How often do you do your AFIB ablations with art line

[coffeebythelake]

I used to do 2x large bore IV and art line. More of an institution thing. The EP cardiologists for the most part are in favor of art lines because they dont need to draw back labs from their sheath. Lately I've been forgoing art lines especially in young and reasonably healthy patients with cases predicted to be short. What's your practice?

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[deleted171991]

No art line, unless I need it for some other reason. One IV/port for the cardiac nurses, one for me (both 20G).

 

[anbuitachi]

I remember there was a thread on this topic not long ago. But generally no a line. Unless they are very sick, same as any other case I guess

 

[deleted162650]

Art lines and GETA for any procedure where they’re crossing the septum. MAC and no art access for procedures that stay on the R-side.

We actually just had a tamponade/code en route from EP to PACU on a pt that was originally just a R-sided ablation but they ended up crossing the septum chasing some other foci. Woulda been nice to have had the a-line in that one.

 

[AdmiralChz]

I remember there was a thread on this topic not long ago. But generally no a line. Unless they are very sick, same as any other case I guess

Yes, there was with literally the same question: alines for ablations

There’s a large variety on how people do them out there. Largely institutional-based.

Some do very few, some put in every time.

 

[Southpaw]

Almost never

 

[MTGas2B]

I think I did, once.

 

[T-burglar]

It’s interesting that we all place arterial lines but not find some way to monitor CVP.

Acute drops in systemic pressure can be from a variety of things in the setting of GETA and a septal crossing. An acute rise in CVP in this setting can really only be one thing unless the patient has a known DVT.

I don’t place central lines but monitoring the CVP makes more sense to me when you’re specifically worried about hemopericardium

 

[deleted171991]

It’s interesting that we all place arterial lines but not find some way to monitor CVP.

Acute drops in systemic pressure can be from a variety of things in the setting of GETA and a septal crossing. An acute rise in CVP in this setting can really only be one thing unless the patient has a known DVT.

I don’t place central lines but monitoring the CVP makes more sense to me when you’re specifically worried about hemopericardium

Hmm, acute rise in CVP, let's see...

From the top of my head:
Increased abdominal pressure
Increased intrathoracic pressure
Failing RV
Increased PAP (hypoxia, hypercarbia, pain, pressors, PE)
Failing LV
Tamponade

 

[T-burglar]

Hmm, acute rise in CVP, let's see...

From the top of my head:
Increased abdominal pressure
Increased intrathoracic pressure
Failing RV
Increased PAP (hypoxia, hypercarbia, pain, pressors, PE)
Failing LV
Tamponade

Only one of those things drives the CVP up to 25 or 30 my man. And that’s tanponade. The rest are small CVP changes. A massive PE or sudden RCA occlusion can do it but in the setting of a septal crossing how likely are those. Critical desaturation can do it especially if the RV is VERY diseased to start but that’s easy enough to rule out.

 

[deleted171991]

Only one of those things drives the CVP up to 25 or 30 my man. And that’s tanponade. The rest are small CVP changes. A massive PE or sudden RCA occlusion can do it but in the setting of a septal crossing how likely are those. Critical desaturation can do it especially if the RV is VERY diseased to start but that’s easy enough to rule out.

If we're speaking about likelihood, there are a limited number of things that can give cardiogenic shock during that procedure (all treated the same way, supportively, until one has a diagnosis). If I had a patient become seriously hypotensive, I wouldn't rely on a CVP, I would want some form of an echo (which is probably easy to get in a cardiac lab) for a definitive diagnosis.

But I am not a cardiac guy, "just an intensivist", and I still have to see one tamponade with these procedures, so I may be wrong. To me, the CVP is an overrated falsely-positive, non-specific POS, and I seldom monitor it for anything, not even for a square-root sign.

Please educate me. I'll appreciate it.

 

[pgg]

We have one cardiologist who will put a femoral a-line in and pass it off for us to transduce. I put a-lines in the rest.

We did have a patient tamponade here a few months ago. It wasn't my case but I'm sure they were glad to have one.

They're convenient for drawing ACT samples. Frequent blood draws is itself an indication for an arterial line. For some reason our cardiologists are reluctant to draw samples off their venous access.

There are some predictably labile portions of these cases, when they goof around with pacing and slam repeated boluses of adenosine in. I think my pre- and intra- and post-event treatment (or nontreatment) are smoother if I have an a-line. I admit the fact that these are predictable events argues against needing an a-line to manage them. And of course, if all you see are q3min NIBP readings of course it's smooth.

The cardiologist is standing right there with surface and intracardiac echo available, and ECG monitoring is about as focused and intense as possible. So I get the argument that they aren't needed.

I still put one in. Easy, low risk, probably some benefit.

 

[Consigliere]

100% of the time per protocol.

 

[T-burglar]

I personally love invasive pressures for operations on the central circulation. Some changes in the RA waveforms that occur are pretty helpful in this specific setting and I’ve argued before complementary to TEE. I do think it’s less useful in the ICU perhaps , unless it’s a CTS ICU.

I am not arguing for placing a line just to monitor this for cardiac caths. I’m just saying that if I had a choice of Arterial line or RAP + NIBP I’d rather have the RAP + NIBP for this specific procedure. You’ll still pick up systemic hypotension from other causes with the cuff but you’ll know immediately if it’s tamponade or if you have to look for something else. Because if pericardial hypertension is bad enough to cause pre arrest systemic hypotension, the CVP will already be strained to the highest degree of compensation (it will be very high like 25 -40)

That’s just how I like to think. If there’s systemic hypotension being able to see the other central pressures is so helpful in my opinion

 

[drmwvr]

As far as tamponade goes,

It’s interesting that we all place arterial lines but not find some way to monitor CVP.

Acute drops in systemic pressure can be from a variety of things in the setting of GETA and a septal crossing. An acute rise in CVP in this setting can really only be one thing unless the patient has a known DVT.

I don’t place central lines but monitoring the CVP makes more sense to me when you’re specifically worried about hemopericardium

I think most places use ICE, don't they? Ours does. Large risk reduction for tamponade and early detection capability to boot. Probably be able to pick it up before intracardiac pressures changes.

 

[Hork Bajir]

For those who want to measure CVP, why not transduce PVP? Easy to do, and even if you're using a small distal PIV, the venous pressure should be no more than 3-5 points higher than your RAP. I'll do it sometimes when I want to check CVP for whatever reason, but don't want to put in a central line. You can either put a stopcock on your drug line and spot-check when you're not giving drugs/fluids, or you can start a small 2nd IV dedicated to this purpose

 

[abolt18]

For those who want to measure CVP, why not transduce PVP? Easy to do, and even if you're using a small distal PIV, the venous pressure should be no more than 3-5 points higher than your RAP. I'll do it sometimes when I want to check CVP for whatever reason, but don't want to put in a central line. You can either put a stopcock on your drug line and spot-check when you're not giving drugs/fluids, or you can start a small 2nd IV dedicated to this purpose

I had never even considered this as a possibility. Thanks for sharing the idea.

 

[drmwvr]

For those who want to measure CVP, why not transduce PVP? Easy to do, and even if you're using a small distal PIV, the venous pressure should be no more than 3-5 points higher than your RAP. I'll do it sometimes when I want to check CVP for whatever reason, but don't want to put in a central line. You can either put a stopcock on your drug line and spot-check when you're not giving drugs/fluids, or you can start a small 2nd IV dedicated to this purpose

If it's that terribly important, why not just transduce off of the 11 fr sheath side arm that is sitting in the proximal IVC? But drawing attention to the anesthetic with low yield/hi novelty maneuvers just makes everyone else wonder why you're the only one that does that stuff.

 

[T-burglar]

If it's that terribly important, why not just transduce off of the 11 fr sheath side arm that is sitting in the proximal IVC? But drawing attention to the anesthetic with low yield/hi novelty maneuvers just makes everyone else wonder why you're the only one that does that stuff.

Right. Which is why I don’t do things like this. But theoretically if you’re placing a monitoring line specifically to watch for tamponade (which is the primary diagnosis you’re fishing for when placing invasive monitoring in the cath lab for septal crossing) then CVP is more specific. Not many other complications will drive the CVP up that high. Other things can happen of course like iliofemoral hemorrhage or RP hemorrhage but this will also be suggested by a low CVP and low systemic pressure.

I’m just providing food for thought. Again, I don’t place lines for monitoring CVP in cardiac cath cases but if you think about it you might agree that it makes more sense

 

[Ronin786]

For those who want to measure CVP, why not transduce PVP? Easy to do, and even if you're using a small distal PIV, the venous pressure should be no more than 3-5 points higher than your RAP. I'll do it sometimes when I want to check CVP for whatever reason, but don't want to put in a central line. You can either put a stopcock on your drug line and spot-check when you're not giving drugs/fluids, or you can start a small 2nd IV dedicated to this purpose

I guess if you're looking for useless numbers that should never guide any sort of management then this has the same utility as CVP.

 

[T-burglar]

too many people read articles online from "reputable" journals and "authorities" dismissing the utility of central pressure measurements. Ask yourself why cardiologists are still bothering with right and left heart caths in the TEE era.

 

[sethco]

too many people read articles online from "reputable" journals and "authorities" dismissing the utility of central pressure measurements. Ask yourself why cardiologists are still bothering with right and left heart caths in the TEE era.

Because they suck at doing TEE?

 

[vector2]

too many people read articles online from "reputable" journals and "authorities" dismissing the utility of central pressure measurements. Ask yourself why cardiologists are still bothering with right and left heart caths in the TEE era.

Woah woah woah, that's not really a fair analogy. RH caths give information about PVR, transpulmonary gradient, pulmonary vasodilator reactivity for pHTN, qp/qs for shunts etc that would be unobtainable otherwise. That's all far different than a spot CVP reading. LHC (other than the obvious angiographic benefit) is still the gold standard for LVEDP measurement and mitral/aortic valve stenosis gradients and it has its place when echo isn't conclusive.

 

[Ronin786]

too many people read articles online from "reputable" journals and "authorities" dismissing the utility of central pressure measurements. Ask yourself why cardiologists are still bothering with right and left heart caths in the TEE era.

Why don't you just look at the JVD under the drapes? Assuming we're doing the cardiologist way...


You shouldn't need a CVP of 30 to inform you that your patient had a tamponade in Cath lab. Not with the large amount of other, more accurate markers available to you. The issue isn't in diagnosing the tamponade, it's resuscitating afterwards, hence the benefit of an a-line. By your logic, you might as well just look for pulsus on your a-line as opposed to waiting on your CVP to climb.

 

[deleted171991]

too many people read articles online from "reputable" journals and "authorities" dismissing the utility of central pressure measurements. Ask yourself why cardiologists are still bothering with right and left heart caths in the TEE era.

Oh, boy! 100, 99, 98, 97... (no, I am not trying to go to sleep)...

As @vector2 said, a cath gives one much more directly-measured information. But let's just start from science (and logic, though the latter is not tested on the MCAT).

The only thing a CVP monitor tells us is... the CVP. Meaning the pressure wherever the heck its tip is. Nothing more, nothing less. That pressure depends on multiple in(ter)dependent factors at various time points in the cardiac cycle. It also depends quite a lot on the respiratory cycle and intrathoracic pressures (hence we are supposed to measure CVP at end-expiration), the latter also being influenced by the intraabdominal pressure, which also influences venous return (along many other things), which is a big part of CVP. I've only started talking about the MANY factors that influence the CVP, but you get my gist.

Now for the waveform, meaning the pressure plotted against time. THAT actually makes more sense. It can be suggestive of various pathologies, in the hands of an expert. Except that, as I said, I still have to meet such an expert.

I can accept that the tamponade waveform and CVP values, especially in the right context, can be suggestive. And I am sure that there may be 2-3 other pathologies where the CVP can be useful in a certain context. But that's where the diagnostic value of pressure monitoring ends, generally, not only in the sinus venosus but anywhere in the body. It's a very non-sensitive and quite non-specific science.

P.S.
FYI, the CVP is DEAD in the modern ICU (e.g., for fluid resuscitation, a toin coss may be better than monitoring the CVP). And that comes from the truly reputable journals and authorities.

 

[T-burglar]

Woah woah woah, that's not really a fair analogy. RH caths give information about PVR, transpulmonary gradient, pulmonary vasodilator reactivity for pHTN, qp/qs for shunts etc that would be unobtainable otherwise. That's all far different than a spot CVP reading. LHC (other than the obvious angiographic benefit) is still the gold standard for LVEDP measurement and mitral/aortic valve stenosis gradients and it has its place when echo isn't conclusive.

I wasn’t making an analogy I was pointing to their continued use in cardiology because they aren’t useless (which is the claim that I’m seeing in this thread)

Don’t forget to mention that RA waves and pressures are part of the work up for cases of pericardial disease like effusive constriction vs. plain constriction vs. restriction.

You’re all free to disagree with me. I’m just a CT dude that likes his cath data and I’m just trying to generate discussion. Anesthesiologists always have grand mal seizures when anyone suggests that a Central venous pressures are cool or PA caths are cool.

 

[deleted171991]

I wasn’t making an analogy I was pointing to their continued use in cardiology because they aren’t useless (which is the claim that I’m seeing in this thread)

Don’t forget to mention that RA waves and pressures are part of the work up for cases of pericardial disease like effusive constriction vs. plain constriction vs. restriction.

You’re all free to disagree with me. I’m just a CT dude that likes his cath data and I’m just trying to generate discussion. Anesthesiologists always have grand mal seizures when anyone suggests that a Central venous pressures are cool or PA caths are cool.

I am just an ICU dude, and I thank you for your part in this discussion.

Of course cath pressures are significant in pericardial or restrictive disease. They are easy to obtain and accurate (the data is measured directly, not derived), the same way the PAC is excellent for diagnosis of PHTN and a central venous line for measuring the CVP. And, of course, when one sees a pressure map of the entire heart, one can easily conclude about the type of disease. Same as with O2 sats and shunts.

Extrapolating from the CVP and its waveform is like extrapolating from the A-line (NIBP plus waveform) regarding the cause of a hypotension. And while both types of waveforms can be sometimes suggestive of pathologies, neither of them is either sensitive or specific enough. But I do see the value of central venous waveforms, if the patient already has a CVC in place.

 

[Twiggidy]

We're dancing around a topic that has a definite answer.....

Any abrupt pressure drop, then stick in the TEE probe and look at the heart. Better yet, be a doctor and put the S5-1 probe on the chest and show them the reason why you should be in the room and not someone else. CVP for an A-fib ablation is overkill when the diagnosis can be made in literal seconds.

 

[cchoukal]

I would not agree that just because a cardiologist "uses a CVP" does not mean that the literature on whether CVP predicts volume responsiveness (which is extensive and high quality, BTW) is somehow wrong. I've seen cardiologists look at the jugular venous distention when a central line is in place, for god's sake, so just because they do something doesn't mean it makes sense.

 

[vector2]

I wasn’t making an analogy I was pointing to their continued use in cardiology because they aren’t useless (which is the claim that I’m seeing in this thread)

Don’t forget to mention that RA waves and pressures are part of the work up for cases of pericardial disease like effusive constriction vs. plain constriction vs. restriction.

You’re all free to disagree with me. I’m just a CT dude that likes his cath data and I’m just trying to generate discussion. Anesthesiologists always have grand mal seizures when anyone suggests that a Central venous pressures are cool or PA caths are cool.

I don't know if analogy was the right word, but you made a jump from ppl disparaging the use of CVP in afib ablations to cardiologists still using RHC/LHC instead of non-invasive imaging. Whatever the word is, I don't think it's a fair comparison for obvious reasons.

And don't get me wrong, I'm CCM trained and a PTE testamur doing a fair number of hearts and a little bit of SICU here and there. I honestly don't mind mind having a PAC for every pump case because I think there is a plethora of valuable data to be had. Hell it's usually the highlight of my day if a patient has severe TR or something and the resident is able to identify a V-wave before I put the probe in. In the unit, I think PACs are criminally underused in patients with mixed etiology shock. Even though CCO/SVO2 swans have their own accuracy/precision issues, they're still the gold standard for hemodynamics in the ICU compared to all the NICOMs, flotracs, picco, lidco, blah blah.

I think we can all agree that CVP and PAC data is cool. The question is whether placing a central line (or monitoring a PVP) is necessary for an afib ablation, esp when so many cathlabs have ICE, or as twiggidy pointed out, a TTE machine sitting in the hallway. Not to mention, how many of us are really that good at CVP waveform analysis? Even if you know the common pathologic waveforms, the monitor is usually wayyy lower res and has a faster sweep than the illustrative images. Not to mention, most of the times I've taken folks to the OR for a pericardial window, they don't have a CVP in so I rarely get to see what tamponade waveforms look like except for the very rare bringback with post-pump bleeding...

 

[T-burglar]

I don't know if analogy was the right word, but you made a jump from ppl disparaging the use of CVP in afib ablations to cardiologists still using RHC/LHC instead of non-invasive imaging. Whatever the word is, I don't think it's a fair comparison for obvious reasons.

And don't get me wrong, I'm CCM trained and a PTE testamur doing a fair number of hearts and a little bit of SICU here and there. I honestly don't mind mind having a PAC for every pump case because I think there is a plethora of valuable data to be had. Hell it's usually the highlight of my day if a patient has severe TR or something and the resident is able to identify a V-wave before I put the probe in. In the unit, I think PACs are criminally underused in patients with mixed etiology shock. Even though CCO/SVO2 swans have their own accuracy/precision issues, they're still the gold standard for hemodynamics in the ICU compared to all the NICOMs, flotracs, picco, lidco, blah blah.

I think we can all agree that CVP and PAC data is cool. The question is whether placing a central line (or monitoring a PVP) is necessary for an afib ablation, esp when so many cathlabs have ICE, or as twiggidy pointed out, a TTE machine sitting in the hallway. Not to mention, how many of us are really that good at CVP waveform analysis? Even if you know the common pathologic waveforms, the monitor is usually wayyy lower res and has a faster sweep than the illustrative images. Not to mention, most of the times I've taken folks to the OR for a pericardial window, they don't have a CVP in so I rarely get to see what tamponade waveforms look like except for the very rare bringback with post-pump bleeding...

I don't disagree with any of this really. Except i maintain that the point i was trying to make is cardiologists haven't thrown out caths because they are still very useful. And they are useful to them for all the same reasons they are useful to any anesthesiologist investigating hemodynamics , whether its an acute instability or to whack out a valve. Have you ever had a surgeon ask you on the spot whether you think the patient has restrictive cardiomyopathy or if you think the patient has pericardial constriction? I have.

Sure if you have ICE or a TTE/TEE right there, then hypotension can just as quickly be diagnosed as tamponade or something else. I'm not debating that. I was simply offering up the idea that in this specific case, hypotension can be a lot of things, but a very high CVP can only be one thing. So in a different dimension the doctors might be monitoring that instead. And, once again, I never suggested actually placing a line to monitor CVP in trans septal cath lab cases in this thread, because that would make you a weirdo in your group.

I think its a shame that some centers have decided PA catheters have no use in the TEE era in cardiac cases (and I'm a TEE/TTE zealot)

 

[drmwvr]

I don't disagree with any of this really. Except i maintain that the point i was trying to make is cardiologists haven't thrown out caths because they are still very useful. And they are useful to them for all the same reasons they are useful to any anesthesiologist investigating hemodynamics , whether its an acute instability or to whack out a valve. Have you ever had a surgeon ask you on the spot whether you think the patient has restrictive cardiomyopathy or if you think the patient has pericardial constriction? I have.

Sure if you have ICE or a TTE/TEE right there, then hypotension can just as quickly be diagnosed as tamponade or something else. I'm not debating that. I was simply offering up the idea that in this specific case, hypotension can be a lot of things, but a very high CVP can only be one thing. So in a different dimension the doctors might be monitoring that instead. And, once again, I never suggested actually placing a line to monitor CVP in trans septal cath lab cases in this thread, because that would make you a weirdo in your group.

I think its a shame that some centers have decided PA catheters have no use in the TEE era in cardiac cases (and I'm a TEE/TTE zealot)

The global utility of CVP aside, as far as cardiac surgery goes, a multi-lumen central catheter is standard. And monitoring the distal port gives what is basically an RAP. So using that pressure relative to what the MAP is doing to contribute to the over all context of the ICU course is pretty reasonable, I think. The quickest way to pick up an evolving tamponade. I wouldn't say "CVP" is dead just yet...

 

[vector2]

I don't disagree with any of this really. Except i maintain that the point i was trying to make is cardiologists haven't thrown out caths because they are still very useful. And they are useful to them for all the same reasons they are useful to any anesthesiologist investigating hemodynamics , whether its an acute instability or to whack out a valve. Have you ever had a surgeon ask you on the spot whether you think the patient has restrictive cardiomyopathy or if you think the patient has pericardial constriction? I have.

You wont find me disagreeing, cath data is useful for anesthesiologists when in the right hands.

As far as a surgeon asking you on the spot (in a presumably anesthetized pt) to differentiate RICM vs CP, all I can say is that that patient has gotten totally inappropriate care up to that point if the diagnosis is coming down to you at that moment. Suspected RICM vs CP should be thoroughly evaluated preop by HF cards and a trained imaging cardiologist who's going to get a BNP, do a full 2d exam with doppler and strain, and get cardiac MR, biopsy, RHC/LHC if necessary. Even still, if I were in that position I would be relying more on 2d appearance and doppler/tissue doppler data vs trying to tease out an M or W configuration on the CVP.

Sure if you have ICE or a TTE/TEE right there, then hypotension can just as quickly be diagnosed as tamponade or something else. I'm not debating that. I was simply offering up the idea that in this specific case, hypotension can be a lot of things, but a very high CVP can only be one thing. So in a different dimension the doctors might be monitoring that instead. And, once again, I never suggested actually placing a line to monitor CVP in trans septal cath lab cases in this thread, because that would make you a weirdo in your group.

Agreed, I think a rocketing up CVP would be pretty specific in this situation, but in any case, whether it be sudden hypotension on the a-line or high CVP, the echo is going to be the first thing everyone jumps to for confirmation. Hell, theres a better argument for having a TEE in for ablations rather than an a-line or CVP if it weren't for the sometimes frequent blood draws.

 

[deleted171991]

Every piece of data can be useful in the right hands, and can cause problems in the wrong ones.

I find that the CVP (and even the PAC) falls in the latter category, because too many people think in cookbook recipes, not in physiologic phenomena. If they were thinking physiologically, they would understand the tremendous limitations such a monitor has. (Most people don't know even the limitations of PP variability on the the A-line tracing.)