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2021 AF Symposium: Challenging Cases in AF Management

Incessant Tachycardia Case by Dr. Andrea Natale

In another presentation of the Challenging Cases in AF Management, Dr. Andrea Natale of the Texas Cardiac Arrhythmia Institute in Austin, TX, described the case of a 78-year-old female who previously had 4 catheter ablations for recurrent A-Fib and atypical flutter before being referred to him.

Incessant tachycardias are some of the rarer forms of normal QRS tachycardias. 

The last ablation worked on the Coronary Sinus (a bundle of small veins in the heart’s rear surface), and also tried to isolate the Left Atrial Appendage (LAA). At that time, they also inserted a Watchman device to close off the LAA.

Challenging Case #2: The Patient: Never-ending Tachycardia

Dr Andrea Natale

Dr Andrea Natale

Presenter: Dr. Andrea Natale of the Texas Cardiac Arrhythmia Institute in Austin, TX

The patient: “She had ‘incessant’ tachycardia (over 100 beats per minute).” [Though tachycardia technically is a slight improvement over A-Fib in that one’s heart beats rapidly in sinus, it’s still very disturbing, hard to live with, and damaging to the heart.]

40% Chance of Re-Connection When Watchman is Inserted Too Soon

“I’m not a fan of putting in a Watchman after the first LAA isolation. In our experience, there is a 40% chance of reconnection.” After this reconnection, one may never be able to re-isolate the LAA after the Watchman is inserted.

Dr. Natale found that the Left Atrium was silent with no A-Fib [one would think that would be the case after 4 ablations!]. But both the left and right septum had signals which needed to be focally ablated These additional ablations put the patient back into sinus.

Epicardial (Outside the Heart) Ablation

Dr. Natale’s team then found a moderate pericardial effusion which they drained.

But since they were already outside the heart, they decided to look around for other signal sources. They found a signal source behind the Watchman. As they ablated epicardially (outside the heart) around the LAA, the patient was stimulated back into tachycardia. They found that areas behind the LAA had reconnected.

When he epicardially ablated these signals, the patient returned to sinus.

Editor’s Comments:

Importance of Left Atrial Appendage (LAA): Dr. Natale and his colleagues are at the forefront of recognizing the importance of  isolating the LAA in order to restore a patient to sinus. Many Electrophysiologists (EPs) never look at the LAA to map A-Fib signals.

Ablating/Isolating the LAA from Outside the Heart: Once a Watchman device is inserted, it covers up any areas behind the device which have reconnected. The only way to get to those areas is from outside the heart (epicardially). Ablating outside the heart is not for the faint of heart. For most EPs, ablating endocardially goes far beyond a simple Pulmonary Vein Isolation procedure (which is performed inside the heart, i.e. endocardially).

We are indebted to Dr. Natale for showing both how to ablate from outside the heart and how to map and isolate signals hidden behind the Watchman device. (The next AF Symposium should schedule a demo of Dr. Natale performing this tricky mapping and ablation procedure.)

Don’t Insert a Watchman Right After a First PVI: Dr. Natale’s cautionary admonition should be embraced by all EPs. But one wonders how many EPs will heed his advice or even become aware of it.

If you find any errors on this page, email us. Y Last updated: Friday, February 26, 2021

Return to 2021 AF Symposium Reports

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