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CARDIAC ABLATION: TYPES AND OUTCOMES CARDIOVERSION AND ABLATION JASSIN M. JOURIA Dr. Jassin M. Jouria is a practicing Emergency Medicine physician, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT Atrial arrhythmias are serious disorders that can cause an irregular and/or rapid heartbeat, which can lead to serious clinical sequelae. Atrial fibrillation is an example of an atrial arrhythmia that can lead to blood clots, stroke, or heart failure. Electrical cardioversion and ablation are two procedures that can minimize these risks and treat atrial arrhythmia. Each of these treatments have risks and neither offers a complete success rate, but they can be very effective in providing greater quality of life, and extending the life expectancy of patients. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 2.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 0.5 hours (30 minutes). Statement of Learning Need Cardioversion and cardiac ablation for the treatment of resistant atrial arrhythmia has been analyzed in the medical literature, including benefits and risks. Clinicians need to understand the indications and efficacy of both procedures to treat atrial arrhythmia and to reduce cardiac system burden. Clinical research is growing with evolving recommendations for clinicians managing refractory atrial arrhythmia and to plan cardioversion or catheter ablation. Course Purpose To provide clinicians with knowledge of cardiac atrial arrhythmias and of the treatments of cardioversion and cardiac catheter ablation to reverse symptoms of atrial arrhythmia and potentially adverse outcomes. 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Cardiac ablation generally involves inserting a catheter into the body and threading it through the circulatory system a. to the heart. b. to the lungs. c. to the left or right carotid artery. d. up to the superior vena cava. 2. The tip of the catheter has an electrode that sends radiofrequency energy through the tip of the catheter a. to stimulate the heart. b. to remove scarring that may be causing arrhythmia. c. to break up blood clots. d. to damage the offending tissue. 3. Prior to an ablation procedure, a clinician may schedule a patient for a transesophageal echocardiogram (TEE) to a. determine if catheterization is possible. b. locate a potential blood clot. c. identify scar tissue within the heart. d. locate the source of an arrhythmia. 4. A patient preparing for a cardiac ablation will typically take an anticoagulant, such as _________, because the risk of thrombus can be high. a. warfarin b. clopidogrel c. propofol d. remifentanil 5. Most patients require enough anesthetic to produce ___________ throughout the cardiac ablation procedure. a. general anesthesia b. mild sedation c. conscious sedation d. anxiolysis 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction Cardiac ablation is a treatment option that has been shown to reduce or eliminate cardiac arrhythmias in many cases. Ablation is used for the treatment of tachyarrhythmias, including atrial fibrillation or atrial flutter, as well as some of the other supraventricular tachycardias. The process of ablation alters the heart muscle by removing or destroying specific heart tissue with the goal of preventing the continuation of the arrhythmia. Catheter ablation may be performed by inserting a catheter using an epicardial or endocardial method, or a combination of the two. Catheter ablation types may also be specific to the type of arrhythmia such as with pulmonary vein antrum (PVA) isolation ablation and atrioventricular (AV) node ablation. Overview Of Cardiac Ablation The term ablation is defined as a process of removing or eliminating abnormal tissue that is causing harm. When cardiac ablation is performed, part of the heart muscle tissue is removed or damaged in a method that will affect how the heart beats. Under normal circumstances, myocardial tissue damage might only lead to further health anomalies but when a cardiac arrhythmia is present, the tissue destruction can change the electrical patterns of the heart enough that it returns to a normal rate and rhythm. Overall, cardiac ablation is a mildly invasive procedure that usually involves a rapid recovery period and few adverse effects. Ablation involves inserting a catheter into the body and threading it through the circulatory system to the heart. The most common site of insertion is the femoral vein in the groin, although other areas are also considered, including the subclavian or internal jugular veins. The tip of the catheter has an electrode that targets the 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com affected node or area within the heart that is causing the arrhythmia. Catheter ablation procedures may use radiofrequency energy to damage the tissue; in some cases, cryoablation is performed, which uses cold temperatures to damage the tissue through freezing. Radiofrequency ablation has been in use longer than cryoablation, and although the two techniques use different methods to destroy tissue, they are both still successful in eliminating areas that cause arrhythmias.48-50,55 Ablation Using Radiofrequency Energy With radiofrequency energy, an electrode sends radiofrequency energy through the tip of the catheter to damage the offending heart tissue, heating it to enough intensity that it causes a burn to produce tissue scarring.16 The average amount of energy applied generally ranges from 20 to 50 watts. The clinician controls when to start and stop the procedure and the rate at which energy is delivered. The catheter can be moved and adjusted slightly within the heart’s structure to destroy the tissue in more than one area that is causing problems. Once the tissue has been scarred, the abnormal cells have been destroyed and electrical signals have been interrupted; the heart is able to function normally again.70,71 Cryoablation With cryoablation, tissue is destroyed using cold instead of heat. A cryoballoon is attached to the end of the catheter. Cryoablation works through liquid nitrogen or argon gas that is compressed and transported through the tip of the catheter.79 The temperature of the gas is extremely cold, so that it freezes and destroys the tissue on contact. Cryoablation is beneficial because the clinician is able to damage some of the tissue in the heart first without permanently scarring it. In this method, the 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com electrophysiologist can determine if the identified location is the area causing the arrhythmia. For example, after inserting the catheter, the cryoballoon is positioned near the point where the arrhythmia is supposedly being generated. The clinician applies the cold gas or nitrogen to the tissue to temporarily disable the cells and can determine if this is the precise location that needs to be destroyed. If it is not the correct location, the tissue can be allowed to rewarm after the cold application. If it is indeed the area that needs to be destroyed,
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