A chill is in the wind, and it is just the beginning of the Fall. With Medtronic's release of the Arctic Front® cryoablation system, we now have the ability to isolate the pulmonary veins in patients with symptomatic atrial fibrillation who have failed antiarrhythmic drug therapy. The procedure requires a 15 French steerable sheath and a proprietary balloon catheter, which is first inflated and then filled with liquid nitrogen in order to create the freeze and isolate the vein. Two 4-minute freezes are recommended. Close vigilance for diaphragm paralysis is recommended, since phrenic nerve paralysis may occur with right-sided freezes.

As healthcare financing becomes more of a political issue as we approach the 2012 presidential elections, cardiologists and specialists such as interventionalists (including electrophysiologists) have to "Get with the Guidelines." The ACC/AHA/HRS have published scientific statements for almost every test and procedure. These guidelines drive quality and, in particular, focused areas including pneumonia, myocardial infarction, and congestive heart failure. Performance in these areas will also have an effect on physician reimbursement.

Other areas of medicine, especially expensive therapies like stents and implantable defibrillators, will be areas of heightened attention. Following the guidelines for your practice and enhancing your medical documentation can be helpful as we move forward toward universal health care. My advice to you is to make every effort to document your rationale for prescribing a particular test or therapy.

As always, all the best and happy documenting!

Sudden cardiac arrest (SCA) is a leading cause of death in this country - it is more common than breast cancer, lung cancer, stroke, and AIDS combined. Notables such as Tim Russert and Michael Jackson have been victims of SCA.

The Heart Rhythm Society, the American Heart Association, and the American College of Cardiology have made SCA research and education a priority, putting a significant emphasis on training medical and allied professionals. However, patients and their families also require a special understanding of all aspects of heart rhythm disorders.

The Heart Rhythm Society, the American Heart Association, and the American College of Cardiology have not yet come up with a consensus statement in regards to performing atrial fibrillation (AF) ablation procedures (including the transseptal component) on therapeutic anticoagulation. Several studies have reported success with this approach, but without any clear guidelines, I am interested in hearing how your labs are performing such procedures, including your results and complication rates.

Issues of interest include:

1) Are there any specific INR cut-offs at your institution for this procedure?

2) What are your target ACT values during the procedure?

3) Are there any specific issues related to the transseptal procedure and handling perforations?

4) Do you routinely use reversal agents at the end of the procedure?

5) Are there any changes in desheathing protocol in patients who are on therapeutic warfarin as compared to those who are not?