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O'Leary ET, Sneider D, Przybylski R, Dionne A, Alexander ME, Mah DY, Triedman JK, DeWitt ES. Comparative utility of omnipolar and bipolar electroanatomic mapping methods to detect and localize dual nodal substrate in patients with atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01800-3. [PMID: 38634991 DOI: 10.1007/s10840-024-01800-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/28/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Catheter-based slow pathway modification (SPM) for atrioventricular nodal reentrant tachycardia (AVNRT) is traditionally performed at empiric sites using anatomical landmarks and test ablation feedback within the triangle of Koch (TK). While studies have described more tailored techniques such as bipolar low voltage bridge (LVB) and wavefront collision identification, few have systematically compared the diagnostic yields of each and none have investigated whether omnipolar mapping technology provides incremental benefit. The objective of this study was to compare the utility of omnipolar and bipolar-derived qualitative and quantitative measurements in identifying and localizing dual AVN substrate in patients with versus without AVNRT. METHODS A retrospective case-control study of consecutive patients with paroxysmal supraventricular tachycardia undergoing electrophysiology study with both omnipolar and bipolar mapping from 2022-2023. RESULTS Thirteen AVNRT cases (median age 16.1 years, 512 TK points) were compared to nine non-AVNRT controls (median age 15.7 years, 332 TK points). Among qualitative variables, an omnipolar activation vector pivot, defined as a ≥45 degree change in activation direction within the TK, had the highest positive (81%) and negative predictive values (100%) for identifying AVNRT cases and had a median distance of 1 mm from SPM sites. Among quantitative variables, the optimal discriminatory performance for successful SPM sites was observed using bipolar voltage restricted to a peak frequency >340 Hz (c statistic 0.75). CONCLUSIONS Omnipolar vector pivot analysis represents an automated, annotation-independent qualitative technique that is sensitive and specific for AVNRT substrate and co-localizes with successful SPM sites. Bipolar voltage quantitatively describes SP anisotropy better than omnipolar voltage, and the addition of peak frequency signal analysis further optimizes the selection of SPM sites.
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Affiliation(s)
- Edward T O'Leary
- Division of Electrophysiology, Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
| | | | - Robert Przybylski
- Division of Electrophysiology, Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Inova Children's Hospital, Falls Church, VA, USA
| | - Audrey Dionne
- Division of Electrophysiology, Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Mark E Alexander
- Division of Electrophysiology, Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Douglas Y Mah
- Division of Electrophysiology, Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - John K Triedman
- Division of Electrophysiology, Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Elizabeth S DeWitt
- Division of Electrophysiology, Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
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O'Leary ET, Harris J, Gauvreau K, Gentry C, Dionne A, Abrams DJ, Alexander ME, Bezzerides VJ, DeWitt ES, Triedman JK, Walsh EP, Mah DY. Radiofrequency Catheter Ablation for Pediatric Atrioventricular Nodal Reentrant Tachycardia: Impact of Age on Procedural Methods and Durable Success. J Am Heart Assoc 2022; 11:e022799. [PMID: 35699163 PMCID: PMC9238659 DOI: 10.1161/jaha.121.022799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Catheter-based slow-pathway modification (SPM) is the treatment of choice for symptomatic atrioventricular nodal reentrant tachycardia (AVNRT). We sought to investigate the interactions between patient age and procedural outcomes in pediatric patients undergoing catheter-based SPM for AVNRT. Methods and Results A retrospective cohort study was performed, including consecutive patients undergoing acutely successful SPM for AVNRT from 2008 to 2017. Those with congenital heart disease, cardiomyopathy, and accessory pathways were excluded. Patients were stratified by age quartile at time of SPM. The primary outcome was AVNRT recurrence. A total of 512 patients underwent successful SPM for AVNRT. Age quartile 1 had 129 patients with a median age and weight of 8.9 years and 30.6 kg, respectively. Radiofrequency energy was used in 98% of cases. Follow-up was available in 447 (87%) patients with a median duration of 0.8 years (interquartile range, 0.2-2.5 years). AVNRT recurred in 22 patients. Multivariable Cox proportional hazard modeling identified atypical AVNRT (hazard ratio [HR], 5.83; 95% CI, 2.01-16.96; P=0.001), dual atrioventricular nodal only (HR, 4.09; 95% CI, 1.39-12.02; P=0.011), total radiofrequency lesions (HR, 1.06 per lesion; 95% CI, 1.01-1.12; P=0.032), and the use of a long sheath (HR, 3.52; 95% CI, 1.23-10.03; P=0.010) as predictors of AVNRT recurrence; quartile 1 patients were not at higher risk of recurrence (HR, 0.45; 95% CI, 0.10-1.97; P=0.29). Complete heart block requiring permanent pacing occurred in one quartile 2 patient at 14.9 years of age. Conclusions Pediatric AVNRT can be treated with radiofrequency-SPM with high procedural efficacy and minimal risk of complications, including heart block. Atypical AVNRT and dual atrioventricular nodal physiology without inducible tachycardia remain challenging substrates.
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Affiliation(s)
- Edward T O'Leary
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Jamie Harris
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Kimberlee Gauvreau
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Courtney Gentry
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Audrey Dionne
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Dominic J Abrams
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Mark E Alexander
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Vassilios J Bezzerides
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Elizabeth S DeWitt
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - John K Triedman
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Edward P Walsh
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Douglas Y Mah
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
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Duman D, Ertuğrul İ, Yıldırım Baştuhan I, Aykan HH, Karagöz T. Empiric slow-pathway ablation results for presumed atrioventricular nodal reentrant tachycardia in pediatric patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1200-1206. [PMID: 34080209 DOI: 10.1111/pace.14291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/29/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In pediatric patients with documented narrow QRS tachycardia that is suggestive of atrioventricular nodal reentrant tachycardia (AVNRT) and not inducible in electrophysiological study (EPS), empiric slowpathway ablation (ESPA) may be considered. There is limited data in children about this topic. METHODS Seventy-nine patients who underwent cryoablation and/or radiofrequency ablation (RFA) for presumed AVNRT between January 2010 and January 2020, with no inducible tachycardia and no other tachycardia mechanisms during EPS, were included in this study. RESULTS The age was between 6 and 18 years. All patients had no structural heart disease. Preablation exhibited sustained SP conduction for all patients. In all cases, the ablation end points were prolongation in wenckebach cycle length (WBCL) with loss of cross and/or jump, and/or echo beat. The end points were not achieved in two patients. Overall, the mean basal WBCL increased to 351 ms (240-500 ms) from 301.3 ms (180-420 ms), evident in the non-recurrence group. Nine patients had a transient AV block that improved. We followed the patients without medication for about 46.9 months (8 months to 10 years). Palpitations occurred again in 9 of 77 patients (clinical recurrence rate 9/79 - 11.3%). The documented ECG recurrence rate was 1.2% (1/79). In the non-recurrence group, WBCL prolongation was higher and mean age was lower than in the recurrence group (13.075 vs. 15.33 years). CONCLUSION In cases with presumed AVNRT, ESPA seems to be a reasonable and safe way. In our study, we found our procedural success rate as 97.4% and follow-up recurrence rate as 12.6% (9+1/79).
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Affiliation(s)
- Derya Duman
- Department of Pediatrics, Division of Pediatric Cardiology, University of Hacettepe, Ankara, Turkey
| | - İlker Ertuğrul
- Department of Pediatrics, Division of Pediatric Cardiology, University of Hacettepe, Ankara, Turkey
| | - Işıl Yıldırım Baştuhan
- Division of Pediatric Cardiology, University of Health Sciences Antalya Training and Research Hospital, Antalya, Dalian
| | - Hayrettin Hakan Aykan
- Department of Pediatrics, Division of Pediatric Cardiology, University of Hacettepe, Ankara, Turkey
| | - Tevfik Karagöz
- Department of Pediatrics, University of Hacettepe, Ankara, Turkey
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Persistence of Palpitations After Slow Pathway Modification for AVNRT in Young People. Pediatr Cardiol 2021; 42:590-596. [PMID: 33394109 PMCID: PMC8479320 DOI: 10.1007/s00246-020-02519-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
Symptoms are the most common indication for ablation in children with atrioventricular nodal reentrant tachycardia (AVNRT). After the procedure, patients may continue to report palpitations. The objective of this study was to quantify the risk and duration of palpitations after pediatric slow pathway modification as well as demographic and technical associations. This was a retrospective review of consecutive patients at a pediatric center who underwent slow pathway modification for AVNRT from 2012 to 2018. Patients with a prior ablation attempt or congenital heart disease were excluded. Palpitations were documented in 35% of patients after ablation. Neither post-ablation echo beats nor other evidence of residual dual AV nodal physiology were associated with a higher risk of post-ablation palpitations. Of the 35 patients with post-ablation palpitations, the median time to resolution of palpitations was 48 months. Acute procedural success was achieved in all 100 cases. There were two recurrences of AVNRT during long-term follow-up and one instance of ectopic atrial tachycardia (3% SVT recurrence). Palpitations after AVNRT ablation occurred in approximately one-third of cases, despite a low recurrence of true arrhythmia. Prior to ablation, patients and families should be counseled that post-ablation palpitations are common and AVNRT recurrence is rare.
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Willy K, Frommeyer G, Dechering DG, Wasmer K, Höwel D, Welle SS, Bögeholz N, Ellermann C, Wolfes J, Rath B, Leitz PR, Köbe J, Lange PS, Müller P, Reinke F, Eckardt L. Outcome of catheter ablation in the very elderly-insights from a large matched analysis. Clin Cardiol 2020; 43:1423-1427. [PMID: 32865252 PMCID: PMC7724238 DOI: 10.1002/clc.23455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/18/2020] [Indexed: 11/08/2022] Open
Abstract
Background Ablation emerged as first line therapy in the treatment of various arrhythmias. Nevertheless, in older patients (pts), decision is often made pro drug treatment as more complications and less benefit are suspected. Hypothesis We hypothesized that different kind of ablations can be performed safely regardless of the pts age. Methods We enrolled all pts aged >80 years (yrs) who underwent ablation for three different arrhythmias (atrial flutter [AFL], atrioventricular nodal re‐entry tachycardia [AVNRT], ventricular tachycardia [VT]) between August 2002 and December 2018. Procedural data and outcome were compared with matched groups aged 60 to 80 years and 40 to 60 years, respectively. Periprocedural and in‐hospital complications were analyzed. Results The analysis included 1191 patients (397 pts per group: 63% AFL, 23% AVNRT, 14% VT) who underwent ablation. Acute success was high in all types of arrhythmias irrespective of age (>80, 60‐80, 40‐60 years: AFL 97%/98%/98%, AVNRT 97%/95%/97%, VT 82%/86%/93%). Rate of periprocedural complications were similar in all groups treated for AFL and AVNRT. For VT ablations significant differences were noted between pts > 80 or 60 to 80 years and those aged 40‐60 years (16.1%/14.3%/3.6%). Most complications were infections and groin haematoma. No strokes, iatrogenic atrioventricular blocks and deaths related to the ablation occurred. Conclusion Ablation appears safe in pts > 80 years. Success rates were comparable to matched younger cohorts. A significant difference was observed for VT patients.
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Affiliation(s)
- Kevin Willy
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Dirk G Dechering
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Kristina Wasmer
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Dennis Höwel
- Department of Cardiology, University Hospital Oldenburg, Oldenburg, Germany
| | - Sarah S Welle
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Nils Bögeholz
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Christian Ellermann
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Julian Wolfes
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Benjamin Rath
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Patrick R Leitz
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Julia Köbe
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Philipp S Lange
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Patrick Müller
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Florian Reinke
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany
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Bertini M, Brieda A, Balla C, Pollastrelli A, Smarrazzo V, Francesco V, Malagù M, Ferrari R. Efficacy and safety of catheter ablation of atrioventricular nodal re-entrant tachycardia by means of flexible-tip irrigated catheters. J Interv Card Electrophysiol 2019; 58:61-67. [PMID: 31236760 DOI: 10.1007/s10840-019-00578-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/07/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Irrigated-tip ablation catheters increase safety and efficacy of ablation procedures, but their use in atrioventricular nodal re-entrant tachycardia (AVNRT) ablation has not been systematically evaluated. The aim of this study is to evaluate the safety and efficacy of radiofrequency (RF) catheter ablation of AVNRT by means of the novel flexible-tip open-irrigated catheter FlexAbility™ and a 3D electroanatomic mapping (EAM) system. METHODS This is a single-center and single-operator study on 80 patients referred for AVNRT catheter ablation. Outcome included acute and long-term procedural success as well as complications reported over a median follow-up of 19 months (interquartile range 6-24 months). RESULTS Acute success was achieved in all 80 patients. One procedure-related major complication, involving the vascular access, occurred. Mean fluoroscopy time was 106 ± 71 s. One patient (1.2%) suffered long-term AVNRT recurrence. Five patients (6.2%) underwent ablation for AVNRT combined with ablation for other clinical arrhythmias. CONCLUSIONS Irrigated RF ablation of AVNRT by means of the novel flexible-tip open-irrigated catheter associated to 3D EAM system is effective and safe. Success rates are comparable to those of other techniques. Complication rate is very low.
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Affiliation(s)
- Matteo Bertini
- Cardiovascular Unit, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8 - 44124 Cona, Ferrara, FE, Italy.
| | - Alessandro Brieda
- Cardiovascular Unit, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8 - 44124 Cona, Ferrara, FE, Italy
| | - Cristina Balla
- Cardiovascular Unit, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8 - 44124 Cona, Ferrara, FE, Italy
| | - Annalisa Pollastrelli
- Abbott Medical Italy, Clinical Department, Viale Thomas Alva Edison, 110, 20099, Sesto San Giovanni, MI, Italy
| | - Vittorio Smarrazzo
- Cardiovascular Unit, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8 - 44124 Cona, Ferrara, FE, Italy
| | - Vitali Francesco
- Cardiovascular Unit, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8 - 44124 Cona, Ferrara, FE, Italy
| | - Michele Malagù
- Cardiovascular Unit, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8 - 44124 Cona, Ferrara, FE, Italy
| | - Roberto Ferrari
- From Maria Cecilia Hospital, GVM Care & Research, Via Madonna di Genova, 1, 48033, Cotignola, RA, Italy
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