DESCRIPTION OF PROCEDURE: The patient was brought to the electrophysiology laboratory in the fasting state after signing informed consent for catheter ablation of AV junction. Presenting rhythm was noted to be sinus rhythm with ICD diagnostic showing that this rhythm had been present for the last couple of days with atrial fibrillation, continuous, in the months preceding that.
The patient’s ICD was reprogrammed to backup VVI pacing at 40 beats per minute. The right groin was prepped and draped in the usual sterile fashion. Local anesthesia was achieved over the right femoral vessels using a combination of 1% lidocaine and 0.5% Marcaine.
Using the Seldinger technique, an 8 French SRO guiding sheath was advanced over a long guidewire into the right atrium. Through the sheath, an EPT Chilli standard curve ablation catheter was advanced.
Great care was taken throughout the procedure to avoid disruption of the ICD leads during catheter manipulation. The catheter was positioned across the tricuspid valve and the His bundle potential was located. The catheter was then drawn back to a more proximal site with large atrial electrogram and barely visible His potential.
At this site, radiofrequency energy was delivered. The patient developed immediate rapid junctional rhythm followed by development of complete heart block, which persisted throughout the ablation delivery. Two short ablation lesions were delivered as we observed the rhythm followed by 60-second energy delivery.
All of these were delivered at the same site, constituted one lesion delivery, total ablation time was 82 seconds. Following the ablation delivery, which resulted in escape pacing at 40 beats per minute, the ICD was reprogrammed to DDD pacing at 90 beats per minute.
We reserved the patient’s rhythm and saw no resumption of AV conduction during a 30-minute waiting period. The electrode catheter was then removed without disruption of the leads.
The sheath was removed and digital pressure was applied until adequate hemostasis was achieved. The patient then left the electrophysiology laboratory in stable condition with a biventricular ICD programmed at DDD 90.
