Tuesday, November 10, 2009

Where Treatment Guidelines Fall Flat

... when cases don't follow the rule book:
All of the planned means of tackling Stellan's SVT today during his ablation failed initially. Heart block was induced each and every time from each and every angle they tried to ablate. Dr. A and his team were left with little choice but to ablate Stellan's AV node in order to get rid of his accessory pathway. But before they did, one of Dr. A's colleagues threw out a wild idea.

"Let's try to go through his aorta."

Not in the plan. Not even in the possible or hypothetical plans. Not considered safe or feasible or wise on a 10 kilo baby. But with few options left before destroying Stellan's node, they decided to risk it.

To be honest, I'm glad I didn't know about it at the time.

So from his groin, they threaded the catheter up into his aorta, down into his atrium and through his valve toward his ventricle. From that angle, even though Dr. A said they were in the exact same spot as they'd tried ablating earlier, there was a money shot. He tried cryoablation. It started to zap his SVT with no heart block. So he tried a little more cryo. Again, no heart block.

So Dr. A pulled out the big dog. The radio frequency ablation catheter. His ultimate goal was to get 2 to 3 seconds of ablating done, even if it destroyed his node.

1 second. 2 seconds. 3, 4, 5.

From that angle, through the aorta, Stellan's AV node remained untouched.

Unbelievably, Dr. A was able to crank up the wattage and ablate Stellan's extra pathway for one solid minute before declaring his pathway dead on arrival.

And his AV node is as happy as the day is long.
Certainly this case didn't "Get With the Guidelines" and might not be the approach most would take in this circumstance. Huge risk was involved for the pediatric electrophysiologist: a higher incidence of stroke for the child, unknown long-term affects to the aorta, a potential to injure the coronary arteries, and a large risk to one's professional career if anything went wrong.

At yet, the doctor considered all other options and did what he thought was best for the child given the circumstances...

... then hit a home run.

And judging by the picture of the child in the referenced blog's sidebar, it looks like the doctor did a pretty fine job.


h/t: A faithful reader.

1 comment:

Anonymous said...

or you could have concluded your blog

At yet, the doctor considered all other options and did what he thought was best for the child given the circumstances...

...and got very luck that God was able to engineer a system that overcame his cowboy-like actions.