesions isolates both the upper and lower left vein openings, another the upper and lower right vein openings. The encircling lesions are in the Antrum rather than near the vein openings.

Almost everyone doing RF ablations today seems to be using Antrum Isolation, for the main reason that the ablations are so far outside the Pulmonary Vein openings that the danger of creating stenosis (swelling of the pulmonary vein openings) is virtually eliminated.
In January 2014, I was privileged to observe doctors doing PVIs in their cath labs. Two of the leading EPs in Florida, Dr. Robert Fishel at JFK Medical Center in Atlantis/West Palm Beach, FL, and Dr. Sidney Peykar at Fawcett Memorial Hospital in Port Charlotte, FL, graciously let me observe, explained their procedures and answered my questions. Though they use different catheters and imaging systems, they both do PVAI and ablate in the antrum far away from the Pulmonary Vein openings as do most EPs today. Their point-by-point ablations burns are amazingly precise, consistent and normally leave no gaps. See my report, Visiting EP Labs as an Observer Instead of as a Patient.

‘Pulmonary Vein Ablation’ (PVA) or ‘Pulmonary Vein Isolation’ (PVI)

In general, types of PVA/PVI include: ‘Segmental Ablation’, ‘Circumferential Ablation’, ‘Anatomically-Based Circumferential PV Ablation’ and ‘Pulmonary Vein Antrum Isolation’. They are all similar in their approach. Their primary emphasis is the ablation/isolation of the Pulmonary Vein openings.

Note:  Many use the term “Catheter Ablation” of A-Fib to include all of the above different ablation techniques.

Other Terms

Newer types of ablation have somewhat different ablation targets:

• ’Complex Fractionated Atrial Electrograms’ [CFAE]

• ‘Autonomic Ganglionated Plexi'[AGP]

Terms that still need to be re-defined

• Rather than ‘Isolation’, the term ‘electrical disconnection’ (used by The French Bordeaux group) may more aptly describes what ‘ablation’ does.

• The terms ‘Pulmonary Vein Potentials’ and ‘Pulmonary Vein Isolation’ both need to be re-defined because not all Potentials come from the Pulmonary Vein openings.


Which of the above procedures is the best? They all have somewhat similar success rates. Though the jury is still out on this, ‘Circumferential Ablation’ is quicker and faster for doctors and requires less mapping, but it’s difficult to make good circular ablations. The Pulmonary Vein openings aren’t always smooth, and the surfaces are not always easy to ablate. The inside of the heart is not a continuously smooth surface. Any gap in the circular ablation may result in more A-Fib. And not all A-Fib comes from the Pulmonary Veins. From a patient’s perspective, you’re better off with a doctor who will carefully map your heart to find out where exactly your A-Fib signals are coming from, and who will check for both Entrance and Exit Block (Isolation).

Also, with ‘Circumferential Ablation’ there might be a greater danger of Stenosis, a swelling of the Pulmonary Vein openings after ablation. PV Stenosis restricts blood flow into the heart and can lead to fatigue, flu-like symptoms and pneumonia. Most EPs now use Pulmonary Vein (Wide Area) Antrum Isolation and stay well away from ablating near the Pulmonary Vein openings.

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Return to Index of Articles: Catheter Ablation

If you find any errors on this page, email us. Y Last updated: Sunday, March 19, 2017

References for this Article
Pappone, C. et al. “Atrial electroanatomical remodeling after circumferential radiofrequency pulmonary vein ablation. Efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation.” Circulation 2001;104:2539-2544.

Updated January 2014[

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