Reappraisal of radiofrequency ablation of multiple accessory pathways.

Complete electrophysiologic study and radiofrequency ablation were performed in 145 consecutive patients with Wolff-Parkinson-White syndrome. Presence of multiple accessory atrioventricular pathways was documented in 20 patients (13.8%); 17 had two, two had three, and one had four accessory pathways. Location of accessory pathways was posteroseptal in 18, left free wall in 15, right free wall in nine, and right midseptal in two. Of the 44 pathways, 36 were found during baseline electrophysiologic study and eight were found after successful ablation of the initially attempted pathways. After delivery 20 +/- 23 pulses (per patient) of radiofrequency energy (37 +/- 6 W, 70 +/- 30 seconds), 43 accessory pathways were ablated successfully without complications. Duration of the procedure (4.5 +/- 1.7 vs 3.7 +/- 1.6 hours, p < 0.05) and radiation exposure time (53 +/- 30 vs 38 +/- 18 minutes, p < 0.05) were longer in patients with multiple pathways, whereas the success rate (95% vs 95%, p > 0.05) and incidence of recurrent conduction (11% vs 11%, p > 0.05) were similar in patients with single or multiple accessory pathways. These findings confirmed that multiple accessory pathways were common in patients with Wolff-Parkinson-White syndrome, and these pathways could be ablated successfully by radiofrequency energy with a success rate comparable to that of a single accessory pathway.

Recurrent conduction in accessory pathway and possible new arrhythmias after radiofrequency catheter ablation.

Radiofrequency catheter ablation was performed in 142 patients with 166 accessory pathways. One hundred thirty-six patients with 160 accessory pathways underwent successful ablation in the first ablation session. Serial follow-up electrophysiologic studies were performed immediately (30 minutes), early (5 to 7 days), and late (3 to 6 months) after successful ablation to determine the recurrent accessory pathway conduction and possible new arrhythmias. After a minimum follow-up period of 6 months (mean, 14 +/- 3 months), accessory pathway conduction recurred in 13 patients (9.6%), with recurrent tachycardia in three patients (2.2%). Five of the recurrent accessory pathways had decremental conduction properties. Incidence of recurrent accessory pathway conduction was similar in different accessory pathway locations (6.4% to 9.0%). Patients with concealed accessory pathways (12.2 vs 2.9%; p < 0.05), and patients without accessory pathway potentials in the ablation site (15.5% vs 2.2%; p < 0.05) had a higher recurrence rate. Patients without tachycardia in the late electrophysiologic study did not have recurrent tachycardia during follow-up. New arrhythmias, including atrial and ventricular arrhythmias, which were detected by 24-hour Holter monitoring, were apparent only on the first day after ablation. The findings indicate that the overall incidence of recurrent accessory pathway conduction was low and that possible new arrhythmias were rare in the late follow-up period.

Arrhythmogenicity of catheter ablation in supraventricular tachycardia.

To evaluate arrhythmogenicity in patients who receive a modified direct-current (DC) shock ablation (distal pair of electrodes connected in common as the cathode) or radiofrequency (RF) ablation of supraventricular tachycardia, a prospective study was performed with signal-averaged ECG, 24-hour Holter monitoring, electrophysiologic study (EPS) for ventricular tachycardia (VT), and treadmill exercise test. Sixty-nine consecutive patients with documented paroxysmal supraventricular tachycardia were included. Twenty-eight patients proved to have atrioventricular nodal reentrant tachycardia, and 41 patients had atrioventricular reciprocating tachycardia that involved accessory atrioventricular pathways. The first 34 patients received DC shock ablation and the other 35 patients received RF ablation. Signal-averaged ECG, Holter monitoring, and EPS for VT were performed before ablation, immediately after ablation, then 1 week, 2 weeks (Holter monitoring), 1 month (except EPS), and 3 months after ablation. Treadmill exercise testing was performed before ablation, and at 1 week and 3 months after ablation. The root mean square, low-amplitude signal and QRS duration of signal-averaged ECG disclosed no significant change after either DC or RF ablation up to 3 months. Late potential developed in only one patient in the DC shock group and it was considered to be innocuous because neither VT nor ventricular fibrillation was noted or induced. Increases in the number of ventricular premature contractions and in short-run VT were detected by Holter monitoring in the first week after either mode of ablation (p < 0.001 for the DC shock group; p < 0.05 for the RF group), which were greater (p < 0.05) and lasted longer in the DC shock group than in the RF group.(ABSTRACT TRUNCATED AT 250 WORDS)

Selective radiofrequency catheter ablation of fast and slow pathways in 100 patients with atrioventricular nodal reentrant tachycardia.

One hundred patients received selective radiofrequency ablation of retrograde fast pathway (32 patients, group I) or slow pathway (68 patients, group II) to treat drug-refractory atrioventricular nodal reentrant tachycardia. In group I, a mean of 6 +/- 3 radiofrequency pulses eliminated the retrograde fast pathway. Thirty patients were free of symptoms and were not receiving antiarrhythmic drugs; two patients had accidental atrioventricular block. One patient had recurrent tachycardia and received a repeated ablation (slow pathway ablation). In group II, a mean of 9 +/- 4 radiofrequency pulses eliminated the slow pathway in 68 patients. All patients were free of symptoms and were not receiving antiarrhythmic drugs. One patient had recurrent tachycardia and received a repeated ablation. Serial follow-up electrophysiologic studies (immediate [20 to 30 minutes], early [5 to 7 days], and late [3 to 6 months]) showed that selective ablation of retrograde fast pathway was associated with nonspecific injury on the antegrade fast pathway (increase of AH interval) without effects on the slow pathway. Selective ablation of slow pathway was associated with nonspecific injury on the retrograde fast pathway in 15 patients (22%), but the antegrade fast pathway conduction parameters did not change significantly. Thus retrograde and antegrade fast pathway may be anatomically similar or have different sensitivities to radiofrequency energy, and slow pathway may be anatomically distinct from fast pathway. We conclude that (1) selective radiofrequency ablation of retrograde fast or slow pathway could cure atrioventricular nodal reentrant tachycardia with a high success rate (98%) and a low recurrence rate (2%) during a follow-up period of 6 to 18 months, but fast pathway ablation was associated with accidental atrioventricular block (5%), and (2) serial follow-up electrophysiologic studies elucidated the possible mechanisms of cure in atrioventricular nodal reentrant tachycardia.

Radiofrequency ablation of left-sided accessory atrioventricular pathways in patients with unusual coronary sinus.

Four patients with left-sided accessory pathways (APs) and unusual coronary sinus (CS) received radiofrequency ablation. Unusual CS included occlusion of CS (patient 1), acute angulation of proximal CS (patients 2 and 3), and narrowing of CS orifice and proximal segment (patient 4). CS catheterization and AP mapping along the CS could not be performed in the four patients. Radiofrequency ablation by left ventricular retrograde technique for the manifest left posteroseptal AP (patient 1), concealed left posterior AP (patient 2), and transseptal left atrial technique for the manifest left posteroseptal AP (patient 3) and manifest left posterior AP (patient 4) were performed successfully without CS catheter guidance. This study suggests that radiofrequency ablation of left-sided AP with unusual CS is feasible by some special techniques.

Reversibility of left ventricular dysfunction after successful catheter ablation of supraventricular reentrant tachycardia.

Fourteen patients (mean age, 48 +/- 19 years) with left ventricular dysfunction in the absence of underlying organic heart disease underwent catheter ablation (nine with direct-current energy and five with radiofrequency energy) to treat drug-refractory, symptomatic supraventricular reentrant tachycardia (mean duration of tachycardia, 22 +/- 17 years). Clinical tachycardias were accessory pathway-mediated tachyarrhythmia (12 patients) and atrioventricular nodal reentrant tachycardia (two patients). Changes of ventricular function after successful ablation, as assessed by radionuclide ventriculography and echocardiography, showed a decrease in left ventricular end-systolic dimension (39 +/- 6 mm to 34 +/- 6 mm; 32 +/- 6 mm; p < 0.05) and in left ventricular end-diastolic dimension (55 +/- 5 mm to 52 +/- 3 mm; 51 +/- 3 mm; p < 0.05) in the early (2 to 3 months) and late (6 to 8 months) follow-up periods, increase of nuclear ejection fraction (38% +/- 8% to 46% +/- 7%; p < 0.05) and fractional shortening (28% +/- 7% to 36% +/- 8%; p < 0.05) in the late follow-up period. Increase of fractional shortening was mainly due to decrease in the end-systolic dimension. These findings suggest that prolonged attacks of uncontrolled supraventricular tachycardia may result in left ventricular dysfunction, which is reversible after successful catheter ablation of the arrhythmias.

Reappraisal of intermediate-term follow-up of radiofrequency ablation of accessory atrioventricular pathways for treatment of Wolff-Parkinson-White syndrome.

To evaluate the safety and efficacy of catheter mediated radiofrequency (RF) ablation in patients with Wolff-Parkinson-White syndrome, 125 patients with accessory pathway (AP) mediated tachyarrhythmias underwent RF ablation. Right-sided APs were ablated from the atrial aspect of the tricuspid annulus (all from the femoral vein approach) and the left-sided APs were ablated from the atrial or ventricular aspect of the mitral annulus. Immediately after ablation, 3 of 8 APs (38%) and 131 of 137 APs (95%) were ablated successfully with RF through a small-tip (2 mm) and a large-tip (4 mm) electrode catheter, respectively. Seven of the 11 APs where RF ablation failed had a later successful DC ablation. During follow-up (3 to 22 months), 11 of the 114 patients (10%) with successful ablation had return of accessory pathway conduction (2 had recurrence of tachycardia (2%)). Complications included transient myocardial injury (peak CK-MB 15 +/- 3 IU/l), transient proarrhythmic effects (more atrial and ventricular premature beats), accidental AV block (1 patient), cardiac tamponade (1 patient) and suspicion of aortic dissection (1 patient). In successful sessions, procedure and radiation exposure time were 3.8 +/- 0.2 h and 45 +/- 4 min, respectively. This study confirms that RF ablation with a large-tip electrode catheter is an effective and relatively safe nonsurgical method for treatment of Wolff-Parkinson-White syndrome.

Radiofrequency catheter ablation for treatment of Wolff-Parkinson-White syndrome--short- and long-term follow-up.

One hundred and twenty-five patients with accessory pathways mediated tachyarrhythmias underwent radiofrequency ablation. Right-sided accessory pathways were ablated from the atrial aspect of the tricuspid anulus (all from the femoral vein approach) and the left-sided accessory pathways were ablated from the atrial or ventricular aspect of the mitral anulus. Immediately after the procedures, 3 of 8 accessory pathways (38%) and 131 of 137 accessory pathways (95%) were ablated successfully with radiofrequency through a small-tip (2 mm) and a large-tip (4 mm) electrode catheter, respectively. Seven of the 11 accessory pathways that failed radiofrequency ablation had a later successful direct current ablation. During follow-up (3 to 22 months), serial electrophysiological study showed that 11 of the 114 patients (10%) with successful ablation had return of accessory pathway conduction (2 had recurrence of tachycardia, 2%). Complications included accidental AV block (1 patient), cardiac tamponade (1 patient) and possible aortic dissection (1 patient). Transient proarrhythmic effects (more atrial and ventricular premature beats) were seen during the first week and sustained ventricular tachyarrhythmias were not inducible. In a successful session, procedure and radiation exposure times (including the time for diagnostic procedures) were 3.8 +/- 0.2 h and 45 +/- 4 min, respectively. This study confirms that radiofrequency ablation with a large-tip electrode catheter is an effective and relatively safe nonsurgical method for treatment of Wolff-Parkinson-White syndrome, with a low complication and recurrence rate.

Follow-up of a modified catheter ablation of the atrioventricular junction in patients with atrial tachyarrhythmias.

In order to reduce cumulative energy, minimize barotrauma and infranodal injury, a modified catheter ablation technique was performed on seventeen patients. These patients had drug refractory atrial tachyarrhythmias (AT) consisting of thirteen with paroxysmal atrial fibrillation (PAf), three with sick sinus syndrome (SSS) with PAf, and one having SSS with rapid left atrial tachycardia. This technique, using the femoral approach, consisted of delivering a direct-current (DC) shock using a dual electrode configuration, to the ablation site adjacent the atrioventricular (AV) junction just before the disappearance of His deflection on the His bundle electrogram. After delivering 1-4 DV shock (mean 2.8) (cumulative energy 556 +/- 260 joules), 9 pts had first degree AV block (1st AVB) and 8 pts had complete AV block (CAVB). Only two pts had a right bundle branch block after ablation. During the clinical follow-up (15.4 +/- 2.7 months), sixteen pts were asymptomatic and were free of antiarrhythmic drugs. One pt was asymptomatic with quinidine which was ineffective before ablation. Pacemaker implantation was performed in 10 pts as a back-up for symptomatic SSS and CAVB. The results show this modified technique is relatively safe and effective.

Reappraisal of electrical cure of atrioventricular nodal reentrant tachycardia--lessons from a modified catheter ablation technique.

A modified catheter ablation technique was studied prospectively in 29 patients with atrioventricular (AV) nodal reentrant tachycardia. A His bundle electrode catheter was used for mapping and ablation. Cathodic electroshocks (100-250 J) were delivered from the distal two electrodes (connected in common) of the His bundle catheter to the site selected for ablation. The optimal ablation site recorded the earliest retrograde atrial depolarization, simultaneous or earlier than the QRS complex, with absence of a His bundle deflection during AV nodal reentrant tachycardia. One additional electrical shock was delivered if complete abolition of retrograde VA conduction persisted for more than 30 min and AV nodal reentrant tachycardia was not inducible during isoproterenol and/or atropine administration. With a cumulative energy of 323 +/- 27 J and a mean of 2.3 +/- 0.5 shocks interruption or impairment of retrograde nodal conduction was achieved. Antegrade conduction, although modified, was preserved in 27 patients, with persistence of complete AV block in 2 patients. Two of the 27 patients still need antiarrhythmic agents to control tachycardia, the other 25 patients were free of tachycardia within a mean follow-up period of 13 +/- 2 months (range 7 to 20 months). Twenty-three patients received late follow-up electrophysiological studies (3-6 months after the ablation procedures), and the AV nodal function curves were classified into 4 types. The majority of the patients (15/23) had loss of retrograde conduction. Among the 8 patients with prolongation of retrograde conduction, 4 patients still had antegrade dual AV nodal property but all without inducible tachycardia. In conclusion, preferential interruption or impairment of retrograde conduction was the major, but not the sole, mechanism of electrical cure of AV nodal reentrant tachycardia.

Catheter ablation of free wall accessory atrioventricular pathways in 89 patients with Wolff-Parkinson-White syndrome--comparison of direct current and radiofrequency ablation.

To evaluate and compare the safety and efficacy of catheter-mediated direct current (DC) or radiofrequency (RF) ablation in patients with free wall accessory atrioventricular pathways, 89 patients with free wall accessory atrioventricular pathway (AP)-mediated tachyarrhythmias underwent catheter ablation. Electrophysiological parameters were similar in the patients with DC (group I, 29 patients with 30 APs) or RF (group II, 60 patients with 64 APs) ablation. Immediately after ablation, it was seen that 27 of 30 APs (90%) had been ablated successfully with DC, but two of the 27 APs had early return of conduction and received a second ablation session; three of eight APs (38%) and 53 of 56 APs (95%) were ablated successfully with RF through a small-tip (2 mm) and a large-tip (4 mm) electrode catheter, respectively. Seven of the eight APs who had a failed RF ablation later had a successful DC ablation. During the follow-up (group I, 14 to 27; group II, 8 to 14 months), all successfully ablated patients had no recurrence of tachycardia. Complications in DC ablation included transient hypotension (two patients), and pulmonary air-trapping (two patients); in RF ablation the complications included cardiac tamponade (1 patient) and suspicious aortic dissection (1 patient); myocardial injury (reflected by peak CK-MB, 34 +/- 5 vs 15 +/- 4 IU.l-1) and pro-arrhythmic effects (new atrial and ventricular arrhythmias) were more severe in those who had DC ablation. Procedure and radiation exposure time were significantly longer in RF ablation (DC, 3.6 +/- 0.2 h, 34 +/- 4 min; RF 4.0 +/- 0.4 h, 46 +/- 10 min). This study confirms that RF ablation with a large-tip electrode catheter is an effective and relatively safe non-surgical method for treatment of free wall accessory atrioventricular pathway-mediated tachyarrhythmias.

Catheter ablation of accessory atrioventricular pathways in 114 symptomatic patients with Wolff-Parkinson-White syndrome--a comparative study of direct-current and radiofrequency ablation.

To evaluate and compare the safety and efficacy of catheter-mediated direct-current and radiofrequency ablation in patients with Wolff-Parkinson-White syndrome, 114 patients with accessory pathway-mediated tachyarrhythmias underwent catheter ablation. Electrophysiologic parameters were similar in patients undergoing direct-current (group 1, 52 patients with 53 accessory pathways) and radiofrequency (group 2, 62 patients with 75 accessory pathways) ablation. Immediately after ablation, 50 of 53 accessory pathways (94%) were ablated successfully with direct current, but 2 of the 50 accessory pathways had early return of conduction and required a second ablation; 72 of 75 accessory pathways (96%) were ablated successfully with radiofrequency current. In the three accessory pathways in which radiofrequency ablation was unsuccessful, a later direct-current ablation was successful. During follow-up (group 1, 14 to 27 months; group 2, 8 to 13 months), none of the patients with successful ablation had a recurrence of tachycardia. Complications in direct-current ablation included transient hypotension (two patients), accidental atrioventricular block (one patient), and pulmonary air trapping (two patients); complications in radiofrequency ablation included cardiac tamponade (one patient) and suspicious aortic dissection (one patient). Myocardial injury and proarrhythmic effects were more severe in direct-current ablation. The length of the procedure and the radiation exposure time were significantly shorter in direct-current (3.5 +/- 0.2 hours, 30 +/- 4 minutes) than in radiofrequency (4.1 +/- 0.4 hours, 46 +/- 9 minutes) ablation. Findings in this study confirm the impression that radiofrequency ablation is associated with fewer complications than direct-current ablation and radiofrequency ablation with a large-tipped electrode catheter is an effective and relatively safe nonsurgical method for treatment of Wolff-Parkinson-White syndrome.

Comparison of direct-current and radiofrequency ablation of free wall accessory atrioventricular pathways in the Wolff-Parkinson-White syndrome.

To evaluate and compare the safety and efficacy of catheter-mediated direct-current (DC) or radiofrequency (RF) ablation in patients with free wall accessory atrioventricular pathways, 95 patients with free wall accessory atrioventricular pathway-mediated tachyarrhythmias underwent catheter ablation. Immediately after ablation, 27 of 30 accessory pathways (90%) were ablated successfully with DC, but 2 of the 27 had early return of conduction and received a second ablation session; 3 of 8 (38%) and 57 of 62 (92%) accessory pathways were ablated successfully with RF through a small-tip (2 mm) and a large-tip (4 mm) electrode catheter, respectively. Complications in DC ablation included transient hypotension (2 patients) and pulmonary air-trapping (2 patients) and in RF ablation, cardiac tamponade (1 patient) and suspicious aortic dissection (1 patient); myocardial injury and proarrhythmic effects were more severe in DC ablation. Procedure and radiation exposure time were significantly longer in RF ablation (DC, 3.6 +/- 0.2 hours, 34 +/- 4 minutes; RF 4.2 +/- 0.5 hours, 50 +/- 10 minutes). This study confirms that RF ablation is associated with little morbidity and few complications, and RF ablation with a large-tip electrode catheter is an effective and relatively safe nonsurgical method for treatment of free wall accessory atrioventricular pathway-mediated tachyarrhythmias.

Safety and efficacy of a modified catheter-mediated ablation of accessory pathways.

Fifty-one consecutive patients underwent modified catheter-mediated direct-current ablation of accessory pathways. Energy was delivered through the distal pair of electrodes (dual electrode configuration) of a 6F quadripolar catheter to the internal surface of the right or left atrioventricular (AV) annulus. In an attempt to prevent the later resumption of accessory pathway conduction, one additional shock was given after the initial successful interruption of accessory pathways. A mean of 2.7 shocks with cumulative energy of 453 +/- 32 Joules/patient interrupted the accessory pathways in 47 patients and modified the accessory pathway conduction in 2 patients. Forty-eight patients were asymptomatic and free of any antiarrhythmic agents with a follow-up ranging from 3-20 months (mean 12 +/- 1 months), without early or late serious complications (AV block or tamponade). Conduction characteristics, concealed or manifest, and recording of accessory pathway activity did not affect the outcome. Mean cumulative energy and number of applications of energy to achieve a successful outcome were lower in patients with concealed (376 +/- 31 Joules, 2.4 +/- 0.2 shocks) than manifest accessory pathways (516 +/- 50 Joules, 2.9 +/- 0.2 shocks). At the successful ablation sites, the mean shortest retrograde ventriculoatrial interval during orthodromic reentrant tachycardia (VA') was 80 +/- 3 msec (78% had VA' less than 90 msec) and was not different between concealed and manifest accessory pathways; the mean shortest antegrade AV interval was 47 +/- 3 msec in manifest preexcitation; the mean ratio of atrial to ventricular wave amplitude was not significantly different between left-sided (0.8 +/- 0.1) and right-sided (1.1 +/- 0.2) accessory pathways (p greater than 0.05). A successful outcome was achieved in 94% of 51 patients. This procedure is relatively safe and effective, regardless of the location of the accessory pathway.

A comparative study of a modified catheter-mediated direct current and radiofrequency ablation on atrioventricular junction.

Conventional His-bundle ablation, performed at the site with the largest His-bundle potential, displays a high incidence of a new right bundle branch block with loss of pacemaker escape. Damage to the perinodal atrial area may decrease the injury to the His-bundle, such that the escape pacemaker activity with a narrow QRS complex is produced. This study reports data from 25 patients with drug-refractory atrial tachyarrhythmias. Nine patients (group I) received radiofrequency (RF) ablation of the atrioventricular junction (AVJ). General anesthesia was not necessary in group I patients. During a mean follow-up period of 10 months, a complete AV block persisted in 5 patients, and a first degree AV block persisted in 2 patients; these patients were asymptomatic and did not require treatment with antiarrhythmic agents. A successful direct-current (DC) ablation was performed in one of the patients with an unsuccessful RF lesion, producing a new right bundle branch block (RBBB). Sixteen patients (group II) received DC ablation of the AVJ. During a mean follow-up period of 20 months, a complete AV block persisted in 9 patients, a first degree AV block was produced in 7 patients, and a new RBBB occurred in 2 patients. Fifteen patients (94%) were asymptomatic without administration of antiarrhythmic agents. Complications, including nonsustained ventricular tachycardia (1 patient) and pericarditis (1 patient), occurred immediately after ablation in group II. Myocardial injury, reflected by creatine kinase-MB isoenzyme, was higher in group II than in group I (25 +/- 2 vs 10 +/- 1 IU/l). We conclude that (1) catheter-mediated RF ablation of the AV junction is safer than DC ablation, (2) a majority of patients with drug-refractory atrial tachyarrhythmias can be successfully treated with RF ablation and (3) failure to achieve AV junction ablation with RF does not mitigate against successful application of DC ablation.