Blog By: Tami Metz, RN

Ventricular tachycardia (VT) ablations can pose to be very complex in nature depending on the individual involved. It is important that each patient is thoroughly prepared and informed throughout the entire process that they are involved. Within this blog I will present the thorough process that we, at St. David's EP lab, initiate for all VT cases that come into our department.

The patients start out in our Cardiology Services Department, which is a pre-operative area. There, they sign all the paperwork that is needed, such as consents for the procedure. Intravenous access is started and labs are drawn and sent off. Specific labs that are needed besides the basic chemistry, complete blood count and coagulative studies include a thromboelastography (TEG) and type and screen. Due to the complexity of these cases, it is imperative that we are prepared for any emergency situation that may arise. An EKG is performed to capture any ectopy that they may be experiencing in the pre-operative setting. Weights are performed pre-operatively to get a baseline due to the administration of fluids that is given during the case with ablation. Finally, the patient must be seen by anesthesia before coming into the lab. They assess the patient thoroughly, as it will be the anesthesia staff that will be taking care of the patient's sedation level throughout the case.

Before the patient reaches the lab, it is important to make sure that all the equipment needed for the case is set up in the rooms and working properly. Once this is determined and the patient is ready, they are brought into the room where a series of steps take place to prepare them for the procedure. After they get onto the table, the staff work together to ensure that all patches are placed correctly on the patient for accurate mapping and monitoring purposes. Anesthesia works on getting the patient set up and ensures that they have accurate continuous hemodynamic monitoring in place. The patient is with limited sedation at this time until there is recorded ectopy documented to proceed with the case. All complex VT ablation patients receive a Foley catheter. The patient is given a propofol infusion during the insertion of the catheter for comfort purposes. Bilateral groins and the subxiphoid area are prepped for access. The physician places an arterial line via the right femoral artery for close monitoring of the patient's blood pressure throughout the procedure. If the patient has an ICD, the device representative will be asked to remain in the room for the entire procedure in case the physician wants them to shock the patient out of the VT if hemodynamics is compromised; if the ICD fails, it is always important for the circulating nurse to be in constant communication and prepared to shock the patient as backup. Heparinization is required if the physician must go to the left side of the heart. Continuous anticoagulation monitoring is performed by the circulating nurse by drawing ACTs (activated clotting time). The expected range of the ACT will be determined by the physician for each specific case. Other medications that are administered during the case may be Isuprel, phenylephrine, epinephrine and IV caffeine. These are just some stimulants that can help to bring out any ectopy during the procedure. Monitoring of the urine output is important as the patient receives continuous fluid administration during RF ablation from the irrigated catheter. If the physician goes epicardial, there is further monitoring of any fluid that may be pulled off from the pericardial space as well.

Once the procedure is completed, the patient is transferred to the Post Anesthesia Care Unit. The patient will remain in this area until they are cleared by anesthesia to go to the floor. The sheaths that were placed during the case are pulled in this area. If a pericardial drain is required to remain, the patient is transferred to the ICU where closer monitoring is performed until it can be removed.

Some potential complications to note that may arise during or after the procedure may include: bleeding of the access site (hematoma), pericardial bleeding (with epicardial access), epicardial coronary artery injury with burning of the cusps in the left ventricle (special precaution is taken with the utilization of angiography and ICE), the left phrenic nerve could be damaged during epicardial ablation, pericarditis with radiofrequency ablation, AV fistula with complicated access, complete heart block due to radiofrequency ablation, stroke and valvular and papillary muscle damage due to ablation or catheter manipulation.

These patients generally spend the night and go home the next day if their procedure did not include any complications. The physician may decide to keep the patient longer if there are any other factors that may warrant continued monitoring and hospitalization. Discharge planning for these patients include: repeat ECHO the next day to rule out effusion, removal of epicardial drain if left in for excessive bleeding, and/or ibuprofen for pleuritic discomfort from epicardial access. Patients are instructed to avoid strenuous activity and lift no more than 10 pounds for 5 days, have a 24-hour Holter monitor in 6 weeks along with a physician follow up, and call the physician's office if they experience any palpitations, lightheadedness, low blood pressure or shortness of breath.

Complex VT ablations present multiple challenges for everyone involved…I feel that at St. David's, we have a tremendous representation of teamwork and communication from all the disciplines that come in contact with the patient. I attribute these valuable relationships to the continued successful outcomes that we provide these patients as they come through our lab.

Tami Metz, RN is the Manager of EP Labs at the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center in Austin, Texas.