Calkins

Case Studies
Hugh Calkins, MD
Case Presentations
Hugh Calkins MD
Case History #1
• Patient J.S., male, 56 yrs
• Paroxysmal atrial fibrillation – 3 times each day,
severe sx
• PMH: Diabetes, hypertension, sleep apnea
syndrome
• Echo: mild LVH nl LV function
• Meds: Lisinopril, insulin Toprol
Case History #1
What Antithrombotic Strategy
Would You Suggest?
A)
B)
C)
D)
E)
F)
G)
H)
I)
Aspirin 80 mg per day
Aspirin 325 mg per day
Coumadin INR 2 – 3.5
Coumadin INR 1.5-2.5
Pradaxa 150 mg bid
Pradaxa 75 mg bid
Xarelto 20 mg per day
Xarelto 15 mg per day
Watchman Device
Case History #1
What Treatment Would You Suggest?
A) Catheter ablation
B) Flecainide
C) Dronedarone
D) Amiodarone
E) AV node ablation and PPM
Case History #1 (continued)
AF recurs despite dronedarone
What Treatment Would You Suggest?
A)
B)
C)
D)
E)
Catheter ablation
Flecainide
Tikosyn
Amiodarone
AV node ablation and PPM
Case History #1 (continued)
f/u appt 3 months post AF ablation – pt in afib
What Treatment Would You Suggest?
A)
B)
C)
D)
E)
Repeat Catheter ablation
MiniMaze procedure
Cardioversion
Amiodarone
AV node ablation and PPM
Case History #1 (continued)
f/u appt 6 months post AF ablation – pt in reports
1 episode of AF each month lasting 20 minutes
What Treatment Would You Suggest?
A)
B)
C)
D)
E)
F)
Repeat Catheter ablation
MiniMaze procedure
Cardioversion
Dronedarone
AV node ablation and PPM
Clinical follow-up
Case History #2
• Patient D.B., male, 69 yrs
• Paroxysmal atrial fibrillation – 1 episode every
three months for 15 minutes
• PMH: no prior medical problems
• Echo: nl LV function
• Meds:none
Case History #2
What Antithrombotic Strategy
Would You Suggest?
A)
B)
C)
D)
E)
F)
G)
H)
I)
Aspirin 80 mg per day
Aspirin 325 mg per day
Coumadin INR 2 – 3.5
Coumadin INR 1.5-2.5
Pradaxa 150 mg bid
Pradaxa 75 mg bid
Xarelto 20 mg per day
Xarelto 15 mg per day
Watchman Device
Case History #2
What Treatment Would You Suggest?
A) Catheter ablation
B) Flecainide
C) Dronedarone
D) Amiodarone
E) AV node ablation and PPM
Case History #2 (continued)
AF recurs on one occasion despite Flecainide
What Treatment Would You Suggest?
A)
B)
C)
D)
E)
Catheter ablation
Continue Flecainide
Tikosyn
Amiodarone
AV node ablation and PPM
Case History #2 (continued)
• Catheter ablation is performed.
• Two weeks later the patient develops an incessant
atrial tachycardia with rapid response.
• The atrial tachycardia recurs despite cardioversion.
• The atrial tachycardia recurs despite repeat
cardioversion on amiodarone.
• A repeat echo reveals an EF of 30%
Case History #2 (continued)
What Treatment Would You Suggest?
A)
B)
C)
D)
E)
Repeat Catheter ablation
MiniMaze procedure
Cardioversion
Amiodarone
AV node ablation and PPM
Case 2:
12-lead ECG at EPS
Intracardiac Tracings
390
390
390
390
390
Entrainment Pacing from RA Isthmus
Activation Mapping with Image Integration
Site with Mid Diastolic Potential (MDP)
RF on
Termination during Entrainment Pacing at Site
with MDP
RF on
Termination during First RF Application
RF on
Substrate Ablation after Termination
Case History #2
What would you do next?
1) Terminate the procedure
2) Test for inducibility, if non inducible stop the
procedure
3) Test for inducibility. If noninducible reisolate the
PVs if not isolated.
4) Test for inducibility. If noninducible reisolate the
PVs even if they are currently isolated based on
lasso mapping. of 30%
End point 1: substrate elimination
End point 2: non-inducibility
Mechanism: small reentry probably related to
PV ablation lesions
Discussion
• Left atrial flutters occur following 5% of AF ablation
procedures.
• Left atrial flutter post AFib ablation can result from
microreentry in close proximity to the pulmonary
veins which is amenable to focal ablation or can be
due to macroreentry.
• The optimal approach to mapping is uncertain.
• A variety of strategies for ablation have been used.
Thank You