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The 2019 HRS/EHRA/APHRS/LAHRS Expert Consensus Sta ...
Preprocedure Assessment (Presenter: Haris M. Haqqa ...
Preprocedure Assessment (Presenter: Haris M. Haqqani, MBBS, PhD, FHRS)
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Video Transcription
Thanks very much, Ed. Thank you, Ed and Frank and the chairs for, first of all, the invitation to be on the committee, and secondly for asking me to speak this afternoon. I didn't write the pre-procedure assessment chapter, but this is what I'll talk on today. And I just want to stress something that we all take for granted, which is the extreme importance of pre-procedural planning, meticulous preparation, because you never know what you might miss if you don't look closely. This was last week in Australia. Poor little Barnhill. He was fine, though. So we'll talk briefly about patient selection, not indications, because Dr. Elkerty will talk about that. Risk assessment, the facilities, what we've said about briefly ECG and pre-procedural imaging beforehand, and patient preparation. So risk scoring is something that's really come of age in the last several years, when particularly Dr. Santangeli, who's in the audience, started looking at acute hemodynamic compromise and early mortality after advanced structural heart disease patients were ablated. And a lot of this mortality was not VT related, as we know. He came up with the pain ESD score from the University of Pennsylvania there. And just the components of this score, the only one that's modifiable intra-procedurally is whether you decide to use general anesthesia or not. And your risk of acute hemodynamic compromise obviously rises across totals of this score, up to a one in four risk of something bad happening intra-procedurally. And just this week in Jack, sorry I haven't put the reference there, but just this week, a couple of days ago, is their bigger effort from Penn, comparing the pain ESD score and the Seattle heart failure score, which initially there was some doubt about whether it predicted procedural risk very well or not. But clearly it does. And you can see here on the right, the pointer's working. Sorry. Across all levels of risk, you have this better performance of the Seattle score in some ways than the pain ESD score for overall survival. But both perform well in terms of the score for VT recurrence. So the point about that is obviously that, as you can see here on the rock curves as well, the Seattle score actually outperforms the other scores. So the point about this obviously is to keep this in mind. We do this subconsciously anyway. But to be cognizant of this when we're doing very, very sick patients in facilities where the ability to bail people out is not necessarily there, or in terms of what support you have during the procedure as well. So now in terms of the procedural facilities, first of all, the venue, what we've said in the document is that when there's advanced structural heart disease, these procedures really need to be performed by experienced operators who have expertise in them and who generally have an on-site CTS backup, not just for surgery, but also for the provision of acute hemodynamic support. In terms of lab equipment, these are all statements that we've said in there that are not at all controversial. The ability to monitor closely and defibrillate, obviously. Also, the ability to interrogate the patient's ICD, as well as the imaging requirements that are necessary. Obviously, transthoracic echo availability at short notice to exclude tamponade. All of our generalized EP equipment that we have in there, as well as facilities for urgent cardiac catheterization. And it goes without saying that this equipment has to be kept in supreme working condition. In terms of personnel, I think the document has left a lot of that accreditation to local facilities in terms of how they accredit operators to perform these procedures, including how they accredit their maintenance of experience and certification. Generally, there will be a catheter operator, the electrophysiologist with or without fellows, as well as the nursing staff, the technicians, and mapping system operators, as well as provision for sedation support, whether that be for general anesthesia or conscious sedation. And then for a lot of the more advanced procedures, the ability to have backup interventional cardiology support, and obviously, CT surgery is important. In terms of what we've said about the surface ECG, I think we have rightly emphasized its importance. Most of these procedures rely on the ECG in a way that other ablations don't. And I think it's always a much more difficult procedure when you don't have a good quality surface ECG of the VT. But one of the other things that we have said a little bit about is the fact that the ECG is also important in sinus rhythm, as well as in VT, both for scar-related and idiopathic arrhythmias in that. During scar-related arrhythmias, we're obviously interested in the exit sites from protected isthmuses. We're interested in unusual sites of exit where either there will be increased procedural difficulty and risk or different access required, whether it's for the right ventricle or epicardial. Obviously, bundle branch reentry is a specific arrhythmia that needs addressing. And of course, for VT in the idiopathic context, the 12 lead being essentially 9 10ths of the mapping necessary in so many cases due to the point source activation. Also, given that that tells us about regions of anatomic complexity that may need additional either access sites or contain additional risk in terms of consenting the patient. But in sinus rhythm, so much more information is available that really can't be ignored, including the substrate for underlying arrhythmia, and particularly in the non-ischemic context to highlight this difference between the infralateral and antraceptal substrates where these VTs look different, obviously, from septal versus epicardial lateral exits. Their sinus rhythm ECGs look different with varying degrees of block, as Dr. Dallabella has shown us. Nicely, this is not from the consensus document, but because he's sitting there, I thought it would be nice to show it. And also, as Dr. Zou has shown nicely, the attenuation of limb lead voltages that's seen with the basolateral epicardial substrate and this massive difference in outcome between the two groups. What we have put in the document is some specific examples of the focal arrhythmia origins, as we see from the right and left side in idiopathic VT. What we've said about pre-procedural imaging is that it is obviously mandatory to exclude intracardiac thrombus before commencing these procedures. But what we've said about other imaging is more at the operator's discretion. And particularly here, we're talking about the role of MRI in both diagnosing more concealed substrate, such as the deep intramural septal stuff that Dr. Marchinski recognized some years ago now. And as a result, we've said, apart from as a class one recommendation to rule out cardiac thrombus, everything else has been 2A or greater. So pre-procedural cardiac MR in non-ischemic or ischemics can be useful to reduce VT recurrence. There's some evidence for that now. And also for procedural planning. But also, critically, before the defibrillator goes in, because no wideband algorithm at the moment has completely removed a susceptibility artifact from ICD. So particularly in the non-ischemic context, that gets a 2A to consider strongly getting a high quality MRI done before the defibrillator goes in to allow for future VT planning, VT ablation planning, should that become required. And then finally, patient preparation. So obviously, informed consent, optimize all of the reversible causes of deterioration during the procedure, including heart failure, ischemia, et cetera. And then define all of the associated comorbidities, essentially looking at those risk scores to define risk and what might be required. Planning access routes, which is obviously of critical importance, particularly taking into account the comorbidities, such as vascular disease, and where the VT exits are, as well as where the substrate is, and what the disease process is, obviously. And then, of course, we've left periprocedural anticoagulation. So this is not post-procedural, but periprocedural anticoagulation in the context of those on pre-existing anticoagulation, very much to operator preference, depending on what the indication is, what the anticoagulant was, what the access routes and closures are likely to be, and what the bridging preferences of the operators are. So we haven't been particularly prescriptive there. So in summary, I think we've done a good job in terms of offering fairly specific recommendations for pre-procedural assessment, particularly in the context of risk assessment, ECG, and imaging recommendations before the procedure. And I think you just can't underestimate how important it is for procedural planning to occur properly to minimize the risk and maximize the success of these procedures. Thanks very much for your attention.
Video Summary
The speaker starts by emphasizing the importance of pre-procedural planning and preparation in medical procedures. They discuss the use of risk scoring to assess the likelihood of complications during the procedure. They also mention the importance of having the necessary facilities and equipment, as well as qualified personnel, for successful procedures. The speaker highlights the importance of the surface electrocardiogram (ECG) in guiding the procedure and discusses the role of pre-procedural imaging, such as MRI, in diagnosis and planning. They conclude by emphasizing the need for patient preparation and informed consent. Overall, the speaker stresses the significance of proper pre-procedural assessment and planning to minimize risks and ensure successful outcomes.
Meta Tag
Lecture ID
16128
Location
Room 12
Presenter
Haris M. Haqqani, MBBS, PhD, FHRS
Role
Invited Speaker
Session Date and Time
May 10, 2019 4:30 PM - 6:00 PM
Session Number
S-SP30
Keywords
pre-procedural planning
risk scoring
facilities and equipment
qualified personnel
surface electrocardiogram (ECG)
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