ABSTRACT
BACKGROUND: Slow pathway elimination of the atrioventricular node (AVN) is essential to treat AVN reentrant tachycardia (AVNRT). However, injury to the AVN conduction (IAVN) is one of the serious complications. Cryofreezing energy is expected to reduce the incidence of IAVN. This study aimed to investigate the usefulness of a novel method to avoid IAVN during cryoablation of AVNRT. METHODS: A total of 157 patients (average age, 65.8â¯years; male, 71) suffering from AVNRT were included. Once the AVNRT terminated during cryo-ablation, then rapid atrial constant pacing (RACP) was performed during freezing at a rate lower 10â¯bpm than that inducing Wenchebach AV block in 74 (47.1â¯%) patients (Group A). The RACP rate was decreasingly reduced by 10â¯bpm in case of the occurrence of IAVN. When the RACP reached 100â¯bpm, the cryoablation was prematurely terminated. Group B patients (83â¯=â¯52.9â¯%) underwent cryoablation during sinus rhythm. All patients were allocated in a randomized fashion. We compared the severity of the IAVN between Groups A and B. RESULTS: There were no significant differences at 12â¯months regarding the freedom from the AVNRT between Groups A and B. However, the duration of the IAVN was significantly longer in Group B than A (pâ¯=â¯0.02). There were no significant differences regarding the distance between the His recording sites and successful ablation sites between Groups A and B. No permanent IAVN requiring pacemaker implantation was provoked in either group. CONCLUSION: RACP was useful to avoid sustained and serious IAVN during cryoablation of AVNRT.
Subject(s)
Atrioventricular Block , Catheter Ablation , Tachycardia, Atrioventricular Nodal Reentry , Humans , Male , Aged , Atrioventricular Node/surgery , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/surgery , Heart Rate , Atrioventricular Block/etiology , Atrioventricular Block/therapy , Catheter Ablation/methods , Treatment OutcomeSubject(s)
Catheter Ablation , Persistent Left Superior Vena Cava , Tachycardia, Atrioventricular Nodal Reentry , Humans , Tachycardia, Atrioventricular Nodal Reentry/surgery , Tachycardia, Atrioventricular Nodal Reentry/etiology , Persistent Left Superior Vena Cava/complications , Persistent Left Superior Vena Cava/surgery , Vena Cava, Superior/surgeryABSTRACT
PURPOSE: Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. METHODS: In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. RESULTS: Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. CONCLUSIONS: ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
Subject(s)
Catheter Ablation , Tachycardia, Atrioventricular Nodal Reentry , Catheter Ablation/methods , Echocardiography , Electrophysiologic Techniques, Cardiac , Fluoroscopy/methods , Humans , Tachycardia, Atrioventricular Nodal Reentry/diagnostic imaging , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/surgery , Treatment OutcomeABSTRACT
Atrioventricular (AV) nodal reentrant tachycardia represents the most common regular supraventricular arrhythmia in humans, and catheter ablation of the so called slow AV nodal pathway has been effectively performed for decades. In patients with congenital heart disease, a combination of different factors makes catheter ablation of AV nodal reentrant tachycardia substrate particularly challenging, including abnormal venous access to intracardiac structures, abnormal intracardiac anatomy, potentially deviant and often unpredictable sites of the specific conduction system, loss of traditional anatomic landmarks, and congenital cardiac surgery that may complicate the access to the AV nodal area. Published experiences have confirmed the efficacy and the relative safety of such procedures when performed by experts, but the risk of complications, in particular AV block, remains non-negligible. A thorough knowledge and understanding of anatomic and electrical specificities according to underlying phenotype are essential in addressing these complex cases. Considering the major consequences associated with AV block in patients with complex congenital heart disease, particularly those without low risk access for transvenous ventricular pacing (eg, single ventricle physiology or Eisenmenger syndrome), the individual risk-benefit ratio should be carefully evaluated. The decision to defer ablation may be the wisest approach in selected patients with either infrequent or hemodynamically tolerated arrhythmias, or when the location of the AV conduction pathways remains uncertain. This narrative review aims to synthetize existing literature on catheter ablation of AV nodal reentrant tachycardia in congenital heart disease, to present main features of common associated pathologies, and to discuss approaches to mapping and safely ablating the slow AV nodal pathway in challenging cases.
Subject(s)
Atrioventricular Node/surgery , Catheter Ablation , Cryosurgery , Heart Defects, Congenital/complications , Tachycardia, Atrioventricular Nodal Reentry/surgery , Action Potentials , Atrioventricular Node/physiopathology , Catheter Ablation/adverse effects , Clinical Decision-Making , Cryosurgery/adverse effects , Heart Defects, Congenital/diagnosis , Heart Defects, Congenital/physiopathology , Heart Rate , Humans , Postoperative Complications , Risk Assessment , Risk Factors , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Treatment OutcomeABSTRACT
[Figure: see text].
Subject(s)
Catheter Ablation/methods , Electrocardiography , Heart Defects, Congenital/complications , Tachycardia, Atrioventricular Nodal Reentry/surgery , Adult , Cardiac Surgical Procedures , Europe/epidemiology , Female , Follow-Up Studies , Heart Defects, Congenital/physiopathology , Heart Defects, Congenital/surgery , Humans , Male , Middle Aged , Survival Rate/trends , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/mortality , Time Factors , Treatment OutcomeSubject(s)
Atrial Fibrillation/therapy , Electrocardiography , Heart Atria/physiopathology , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Aged , Atrial Fibrillation/diagnosis , Cardiac Pacing, Artificial/adverse effects , Diagnosis, Differential , Humans , Male , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/physiopathologyABSTRACT
BACKGROUND: While outcomes of intra-atrial reentrant/focal atrial tachycardia (IART/FAT) catheter ablation have considerably improved in adult congenital heart disease (ACHD), recurrences remain common with different circuits frequently encountered. OBJECTIVE: We aimed to assess the value of programmed atrial stimulation after successful clinical IART/FAT catheter ablation in patients with ACHD. METHODS: This is a retrospective study including all patients with ACHD undergoing IART/FAT catheter ablation in a tertiary center. After successful catheter ablation of clinical arrhythmia, survival free from arrhythmia recurrence was analyzed according to whether all inducible IARTs/FATs were targeted. RESULTS: From 2004 to 2020, 238 IART/FAT catheter ablation procedures were performed (mean age 44.1 ± 15.0 years; 61.3% men). Acute procedural success of clinical arrhythmia was achieved in 208 procedures (87.4%). Among 122 procedures with programmed atrial stimulation (58.7%), at least 1 other IART/FAT was induced in 61 patients (50%). All inducible IARTs/FATs were ablated in 54 patients (88.5%), whereas 7 patients (11.5%) presented with at least 1 nontargeted inducible IART/FAT. Patients with nontargeted inducible IART/FAT had a higher risk of atrial arrhythmia episodes than did inducible patients treated with ablation of all IARTs/FATs (hazard ratio 5.7; 95% confidence interval 1.7-18.4; P = .004), with 12-month atrial arrhythmias recurrence rates of 22.9% and 77.7%, respectively. Inducible patients with successful ablation of all IARTs/FATs had a risk of recurrence similar to that of noninducible patients (hazard ratio 0.6; 95% confidence interval 0.3-1.3; P = .215). CONCLUSION: Beyond clinical IART/FAT catheter ablation in patients with ACHD, our findings suggest the interest of systematically targeting all remaining inducible arrhythmias, irrespective of whether previously documented.
Subject(s)
Catheter Ablation/methods , Electrocardiography , Heart Atria/physiopathology , Heart Defects, Congenital/complications , Tachycardia, Atrioventricular Nodal Reentry/surgery , Adult , Female , Follow-Up Studies , Heart Defects, Congenital/physiopathology , Humans , Male , Middle Aged , Recurrence , Retrospective Studies , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/physiopathologyABSTRACT
AIMS: We used a new grid-style multi-electrode mapping catheter (Advisor™ HD Grid, Abbott) and investigated its use for high density mapping of atrial tachycardias in adult patients with congenital heart disease. PATIENTS AND METHODS: All patients with congenital heart disease who had mapping of atrial tachycardias using the new grid-style catheter between March 2018 and April 2019 were included. RESULTS: A total of 24 adult patients had high density mapping of atrial tachycardias using the grid-style multi-electrode catheter. Mean procedure duration was 207 ± 72 min., mean fluoroscopy time was 7.1 ± 7.9 min. In patients with right atrial substrates, fluoroscopy time was shorter compared to biatrial or left atrial substrates (0.9 ± 2.2 min for right atrial substrates, n = 19 vs. 6.3 ± 8.3 min for left atrial substrates, n = 2 and 7.5 ± 4.3 min for biatrial substrates, n = 3, p = 0.01). A mean number of 14.814 ± 10.140 endocardial points were collected and 2.319 ± 1244 points were finally used to characterize the tachycardia. Procedural success was achieved in 21/24 (88%) subjects and partial success in 2/24 (8%) patients. Recurrence rate was low (12.5%). In one patient, radiofrequency ablation within the cavotricuspid isthmus resulted in occlusion of a branch of the right coronary artery. No complications related to the use of the mapping catheter itself occurred. CONCLUSION: High density mapping of AT using the grid-style catheter showed promising results with respect to procedural and midterm outcome and fluoroscopy time. Using the grid-style catheter might offer advantages compared to other multi-electrode catheters used for high density mapping of AT in patients with CHD.
Subject(s)
Body Surface Potential Mapping/methods , Catheter Ablation/methods , Heart Atria/physiopathology , Heart Defects, Congenital/complications , Heart Rate/physiology , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Tachycardia, Atrioventricular Nodal Reentry/etiology , Adult , Female , Follow-Up Studies , Heart Defects, Congenital/diagnosis , Heart Defects, Congenital/physiopathology , Humans , Male , Recurrence , Retrospective Studies , Tachycardia, Atrioventricular Nodal Reentry/surgery , Treatment OutcomeSubject(s)
Atrioventricular Block/complications , Atrioventricular Node/injuries , Cardiac Surgical Procedures/adverse effects , Electrocardiography , Postoperative Complications , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Paroxysmal/etiology , Atrioventricular Block/physiopathology , Atrioventricular Node/physiopathology , Catheter Ablation/methods , Heart Defects, Congenital/surgery , Humans , Iatrogenic Disease , Infant , Male , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Tachycardia, Atrioventricular Nodal Reentry/surgery , Tachycardia, Paroxysmal/physiopathology , Tachycardia, Paroxysmal/surgerySubject(s)
Atrioventricular Node/physiopathology , Dextrocardia/complications , Heart Rate , Tachycardia, Atrioventricular Nodal Reentry/etiology , Action Potentials , Adult , Dextrocardia/diagnostic imaging , Electrocardiography , Humans , Male , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Time FactorsABSTRACT
BACKGROUND: Catheter ablation is commonly performed to treat atrial arrhythmias in adult congenital heart disease (ACHD). Despite the frequency of ablations in the ACHD population, predictors of recurrence remain poorly defined. OBJECTIVE: We sought to determine predictors of arrhythmia recurrence in ACHD patients following catheter ablation for atrial arrhythmias. METHODS: We performed a retrospective study of all catheter ablations for atrial arrhythmias performed in ACHD patients between January 12, 2005 and February 11, 2015 at our institution. Prespecified exposures of interest and time from ablation to recurrence were determined via chart review. RESULTS: Among 124 patients (mean age: 45 years) who underwent catheter ablation, 96 (77%) were treated for macro-reentrant atrial tachycardia, 10 (7%) for focal atrial tachycardia, 9 (7%) for atrial fibrillation, 7 (6%) for atrioventricular nodal reentrant tachycardia, and 2 (2%) for atrioventricular reentrant tachycardia. 15 (12%) required transseptal/transbaffle puncture. Fifty-one percent of patients recurred with a median time to recurrence of 1639 days. By univariate and multivariable analysis, body mass index (BMI) and Fontan status were the only variables associated with recurrence. Dose-dependent effect was observed with overweight (HR = 2.37, P = .012), obese (HR = 2.67, P = .009), and morbidly obese (HR = 4.23, P = .003) patients demonstrating an increasing risk for arrhythmia recurrence postablation. There was no significant different in recurrence rates by gender, age, non-Fontan diagnosis, or need for transseptal puncture. CONCLUSIONS: In our cohort of ACHD patients, BMI was a significant risk factor for arrhythmia recurrence postablation, independent of Fontan status. These findings may help guide treatment decisions for persistent arrhythmias in the ACHD population.
Subject(s)
Catheter Ablation/methods , Heart Atria/physiopathology , Heart Defects, Congenital/complications , Tachycardia, Atrioventricular Nodal Reentry/epidemiology , Adult , Electrocardiography, Ambulatory , Female , Follow-Up Studies , Heart Atria/diagnostic imaging , Humans , Incidence , Male , Middle Aged , New York/epidemiology , Postoperative Period , Predictive Value of Tests , Recurrence , Retrospective Studies , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Time FactorsABSTRACT
OBJECTIVES: This study sought to describe atrial arrhythmia mechanisms, acute outcomes, and long-term arrhythmia burdens following catheter ablation in adult atriopulmonary (AP) Fontan patients. BACKGROUND: Atrial arrhythmias are a significant cause of morbidity and mortality in the AP Fontan population. METHODS: Sixty consecutive atrial arrhythmia ablations were reviewed in 42 AP Fontan patients (31 ± 8 years of age), performed between 1998 and 2017. The number of induced and ablated tachycardias was recorded for each case, as well as the ability to ablate the suspected clinical tachycardia. Longer-term arrhythmia burden was assessed by using a 12-point clinical arrhythmia severity score. RESULTS: Intra-atrial re-entrant tachycardia (IART) was induced in 93% of cases (n = 56), atrioventricular re-entrant tachycardia in 2 (3%) and atrioventricular nodal re-entrant tachycardia in a single case. The mean number of tachycardias induced per case was 2.3. The critical isthmus for IART was mapped to the lateral (n = 10), inferolateral (n = 8), posterior/posterolateral (n = 16), or septal (n = 10) systemic venous atrium, or to the pulmonary venous atrium (n = 4). Ablation of all inducible tachycardias was achieved in 62%, ablation of at least one (but not all) inducible tachycardias in 25%, with failure to ablate any tachycardias in 13%. The suspected clinical arrhythmia was ablated in 50 cases (83%). Catheter ablation resulted in a significant reduction in arrhythmia score at 3 to 6, 12, and 24 months, irrespective of whether all inducible tachycardias were ablated, or the suspected clinical arrhythmia only. Twelve patients (29%) underwent at least one repeat ablation procedure, with a mean time between ablations of 2.7 ± 3.0 years. There were no cases of periprocedural death, stroke or cardiac tamponade. CONCLUSIONS: Catheter ablation can be a safe and effective intervention that will significantly reduce arrhythmia burden in the AP Fontan patient.
Subject(s)
Catheter Ablation , Fontan Procedure/adverse effects , Tachycardia, Atrioventricular Nodal Reentry , Adolescent , Adult , Child , Heart Defects, Congenital/surgery , Humans , Middle Aged , Postoperative Complications/physiopathology , Postoperative Complications/surgery , Retrospective Studies , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Tachycardia, Atrioventricular Nodal Reentry/surgery , Young AdultABSTRACT
PURPOSE: This study aimed to determine the incidence, prevalence, and predictors of atrial arrhythmias (AAs) in patients with symptomatic sinus node dysfunction (SND) who required permanent pacemaker implantation. Also, we evaluated the impact of atrial pacing (AP) on AAs. METHODS: All consecutive patients who underwent pacemaker implantation from 2005 to 2011 were included. Atrial fibrillation (AF), atrial flutter (AFL), atrial tachycardia (AT), and AV nodal reentrant tachycardia (AVNRT) were detected via pacemaker interrogation and clinical documentation. RESULTS: The study group included 322 patients (44% male) with mean age 68.8 ± 15 years and followed for an average of 5.6 ± 2.2 years (median 5.7 years). Overall, 61.8% were found to have any AA at follow-up. Individual prevalence of AAs was high as follows: AF 43.5%, AFL 6.5%, AT 25%, and AVNRT 6.8%. AF was documented in 23% of patients (n = 74) prior to pacemaker; among those, 15% (n = 11) had no recurrence of AF with average AP of 74%. The incidence of new-onset AF after pacemaker was 15.8%. In subgroup analysis, prevalence of AF was increased by 16% with high rate of AP (81-100%) and 17% with lower rate of AP (0-20%). Incidence of new-onset AF was not affected by AP. Diabetes, hypertension, and left atrial enlargement were predictors of AAs. White men and women had higher prevalence of AF. CONCLUSIONS: AAs are highly prevalent in SND, particularly in white patients. Paroxysmal AF is suppressed with AP in minority, but there is no impact of AP on new-onset AF. Patients with diabetes, hypertension, and dilated atria must be monitored closely for early detection of AAs.
Subject(s)
Sick Sinus Syndrome , Aged , Aged, 80 and over , Atrial Fibrillation/diagnosis , Atrial Fibrillation/epidemiology , Atrial Fibrillation/etiology , Atrial Flutter/diagnosis , Atrial Flutter/epidemiology , Atrial Flutter/etiology , Cardiac Pacing, Artificial/adverse effects , Cardiac Pacing, Artificial/methods , Electrocardiography/methods , Female , Humans , Incidence , Male , Middle Aged , Pacemaker, Artificial , Prevalence , Recurrence , Risk Factors , Sick Sinus Syndrome/complications , Sick Sinus Syndrome/diagnosis , Sick Sinus Syndrome/physiopathology , Sick Sinus Syndrome/therapy , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Tachycardia, Atrioventricular Nodal Reentry/epidemiology , Tachycardia, Atrioventricular Nodal Reentry/etiology , United States/epidemiologySubject(s)
Electrocardiography , Heart Conduction System/physiopathology , Heart Defects, Congenital/complications , Tachycardia, Atrioventricular Nodal Reentry/etiology , Electric Countershock/methods , Heart Defects, Congenital/physiopathology , Humans , Male , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Tachycardia, Atrioventricular Nodal Reentry/therapy , Young AdultABSTRACT
BACKGROUND: Right atrial (RA) dual-loop reentrant tachycardia has been described in patients who have undergone open heart surgery. However, the prevalence, electrophysiological (EP) substrate, and ablation outcomes have been poorly characterized. OBJECTIVE: The purpose of this study was to investigate the prevalence, EP substrate, and ablation outcomes for RA dual-loop reentrant tachycardia after cardiac surgery. METHODS: We identified all patients with atrial tachycardia (AT) after cardiac surgery. We compared EP findings and outcomes of those with RA dual-loop reentrant tachycardia to a control group of patients with RA macroreentrant arrhythmias in the setting of linear RA free-wall (FW) scar. RESULTS: Of the 127 patients with 152 postsurgical ATs, 28 of the ATs (18.4%) had RA dual-loop reentry and 24 of 28 (85.7%) had tricuspid annular reentry combined with FW incisional reentry. An incision length >51.5 mm along the FW predicted the substrate for a second loop. In 22 of 23 patients (95.7%) with initial ablation in the cavotricuspid isthmus, a change in the interval between Halod to CSp could be recorded, and 15 of 23 patients (65.2%) had coronary sinus activation pattern change. Complete success was achieved in 25 of 28 patients (89.3%) in the dual-loop reentry group and in 64 of 69 patients (92.8%) in the control group. After mean follow-up of 33.9 ± 24.2 months, 24 of 28 patients (85.7%) and 60 of 69 patients (86.95%) were free of arrhythmias after the initial procedure in the 2 groups, respectively. CONCLUSION: The prevalence of RA dual-loop reentry is 18.4% of ATs with prior atriotomy scar. A long incision should alert physicians to the possibility of a second loop at the FW. Halo and coronary sinus activation patterns provide important clues to circuit transformation.
Subject(s)
Cardiac Surgical Procedures/adverse effects , Catheter Ablation/methods , Electrophysiologic Techniques, Cardiac/methods , Heart Conduction System/physiopathology , Postoperative Complications , Tachycardia, Atrioventricular Nodal Reentry/epidemiology , Adult , China/epidemiology , Female , Heart Conduction System/surgery , Humans , Male , Middle Aged , Prevalence , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/surgery , Treatment OutcomeSubject(s)
Accessory Atrioventricular Bundle , Bundle-Branch Block/diagnosis , Ebstein Anomaly/complications , Electrocardiography , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Tachycardia, Ventricular/diagnosis , Ablation Techniques , Action Potentials , Bundle-Branch Block/etiology , Bundle-Branch Block/physiopathology , Bundle-Branch Block/surgery , Cardiac Pacing, Artificial , Ebstein Anomaly/diagnosis , Ebstein Anomaly/physiopathology , Heart Rate , Humans , Male , Predictive Value of Tests , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Tachycardia, Atrioventricular Nodal Reentry/surgery , Tachycardia, Ventricular/etiology , Tachycardia, Ventricular/physiopathology , Tachycardia, Ventricular/surgery , Time Factors , Young AdultSubject(s)
Accessory Atrioventricular Bundle , Action Potentials , Heart Rate , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Supraventricular/etiology , Cardiac Pacing, Artificial , Catheter Ablation , Diagnosis, Differential , Electrocardiography , Electrophysiologic Techniques, Cardiac , Humans , Male , Middle Aged , Predictive Value of Tests , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Tachycardia, Atrioventricular Nodal Reentry/surgery , Tachycardia, Supraventricular/diagnosis , Tachycardia, Supraventricular/physiopathology , Tachycardia, Supraventricular/surgery , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: Anatomic macroreentrant atrial tachycardias (MATs) are conventionally reported to depend on the cavotricuspid isthmus, the mitral isthmus, or the left atrial roof, and are commonly seen following catheter ablation for atrial fibrillation. OBJECTIVES: To define the precise circuits of anatomic MAT with ultrahigh-resolution mapping. METHODS: In 57 patients (mean age, 62 years; 10 female) who developed ≥1 anatomic MAT, we analyzed 88 MAT circuits including 16 peritricuspid, 42 perimitral, and 30 roof-dependent circuits, using high-density mapping and entrainment. RESULTS: Of 16 peritricuspid atrial tachycardias (ATs), 8 (50.0%) showed a circuit not limited to the tricuspid annulus. However, cavotricuspid isthmus ablation terminated the tachycardia in all patients. Similarly, 26 of 42 perimitral ATs (61.9%) showed a circuit not limited to the mitral annulus, and a low-voltage zone <0.1 mV around the mitral annulus was associated with nontypical perimitral ATs (P < .0001). The practical isthmus was not in the mitral isthmus in 13 of these 26 perimitral ATs (50%). Finally, 22 of 30 roof-dependent ATs (73.3%) had a circuit not rotating around both pairs of pulmonary veins. Brief assessment of the activation direction on the posterior wall in relation to that on the septal, anterior, and lateral wall helped deduce the circuit of roof-dependent AT in 27 of 30 (90.0%). Practical isthmus was not in the roof in 8 of 22 (36.4%). Practical isthmuses mapped with the system were significantly shorter than the usual anatomic isthmuses (16.1 ± 8.2 mm vs 33.7 ± 10.4 mm) (P < .0001). CONCLUSIONS: High-density mapping successfully identified the precise circuits and the practical isthmus of anatomic MATs in patients with prior atrial fibrillation ablation.
Subject(s)
Atrial Fibrillation/surgery , Body Surface Potential Mapping/methods , Catheter Ablation/adverse effects , Image Enhancement/methods , Postoperative Complications , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Female , Follow-Up Studies , Humans , Male , Middle Aged , Prospective Studies , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Atrioventricular Nodal Reentry/physiopathologySubject(s)
Bundle-Branch Block/etiology , Tachycardia, Atrioventricular Nodal Reentry/etiology , Tachycardia, Paroxysmal/etiology , Action Potentials , Adult , Bundle-Branch Block/diagnosis , Bundle-Branch Block/physiopathology , Cardiac Pacing, Artificial , Electrocardiography , Electrophysiologic Techniques, Cardiac , Heart Rate , Humans , Male , Tachycardia, Atrioventricular Nodal Reentry/diagnosis , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Tachycardia, Paroxysmal/diagnosis , Tachycardia, Paroxysmal/physiopathology , Time FactorsABSTRACT
Ebstein's anomaly (EA) is a rare congenital heart disease characterized by "atrialization" of the right ventricle, due to apical displacement of the tricuspid leaflets into the right ventricle. Patients with EA may develop all kinds of supraventricular arrhythmias requiring radiofrequency ablation. Atrial fibrillation (Afib) is a common arrhythmia in EA patients, and results in debilitating symptoms that often require surgical treatment. This is a follow-up report of 2 patients with EA undergoing radiofrequency ablation for Afib. The first patient underwent pulmonary vein isolation (PVI) and the ablation of a concomitant atrioventricular nodal reentrant tachycardia. The second patient was also treated with a PVI and a redo PVI 8 months later. Both patients remain in sinus rhythm 8 months on. Radiofrequency ablation is the therapy of choice for patients with pharmacological refractory Afib, but it is not common in patients with EA.