Sumit Verma
@sumitvermaep
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Director of Cardiac EP at Baptist HVI, Alum UIC, MCG, Yale. Tennis player. Tweets are not medical advice.
Pensacola, FL
Joined May 2009
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Tissue transfer repair CPT 14001 can be applied where there is device erosion and a skin flap is created to cover the defect. Measurements of the size of flap are required for documentation/billing. Also, this allows access for complete excision of infected capsule.
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No one should ever have a EF of 36% when being referred to an EP doc
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NICM EF20 CRT >60% PVC burden, NYHA 4, recent failed Epi/Endo RFA. LV Summit septal vein signal with 2Fr EP star, 10 cc Alcohol inj > transient PEA but resuscitated. PVCs suppressed
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My preferred incision to evacuate a hematoma after recent device intervention is at the lower end of the device using suction and irrigation through a small incision only. Much quicker healing and doesn’t disrupt the entire suturing at the top.
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PFA pricing is very aggressive and some centers will choose to sit it out. Many experienced centers already do AF cases very efficiently so the added benefits are debatable especially in view of the cost.
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Our group did +2300 cases in 2023- incl VT/AF RF/cryo, devices, lead extrac, 335 LAAO etc with a cumulative 0.4 % Minor complic (conservatively managed) and 0.6% Major complic rate (reintervention, drains, surgery etc)-incl one mortality (vasc) 0.04% for a total AE rate of 1%
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Should 3D mapping be part of a diagnostic EP study in patients with suspected ARVD ? Endocardial Voltage map with Optrell (0.5-1.5v). No Inducible VT, MRI pending
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s/p CAB ischemic VT - isthmus identified at base of AIV. Double balloon -alcohol 20cc inj-VT slowed from 500 to 640 ms. Termination with adjacent endo lesion (green dot)
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Apical VT ablated epicardially in a HCM patient with LV mural thrombus. Unusual scar distribution for HCM without prior MI
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Redo perimitral flutter. VOM alcohol injection with immediate slowing and term
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If you ever wondered what a 40 year old lead looks like after extraction. Credit to my partner Dr Thabet Alsheikh
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Petition to reject constant focus on increasing EP lab efficiency in favor of ideas to improve long term outcomes of the first procedure.
#Epeeps
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Don’t ablate the atrial septum unless you have a really good reason to. It causes the most interatrial delay that lead to subsequent flutters. Leave those fractionated signals alone.
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It feels illegal to use high density mapping for ablating a simple left sided AP, having done them for years without 3D mapping or even ICE. Expert mappers
@slate11p
Andrea Griffith
#omnipolar
#Abbottcardio
#Ensitex
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Idea for an EP meeting but only allowed to present failed studies and cases that ended badly
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The management of tamponade in EP lab is not well outlined. Besides acute drain placement other issues like use of auto transfusion, prothrombotic agents, how long to wait before sending the patient for surgery, differing outcomes vis a vis expected location of perf, accounting
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Posteromedial pap muscle PVC with bigeminy. QRS 200 ms, SOO distal tip of PM, ablated transseptally with steerable sheath for stability. 40W/5-10g contact force
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Unable to cross inferior to the closure device so went through it
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New hospital building, new labs, same team, purple mood lighting
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My least favorite thing to do is remove loop recorders - by a wide margin.
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Tachy Brady with AF rates 140/SR 40- intolerant of sotalol. Lesion set PVI+PW+targeted SVC/AO GP ablation only. Final HR 70s sinus immediately after GP ablation.
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A surgically ligated LAA stump doesn’t have to be large or pectinated to form a clot.
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To my 75 yr old patient going paragliding next month, please hold your Eliquis for 48 hours
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Ischemic VT of the day. Pacemap wasn’t perfect but close enough ( site at the white circle). Substrate guided RF. Non Inducible with triples at end
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How is PFA the future when the only advantage it offers is a little more speed but at a (?) higher cost?
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EF 60, previous ICD, multiple shocks, Refractory AF with RVR with MVVT both independent of AF and triggered secondary to RVR.
Combined Inferior wall VT RF+ PVI+ AVN RFA. Of course a late add on case.
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Right Para-Hisian PVC focus. The conduction system can be surprisingly resilient when it wants to be. 40W, 60 sec. 8 mm separation
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CSP lead damaging the conduction system leading to CHB. A potential mechanism for therapeutic benefit in AF patients ? I was planning AVN ablation anyway for refractory PAF
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PVC ablation
#SOO
at the anterior papillary muscle of the TV, next to the moderator band. Interestingly the MB was first described by Leonardo da Vinci.
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Link to my article on our Lead extraction program in EP Lab Digest this month
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Contact force catheter in AVNRT- bump mapping slow pathway with 10-20g force can yield junctional beats that allow assessment of conduction before RF is delivered.
#EPeeps
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40 M referred for gen change. 9 yr old functioning dual coil lead. System extracted (16 Fr laser sheath +Tightrail) and SICD implanted. Recovered NICM, primary prevention ICD. Extraction decision driven by patients age and anticipated longevity.
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Special meeting my son- Sahil at work as he’s doing his third year clinical rotations
#FSUmed
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NICM, EF 20. 80 percent BIV paced due to frequent PVCs, MMVT with shocks CL 320 ms
Epicardial +endo mapping ablation. All lesions are endocardial.
PVC focus anterior and VT isthmus ablated in inferior part of same inferolateral scar //TS +retrograde +Epi
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Repetitive focal VT, prior SAVR, Anterior septal MI and prior scar related VT RFA. SOO ? 1,2,3
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The inferior phrenic vein is used sometimes as an inferior pathway to implant a Remede lead. Here it’s seen in proximity to the medial inferior CTI
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Brugada-like pattern elicited by placing V1/V2 in the 2nd Intercostal space versus the 4 th- with a baseline LBBB
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The so called “blanking period” after AF ablation should be renamed the “utter failure period”
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A few EP procedures that I have combined when necessary.
1. Pacer+ AVN Ablation
2. AF RFA + PVC RFA
3. AF RFA+ VT (scar based) RFA
4. AF RFA+ LAAO
5. VT RFA+ ICD
Widespread application limited mostly by reimbursement and not technical or safety issues.
#Epeeps
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My advice to a young patient with cardiac inhibitory syncope - If someone wants to put a pacemaker in you- RUN 🏃
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De novo flutter- anterior LA scar noted with AFL termination in 2 sec at site A and a second irregular AT ablated at site B. Not an uncommon pattern of scar in hypertensive LA enlargement
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Reasons to proceed with left sided implant once a persistent Left SVC is identified
#EPeeps
It’s Friday afternoon
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I like a challenge
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Too lazy to prep Rt side
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Better for the patient
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#Epeeps
Prior Mech MVR, AF-RFA. Interatrial delay resulting in left sided pacemaker syndrome. LAA on time with Ventricle, somewhat corrected with DDI Mode. Not an uncommon complication of extensive anterior LA wall ablation. If you can’t control the HF symptoms would you ..
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How many patients have been harmed by empiric PW isolation without demonstrable involvement in AF/AFL
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The more you ablate the less likely you are to prescribe AA drugs
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Medtronic VDD 5032 - a unique lead that has two lumens for stylets or LLDs. The purpose of the atrial lumen ? Not required during implantation so probably just to keep the lead IS1 compliant. Implanted in 1998
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The posterior LA wall is like the sibling who gets blamed first for causing trouble , when it’s mostly just participating in the fun initiated by others
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@Nashwa_Salem_
You tell them exactly how long you’ve been doing it. Be confident and avoid being defensive at all costs. This is also an issue with experienced operators performing a new procedure for the first time. Best to be upfront.
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HFpEF, prior LAA ligation and surgical MAZE. Persistent AF. Voltage scale 0.07-0.5. Not much left to ablate
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Lead cast and mobile vegetation seen after extraction of 4 leads -combined age 36 years. MRSA. Removed with AngioVac. Difficult to see before due to lead artifact.
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Post atriotomy flutter ablated from lateral RA scar - IVC isthmus.
Concealed entrainment and termination at circled site
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Prior myocarditis with rec MMVT 300 ms, Epi scar much larger than Endo. Epi ablation only. Post non induc with triples on Isu. Site located conveniently on mid/distal inferior wall between PDA and left phrenic nerve (maroon dots)
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Left bundle pacing without a guiding sheath. Abbott 2088 lead.
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14 yr old dual coil passive fix Guidant 0175 lead with GORE removed due to can erosion. Surprisingly few adhesions on the proximal coil and on the tined distal electrode. 16F laser+Visi
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Is there a strong argument for interventional cardiologists to implant LAAO devices ? Societies should limit this to EP
#Epeeps
#CardioTwitter
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@finnakerstrom
@DrRoderickTung
@CopGAG
@javadm20
@MDTolgaAksu
@jongichun
We did a report using retrograde trans aortic NCC angio to guide TSP. It is a very useful landmark if not using ICE as there was a consistent relationship between NCC margins and TSP site. Here you are clearly staining the NCC.
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@javadm20
I would introduce the ablation catheter back in carefully through the correct lumen before it is taken out of the groin as that segment may break off in the fem vein
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Recurrent strokes (x2) on ASA+Clopidogrel. TEE- Atrial septal aneurysm without PFO, Chicken wing LAA. No documented AF. Cardioembolic or not ?
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Don’t shame your colleagues who won’t give up the BRK for newer TSP tools
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@DaneshModi
#zerofluoro
has limitations that haven’t been addressed. Navigating preexisting device leads, IVC filters, ASD closure devices, venous anomalies, pericardiocentesis all require availability of fluoroscopy
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It is ok to present a messed up case without prefacing it with “done by fellow” or “previously done at another institution”
#EPeeps
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Would you go around the arteries to access the vein or switch to the other side ?
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@V_Mardigyan
@Dr_JozaEP
@Marek_Jastrz_EP
@curilakarol
@clementy_ep
@shunmug_his_mdu
@Hisdoc1
@mjoc32
@dontdisGD
@AveragingBogey
@psharmadoc
@DrRoderickTung
Localize in RAO, fix lead in LAO. Avoid too many attempts
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Fishing 🎣🐟 out an acutely dislodged Aveir followed by reimplantation of the same device
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If you ablated for 8 hours today you looked at over 40k individual heartbeats
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CMS should encourage combining EP procedures such as AF ablation and LAAO - not discourage it.
#Epeeps
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@drjohnm
It seems the data in favor of US is already so compelling that randomizing seems unethical at this point
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Industry - here is some new tech but it costs more
Doc- is it better for patients ?
Industry - we are still gathering data but you can do two more cases a day to make up the cost
#Epeeps
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Certainly tempting to upgrade CRT non responders to LBB pacing. Connections are going to be a doozy, Extract, abandon, DF1 or DF4, keep the CS lead in circuit or not. Fun times ahead.
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Someday the pace/AV node ablation technique will be relegated to the wastebasket of EP history. Sooner the better !
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When you found the spot but need to switch to Cryo instead of using RF
#HouseOfTheDragonHBO
no
#Dracarys
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