For cardiovascular nursing masters students

1. GROUP ASSIGNMENT ON EP STUDY AND CATHETER
ABLATION
BY; MAHLET ADISS
MULUBRHANGEBRU
MELESE ADANE
TEWODROS AYELE
MENBER YILMA

2. ELECTROPHYSIOLOGY
STUDY AND CARDIAC
ABLATION

3. OUTLINE
• Identify what is electrophysiology study/ cardiac ablation
• Their indications, pre-procedure preparation
• Risk of each procedures and contraindications
• Techniques used during procedure and post procedure care
• Nursing interventions
• Sheath removal technique

4. INTRODUCTION
• Anatomy & physiology of the heart's conduction
system:
 Comprises specialized cardiac muscle cells
and conducting fibers (SA, AV nodes, HIS
bundle, and Purkinje fibers)
 Conduct impulses through the heart and
initiate the cardiac cycle and coordinate the
synchronized contractions of the four cardiac
chambers.
Bundle of his

5. ARRHYTHMIA MECHANISM
Three distinct mechanisms are described:
• enhanced automaticity
• re-entry
• triggered activity.
The first two account for nearly all clinical tachycardias,

6. SVT
Atrioventricular nodal re-entry tachycardia (AVNRT)
• In AVNRT, there are two functionally and anatomically different pathways
within the AV node: one is characterized by a short effective refractory
period and slow conduction, and the other has a longer effective refractory
period and conducts faster.

7. ECG….
• The rhythm is recognized on ECG by normal regular QRS complexes,
usually at a rate of 140-240 per minute. Sometimes the QRS complexes
will show typical bundle branch block. P waves are either not visible or are
seen immediately before or after the QRS complex because of
simultaneous atrial and ventricular activation.

9. ATRIOVENTRICULAR RECIPROCATING TACHYCARDIA
(AVRT)
• There is a large circuit comprising the AV node, the His bundle, the
ventricle and an abnormal connection from the ventricle back to the
atrium= an accessory pathway or bypass tract.
• Result from incomplete separation of the atria and the ventricles
during fetal development.
• Atrial activation occurs after ventricular activation and the P wave is
usually clearly seen between the QRS and T complexes

10. THE WOLF PARKINSON WHITE SYNDROME (WPW)
 An abnormal band of atrial tissue connects the atria and ventricles and can
electrically bypass the normal pathways of conduction; a re-entry circuit
can develop causing paroxysms of tachycardia.
 ECG shows:
- Short PR interval
- Delta wave on the upstroke of the QRS complex

12. ATRIAL FLUTTER (HR200-350/MIN)
• A condition in which the electrical signals come from the atria at a fast but even
rate, often causing the ventricles to contract faster and increase the heart rate.
• When the signals from the atria are coming at a faster rate than the ventricles can
respond to, the ECG pattern develops a signature "sawtooth" pattern, showing two
or more flutter waves between each QRS complex

14. ATRIAL FIBRILLATION (AF)
• A condition in which the electrical signals come from the atria at a very
fast and erratic rate. The ventricles contract in an irregular manner because
of the erratic signals coming from the atria.
• The ECG shows normal but irregular QRS complexes, fine oscillations of
the baseline (so-called fibrillation or f waves) and no P waves.
• Common causes include CAD, valvular heart disease, hypertension,
hyperthyroidism and others. In some patients no cause can be found 'lone

16. VENTRICULAR TACHYARRHYTHMIAS
• life-threatening ventricular tachyarrhythmia's (Sustained ventricular
tachycardia and ventricular fibrillation)
• Torsades de pointes

17. VENTRICULAR TACHYCARDIA (VT)
• A condition in which an electrical signal is sent from the ventricles at a
very fast but often regular rate.
• The ECG shows a rapid ventricular rhythm with broad (often 0.14 s or
more), abnormal QRS complexes. AV dissociation may result in visible P
waves

19. VENTRICULAR FIBRILLATION (VF)
• A condition in which many electrical signals are sent from the ventricles at
a very fast and erratic rate. As a result, the ventricles are unable to fill with
blood and pump.
• This rhythm is life-threatening because there is no pulse and complete loss
of consciousness.
• The ECG shows shapeless, rapid oscillations and there is no hint of
organized complexes

20. TORSADES DE POINTES
• This is a type of short duration tachycardia that reverts to sinus rhythm
spontaneously.
• It may be due to:
- Congenital
- Electrolyte disorders e.g. hypokalemia, hypomagnesemia,
hypocalcemia.
• QRS complexes are irregular and rapid that twist around the baseline. In
between the spells of tachycardia the ECG show prolonged QT interval

22. ELECTROPHYSIOLOGY STUDY
• EP study is a test performed to assess the heart's electrical system or activity in
order to diagnose abnormal heartbeats.
• During an EP study, a thin tube called a catheter is inserted into a blood vessel
that leads to heart.
• Then specialized electrodes are placed in the heart to send electrical signals and
measure electrical activities of heart.

23. PURPOSE
• Identify location of arrhythmia
• How well certain medicines work to treat arrhythmia.
• Indication of cardiac ablation
• Indication for pacemaker or ICD
• To identify potential risk for heart problems such as: fainting or sudden cardiac
death due to cardiac arrest

24. PRE-PROCEDURE
• Take full history and physical examination
• Counsel alleviate fear and anxiety
• NPO patient for 6 to 8 hours before the test
• Keep IV line open and put on parenteral fluid
• Mostly Anti-arrhythmic stop 3 days earlier before the procedure
• Ensure patient sign consent

25. CONT.…
• Collect pre procedure investigation such as CBC, renal function, serology
test, patient weight and height, ECG, Echo
• Removed patient jewelry
• Put patient on monitor
• Prepare emergency drugs

26. CONT... EMERGENCY DRUGS
• Atropine1mL=1mg no dilution.
• Adrenaline 1mg /1mL will be dilute with 9ml N/S.
• NTG 10mg/10ml (1mg/1ml)
• Amiodarone150mg/3ml loading dose 300mg (2amp) dilute with 20_30ml of
D5W push over a minimum of 3 mints.

27. RISK OF THE PROCEDURE
• Abnormal heart rhythms that make dizzy.
• Heart attack (myocardial infarction) and stroke
• Heart valve damage
• Blood clots
• Infection, bleeding and bruising at the site where the catheter went in

28. DURING THE PROCEDURE
• Only slight sedation, fully sedation forbidden
• Lie on a table near an X-ray camera and other equipment.
• Local anesthetics give on puncture area
• Puncture then insert thin tubes, or catheters, into your veins in those areas
• Mostly two catheters inserted, one is for to help guide the procedure and other for
electrophysiology study.
• The catheters will thread through vein to heart.
• Small electric pulses will be sent through the catheters to make heart beat at
different speeds.

29. CONT.…
• The patient may feel his heart beat stronger or fast.
• The catheter then record the electrical activity of the heart.
• This allow to locate the problem area of the heart.
• If the type and location of the abnormal heart rhythm is found, the treatment
decided.
• Cardiac ablation or insertion of a pacemaker or ICD may be done during or right
after the EP study

30. POST-PROCEDURE
• The catheters and IV will be taken out.
• Direct pressure applied to stop the bleeding.
• Transfer the patient to recovery unit.
• Order to lie supine for few hours.
• Keep the arm or leg used for the test straight.
• Keep NPO/parenteral fluid 4-6hrs.

31. CARDIAC ABLATION
• Catheter ablation is a procedure that uses radiofrequency energy (similar to
microwave heat) to destroy a small area of heart tissue that is causing rapid and
irregular heartbeats.
• The procedure is also called radiofrequency ablation.
• Destroying this tissue helps restore heart’s regular rhythm. Catheter ablation
destroys the abnormal tissue without damaging the rest of the heart.

32. INDICATIONS
• Arrhythmias
 symptomatic recurrent supraventricular tachycardia due to atrioventricular (AV)
nodal reentrant tachycardia (AVNRT), Wolff-Parkinson-White (WPW) syndrome
Ventricular tachycardia
Unifocal atrial tachycardia
Atrial flutter and
Atrial fibrillation
• Arrhythmia don’t respond to pharmacological management or cause severe side
effect

33. CONTRAINDICATIONS
• Left atrial ablation and ablation for persistent atrial flutter should not be
performed in the presence of known atrial thrombus. Similarly, mobile left
ventricular thrombus would be a contraindication to left ventricular ablation.
• Mechanical prosthetic heart valves are generally not crossed with ablation
catheters.
• Women of reproductive age should not be exposed to fluoroscopy if any
possibility exists that they are pregnant.

34. RISK OF THE PROCEDURE
• Arrhythmias
• Bleeding where the catheter is inserted
• Infection
• Blood clots
• Heart or blood vessel damage
• Damage to the vessel where the catheter was inserted
• Heart attack/stroke

35. PRE-PROCEDURE
• Take full history and physical examination
• Do investigations and collect, mentioned above
• Shave the groin area
• Don’t take Anti-arrhythmic drug for 6-8hrs.
• NPO for 6-8hrs, keep IV line open and hydrate with parenteral fluids
• Prepare emergency drugs, mentioned above

36. DURING PROCEDURE
• Maintain sterile area
• Attach patient with monitor and strictly follow
• Draping patient with sterile drape while exposing puncture area
• Clean puncture area by using iodized solution
• Give local anesthetic on puncture site
• 3 puncture site used

37. CONT.…
• Insert sheath by using puncture needle through the blood vessel
• Inserts electrode catheters, through the sheath and feeds these tubes into heart.
• To locate the abnormal tissue causing arrhythmia, sends a small electrical impulse
through the electrode catheter. This activates the abnormal tissue that is causing
arrhythmia.
• Other catheters record the heart’s electrical signals to locate the abnormal sites.

38. CONT.…
• Places the catheter at the exact site inside heart where the abnormal cells are and
then, a mild, painless, radiofrequency energy (similar to microwave heat) is sent
to the tissue.
• This destroys heart muscle cells in a very small area that are responsible for the
extra impulses that caused arrhythmia.
• After the procedure ended remove the catheter
• Dress the puncture site with out removing the sheath

39. POST-PROCEDURE
• Transfer patient to a recovery room
• Counsel patient don’t bend his leg, if the puncture is femoral
• Put on monitor and follow v/s and cardiac rhythm
• Watch for any swelling, pain or bleeding at the puncture site
• Announce patient to inform early if has chest pain
• Counsel to well complied with medication and follow up time
• Give instruction about what to do at home

40. NURSING INTERVENTION
• Watch for any symptoms of pain or tightness in the chest or signs of stroke (face
drooping, arm weakness, speech difficulties).
• Check for bleeding or swelling at the puncture site
• Monitor heart rhythm
• Talk to patient about test result, treatment options and plans for follow up
• Counsel about what he/she do at home

41. INSTRUCTIONS INCLUDE
• Don’t drive at least 24hrs or until feel healthy.
• Avoid heavy physical activity until at least for a week
• Don’t lift anything weighing more than 10 pounds.
• Don’t take a bath, swim or otherwise submerge the incision site in water
for one week
• Keep the incision site clean and dry

42. CONT.…
• Call your health care professional if you notice any signs of infection
• Announce the puncture site may be sore for several days.
• A small bruise at the puncture site is normal.
• If the site starts to bleed, lie flat and press firmly on top of it
• Have someone call the doctor or hospital

43. CONSULT IMMEDIATELY
• Catheter insertion site feeling numb or tingling.
• Affected hand or foot feeling very cold or changing color.
• The puncture site looking more and more bruised.
• The puncture site beginning to swell or fluids coming from it.
• Have a fast or irregular heartbeat, SOB, fever
• Feel sick to stomach or sweat a lot

44. FEMORAL PUNCTURE SITE CARE AND SHEATH
REMOVAL
Before removing a femoral artery sheath, make sure:
• To check the type and time of procedure performed, size of sheath inserted,
amount of heparin administered and operator’s orders.
• Heparin is stopped or, if available, ACT is < 150 sec.
• Vital signs are stable, patient is on monitor and there is no active chest pain.
• There is a functioning iv line.
• Atropine is ready and with in reach, if needed.

45. REMOVING THE SHEATH
• Stand on the side of puncture, adjust bed height or use foot sole (allows adequate
compression without fatigue).
• Put on surgical glove, Clean the area (including the sheath) with antiseptics.
• Give 10ml of local anesthetic (1% lidocaine) to the skin around the puncture site.
• Aspirate 5ml blood through the side arm of the sheath and discard but never flush
back! If no blood comes out on aspiration, just proceed with the removal.

46. CONT.…
• Put three fingers of the left hand 2-3cm above the site of arterial puncture (not directly
over the puncture site!)
• For venous compression: put one finger distal to, one directly over and the other proximal
to the puncture site.
• Pull the sheath slowly (at similar angle of insertion) and take it out, check for clot in the
sheath and completeness of parts of the sheath.
• As soon as the tip comes out, gently release the pressure of your fingers and deliberately
allow a little spurt of bleeding (to wash out any clot).

47. CONT.…
• Then, put your other hand on your fingers and apply constant gentle pressure and
don’t interrupt to check for bleeding or change of hands (especially first 5
minutes)!
• Completely obliterate the distal pulse for 5 minutes, then gradually ease the
pressure
• Check distal pulse after 5 minutes (by assistant) while still compressing (ease the
pressure so that dorsalis pedis becomes faintly palpable during this period), and
watch for change in color of the limb. Decrease pressure further every 5 minutes.

48. CONT.…
• After releasing the pressure at the end, check for any oozing, hematoma;
cover the area with palm and ask the patient to cough gently.
• Apply bandage over the site
• Tell the patient to report if he/she feels any warmth, wetting or swelling of
the site.
• Inform the patient to hold the site during coughing, sneezing, laughter and
to keep the punctured leg straight.

49. DILEMMAS
• During electrophysiology (EP) studies and catheter ablation procedures, several dilemmas
or challenges may arise, requiring careful consideration and decision-making by the
healthcare team. Some of the common dilemmas encountered include:
• 1. Patient Selection:
• Determining the appropriateness of EP study and catheter ablation for individual patients
can be challenging, particularly in cases where the benefits and risks are less clear.
• Balancing the potential benefits of symptom relief and arrhythmia control with the risks of
procedural complications and the burden of invasive therapy is crucial.

50. CONT.…
2. Risk-Benefit Assessment:
• Assessing the risks and benefits of EP study and ablation procedures requires
consideration of various factors, including the patient's comorbidities, arrhythmia
severity, procedural complexity, and expected outcomes.
• Balancing the potential benefits of arrhythmia control and improved quality of
life with the risks of procedural complications, recurrence of arrhythmias, and the
need for additional interventions is essential.

51. CONT…
3. Resource Allocation:
• EP studies and catheter ablation procedures require specialized equipment,
skilled personnel, and dedicated facilities, posing challenges related to
resource allocation and healthcare delivery.
• Optimizing procedural efficiency, prioritizing patient access to care, and
balancing healthcare costs with clinical benefits are important
considerations

52. REFERENCE
1. https://www.heart.org/en/health-topics/arrhythmia/symptoms-diagnosis--
monitoring-of-arrhythmia/electrophysiology-studies-eps
2. https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-
arrhythmia/ablation-for-arrhythmias