Interesting cases, interesting day

October 23rd, 2021

Came to the hospital around 7:30 AM.

I am writing the list of the patients on the whiteboard. 10 cases. Has to be an interesting day...

I have some time to prepare everything for our EP session. I am bringing the Mobile EP-tracer and the cryo console to the lab, prepare the RF ablator and check if we have all the supplies... Is necessary to bring the cryoballoon sets and the ACT machine from operation room.

At 8:00 AM, Vasile Bogdan, the technician from Medtronic is in place. He came with some informational materials for the patients. In a couple of minutes Irina Boiciuc, EP fellow is arriving. We discuss a little bit about the cases we will have and about some news in the field. Also, about the order of the procedures.

Around 9 o'clock professor Erdem Diker and professor Basri Amasyal? are arriving. There is also Kamil with them. We greet all of them, shake hands and look together at the whiteboard. 10 cases. A lot of things to do.

9:50 AM. Our first patient is on table. Is the patient with paroxysmal atrial fibrillation. We have to do PVI using cryoballoon. Place all the sheaths, including FlexCath advance. Septostomy. Heparine. Arctic Front Advance Cryoballoon in place. Inflation. Contrast to check occlusion. Good occlusion. Freeze. Error on the screen. Deflate. Inflate. Freeze. Error. Need to solve. It takes a couple of minutes to identify the issue and to solve it. With Bogdan's help we are solving and everything is going smoothly after that. At 11:10 the procedure is done.

12:00 PM - 2 PM. Our second patient for cryoballoon PVI. He has left common ostium of the pulmonary veins. We have some issues with right superior vein, but after some attempts the vein is isolated. Final check. Well done. Smiling.

We need to move forward. Still 8 cases to solve.

2:10 PM. The next case is a case of a 16-years-old young lady. Is a SVT case. HRA and RV catheters in place. We try to induce the arrhythmia. There is PR>RR phenomenon and a jump, but no echo beats, also no inducible tachycardia. Erdem Diker is asking to give 1mg Atropine. I am trying to induce arrhythmia again. Nope. We discuss with Erdem Diker and give 2.5 mg intravenous metoprolol. Let's do it again, let's induce the AVNRT! Cannot induce. We discuss with the patient and taking into consideration the typical symptoms and the substrate for AVNRT we ablate the slow pathway. Done.

Next case. Is 3 o'clock.

Challenging case. The patient has CAD, paroxysmal atrial fibrillation and atrial flutter attacks. Also has an VR ICD, implanted in Munich, Germany in 2020. He has inappropriate shocks delivered by the ICD. During the last consult he showed me an interesting ECG from his archive where he has intermittent delta wave. Only one ECG with delta wave, also during atrial fibrillation runs he does not have preexcitation. I am sure the patient has concealed AVRT. We discuss with Erdem Diker, Basri Amasyal? and Irina the case. The patient is in atrial fibrillation at the beginning of our procedure. We decide to start with cryo and after to check the AVRT.

Together with Irina we program all the ICD therapies OFF. Professor Basri is performing the PVI. During programed stimulation there is AVRT. Let's do the accessory pathway mapping now. And yes, there is left posterolateral concealed accessory pathway! We apply some RF currents. Try to induce. There is no more AVRT. Amazing case!

Now we take a small break and discuss about our 4th case. It is worth to be published.

I explain to our team that we will have another similar case today. Really nice day.

5:50 PM. Our 5th patient is on table. Is a SVT case. We induce typical AVNRT, ablate the slow pathway and that's all.

7:10 PM. Is a PVC case. PVCs with left bundle block morphology, inferior axis, transition is V3. The PVC burden is 61% and is making our job easier. We are mapping the RVOT and quickly find the origin of the PVCs being septal anterior superior region of the RVOT. RF applications and no more PVC on the screen... We wait 10 minutes. No PVC. The procedure is finished! We all are happy. It took only 10 minutes to solve the case. But we still have other 5 cases.

7:40 PM. Our 6th patient is on the table. Is a 64-years-old lady. She has tachycardia attacks from her teens. She has documented SVT during Holter ECG monitoring in 2021. We start the programed stimulation. VA conduction is decremental. There is PR>RR phenomenon. We understand that the SVT is an AVNRT. We ablate the slow pathway.

Is nice to ablate an AVNRT in a 64-years-old lady.

At 8:15 PM another patient with PVCs is on the table. She also has frequent PVC coming from RVOT according to the surface ECG. We do the mapping and find the spot being located in septal anterior superior region and septal superior free wall of the RVOT.

We apply RF currents. No more PVCs from RVOT. She still has some rare PVCs with other morphology. The case is done. Good job.

Before the next case I am explaining to the team the our next case is similar with the AVRT we just ablated some couple of our before. I am explaining that is a case of the patient with rare attacks of atrial fibrillation that are not preexcited. But in patient's ECG archive there are some ECGs with manifest delta wave. He also has SVT runs. So, again, is an AVRT case.

At 9:20 PM the patient is on table. The HRA and RV catheters in place. We start the stimulation. During atrial stimulation SVT with 300ms CL is induced. We make the differential pacing maneuvres. AVRT. Is taking some time to locate the pathway. Is left posteroseptal and we ablate it via aortic retrograde approach.

We finished the procedure and look on the clock. There is 10:20 PM. One more procedure to perform, is the last one.

10:40 PM. The patient is on the table. Is a patient for redo procedure, she has fascicular VT. We ablated her 1 year ago and she was fine for 6 mont, but there is a recurrence of the VT. At least we know from where the arrhythmia is coming. We are mapping Purkinje fibers potentials from the LV and apply some RF currents in the posteroseptal and apical region of the LV. Done. Is 11:05 PM.

We are all happy and discussing some last ideas about the day. Is time to go home.

I am writing and printing the last reports and make the prescriptions for the patients. Also, I decide to eat one more slice of pizza. After that, at 11:53 PM, I send the report about the cases to our administration. Now, is finally the time to go home. Interesting cases, interesting day.