Dr. Robert Fishel – JFK Medical Center – Radio Frequency Ablation Treatment

– What we’re going to do
today is a catheter ablation for atrial fibrillation,
basically from start to finish. So I just want to tell
patients this is basically, for the most part, a very easy procedure for somebody with experience to do, although it is something
that requires a doctor who has done a number of these. I don’t think you would
want to go to a doctor who does these sort of as a sideline. The way we do these ablations,
is you put little tubes, and they’re sort of like IVs. So we put them into the veins in the leg. The veins in the leg are very large. Could you lock the door there, please. Good. Let’s start again. The way we do these procedures
is we put little tubes in, called sheaths. These are put into the veins
in the legs and we put a few of them in. And you can see that basically
it’s a very small, little tube and it goes into the
vein in the leg and from these sheaths, we can actually put catheters. These are basically electrical
wires, through the tube and up into the heart of a patient. Then we’re in the heart, we
can record electrical signals, we can do our mapping,
and we can do our ablation and eliminate the abnormal tissues that cause atrial fibrillation. Alright, so I’m going to
start by putting the tubes in the leg of the patient, and I’m going to put the
catheters in and then we’re going to do our map, that three-dimensional map, and then from there we’re
going to do our ablation. Today we’re using a technology
which I talked about in another segment, called force sensing. And the way this technology
works, is it can actually measure the actual force
that the catheter is pushing on the tissue. So unlike the old days,
which were about a year ago, we now actually know whether
they’re actually floating on tissue or touching it. We know how hard we’re touching
it, we know whether we’re touching it enough or
touching it too hard. So when we do the ablation, we
will know if we actually have good contact with the tissue,
and that’s what you need to get a good ablation. We want to eliminate
certain abnormal areas that are causing atrial fibrillation. And the problem until recently
has been that you really didn’t know if you
really had good contact, and how hard the contact
was and you need that. If you don’t have that,
patients can have a recurrence because you’ve only stunned the areas and then the atrial
fibrillation comes back. Okay? Ready? Let’s get started. By the way, this is Steve Egglands, one of our fantastic nurses here. We have Jay over there. We have Michelle over there. We have our anesthetist in the back. We have an entire crew of
people dedicated to doing this case from start to
finish, safely and effectively. And that’s, by the way, the
other thing that you need if you see a doctor and
you have an ablation. You want to not just have
the doctor, you want to have the facility. You want to have the mapping equipment. You want to have all
the safety precautions that we typically take that are in place. You want to be in a place
that has open heart surgery, although we have never, in my
career, ever needed to use it, we want to have that in
case there is some type of complication. We want to be ready for it. And really, the other thing
we need, is we need a crew of people who are technically experienced, who know the equipment I need, who know how the procedure’s done. Because it’s not just me, it’s
all the other people here, including the gentleman
behind us who you’ll see in a second, Mike Driver, who
works for Biosense Webster, who’s going to help us
with our mapping today. – [Nurse] Alright, so
ready to get started? – Let’s get started. So you can see it’s very easy
for me to put these tubes in the patient here. It’s only a little needle stick. It takes me about a minute
to put each side’s tube in and we will typically use
both groins in the patient. It’s just easier on the patient
if they have the catheters in both sides rather than one side. Thank you. Okay, so Steve, you can
just hold a little pressure here for a second please. Thank you. And we’re going to put another
two tubes in the left side. Now, physicians will sometimes
put a number of different catheters in and it
depends on who you go to and their experience
and their comfort level, but they’ll sometimes put
in ultrasound catheters and other types of mapping catheters. Our philosophy is that we’ll
use those if we need to, but we try and minimize
the trauma to the patient. So for most of the cases I
do, we’ll usually just put in four sheaths, okay, for our
mapping and reference catheters and for our ablation catheter. Alright, so I’m going to put another two in on the left side now. It’s really very easy
to put these things in; only takes about a second. So this is basically
the extent of the trauma that the patient has, which
is at least for their groin, it’s four needle sticks. The nice thing about this is
also these are in the vein. They typically heal very
well, without a score and with only a little bit of a bruise, which goes away in two to four weeks after the ablation procedure. You can let go, Steve, that’s fine. These are such small tubes,
sometimes have to wiggle them a little bit to get them into the skin. Alright, they’re in. And so now we have completed, basically, the surgical portion of
this ablation procedure. There’s going to be no
additional punctures or cutting or anything to this patient. We’re done with that. Everything else is going to
be in putting catheters in and actually finding
the areas in the heart where the abnormal rhythm’s coming from and fixing those abnormal areas. So we do need to use a little
bit of X-ray, but not a lot, to put our catheter’s in. So could we lower the lights please. Lower the lights there, please. Michelle. Michelle Rogers, our excellent
electrophysiology nurse. And Michelle, could you move
the monitors a little closer to me, please? So this is one of our catheters. It’s a quadripolar catheter. This is going to go into the right atria. And you’re going to see, I’m
going to X-ray in a second, you’ll see on the X-ray, this particular patient has
a pacemaker defibrillator. The NG is good. What Jay is doing, she’s
actually putting some X-ray dye into the esophagus of
this particular patient, to make sure that we are
careful with the esophagus, which is one of the structures
we want to be careful about when we do an ablation. So if you look at the X-ray
you can see there’s some– That’s good, Jay, you can pull it out. Just putting some X-ray dye in
it; it’s a safety precaution. And really, safety is number one to us. We want to try and be as safe as possible when we do these ablations. Going to put another reference
catheter into the heart now. This is a 10 electrode catheter. But you can see how
small this catheter is, it’s sort of like a thick
hair, the size of it. So this is minimally
traumatic for most patients, having these things in. They just have four tiny
little holes in the veins of the leg; they’re basically big IVs. And when you pull them out,
patients can usually go home. For many patients, we can send
them home the same day even and they can go back to work the next, but since we’re using
a general anesthesia, we usually keep people overnight, just to be on the safe
side, in case they have any side-effects from the
anesthetic or from the ablation or anything else, although
typically that’s not an issue for most of our patients. Okay, very good. So that is in the coronary
sinus, this catheter, which is one of the veins in the heart. And now, we are ready to
go over to the left side of the heart, which is where
atrial fibrillation comes from. So I have to change this little tube for–

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