Drawing the Lines: How a Telescoping Sheath is Changing One Lab's Approach to Atrial Fibrillation

Martin N. Wiseman, MD
Martin N. Wiseman, MD
Since then, our LACA technique has evolved so that the lesions resemble one continuous line circling the left atrium. This evolved technique eliminates the need to burn on the posterior left atrial wall, decreasing the risk of atrio-esophageal fistula. Additionally, for the last four months we have begun to use the Telesheath Left Atrial Introducer System from St. Jude Medical. This sheath-in-sheath guiding introducer provides three-dimensional movement and good stability throughout the left atrium, and has dramatically decreased average AF ablation procedure times. Today, in a normal sized atrium, mapping takes our team about 15 minutes and ablation lasts approximately one hour. Standard practice at Hillcrest is to map only the posterior aspect of the left atrium, as no ablation lesions are made in the front of the atrium. When our St. Jude Medical Representative first demonstrated the Telesheath system, it was immediately clear to me that it could be a solution to many challenges inherent to ablation of AF. The mobility and flexibility enabled by the introducer make lesions that were previously difficult or impossible to create become routine steps in the procedure. For instance, creating the superior roof line could be difficult without this system; however, it is very easy with Telesheath. In fact, the telescoping design allows us to be much more flexible in our approach to the case; if anything is missed the first time around, it s extremely easy to go back to a location and complete the lesion. What is especially notable about the sheath is its ability to support very long drags of the ablation catheter. In fact, by moving only the inner sheath and catheter we can complete lesions up to one-third of the total line length. This provides outstanding speed and accuracy during AF ablation, without sacrificing anything to achieve them. The Telesheath Left Atrial Introducer System also provides a stable platform from which to perform ablation. A stable platform is everything in this business; it puts you in the best possible position for procedural success. This stability also improves tip-to-tissue contact, which is critical for effective ablation. Without the Telesheath system, the catheter may drift out of position, which could result in a less effective lesion. With this tool, there are multiple curves and multiple approaches I can use to position the catheter truly along the wall of the left atrium. Standard Clinical Procedure We begin each AF ablation procedure with a standard transseptal catheterization. The Telesheath introducer is then placed, via sheath exchange, and points are taken for the CARTO map. Once the posterior aspect of the left atrial map is complete, we can begin ablation. Using a Stockert 70 generator and 8 mm ablation catheter, the Telesheath system allows us to keep the radiofrequency (RF) energy on while moving the catheter every 30 seconds. Consequently, we are able to create true drag burns. Ablation catheter temperature is set at 55 ºC. Currently, our objective is to exclude the entire posterior wall of the left atrium, along with the pulmonary veins. This should be effective in reducing AF occurrences for the patient, without incurring unnecessary risk of future complications. Of course, the best judge of procedural success is recurrence. During the period we ve been using the Telesheath system, we ve been able to create technically very satisfactory looking lesions and things look positive, but only time will tell. We now use the Telesheath Left Atrial Introducer System on every AF case, as well as on some left atrial flutter ablations. Getting Started While the Telesheath system can make performing AF ablation faster and easier, its use should not be undertaken lightly. This is an 11 French (Fr) ID outer introducer with an 8 Fr ID stiff inner sheath which has a right angle. Though the distal tip is much softer and more atraumatic than the sheath body, it should only be used by experienced operators, as there is a distinct risk of perforation in less experienced hands. It is important to pay close attention to guidewire management in these rigid intracardiac catheters. Before using the Telesheath system, it is wise to first gain experience with conventional transseptal mapping. This way, the operator can learn their way around the left atrium, watching for perforations and getting used to the anatomy. Only when very comfortable with left atrial anatomy should an operator attempt to use Telesheath for the first time. The Shortest Distance Between Two Points Once an operator is comfortable working in the left atrium, the Telesheath Left Atrial Introducer System can provide great benefit. The operator simply decides where to go and can go there quickly. At Hillcrest, we are actually improving our case turnover when using the product. Not only are the cases being completed more quickly, we are often creating more lesions in better positions. Our time is being used effectively to complete lesions rather than ineffectively struggling to position the catheter. The Telesheath system is simply an order of magnitude better than anything I ve used before.