Efficacy and safety of cryoablation of para-Hisian and mid-septal accessory pathways using a specific protocol: single-center experience in consecutive patients

Novel method to avoid serious injurious effects on the atrioventricular nodal (AVN) conduction during catheter ablation of the AVN slow pathway utilizing cryofreezing energy

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, 65.8 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 10 bpm than that inducing Wenchebach AV block in 74 (47.1 %) patients (Group A). The RACP rate was decreasingly reduced by 10 bpm in case of the occurrence of IAVN. When the RACP reached 100 bpm, the cryoablation was prematurely terminated. Group B patients (83 = 52.9 %) 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 12 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 (p = 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.

Canadian Cardiovascular Society 2023 Guidelines on the Fitness to Drive

Cardiovascular conditions are among the most frequent causes of impairment to drive, because they might induce unpredictable mental state alterations via diverse mechanisms like myocardial ischemia, cardiac arrhythmias, and vascular dysfunction. Accordingly, health professionals are often asked to assess patients' fitness to drive (FTD). The Canadian Cardiovascular Society previously published FTD guidelines in 2003-2004; herein, we present updated FTD guidelines. Because there are no randomized trials on FTD, observational studies were used to estimate the risk of driving impairment in each situation, and recommendations made on the basis of Canadian Cardiovascular Society Risk of Harm formula. More restrictive recommendations were made for commercial drivers, who spend longer average times behind the wheel, use larger vehicles, and might transport a larger number of passengers. We provide guidance for individuals with: (1) active coronary artery disease; (2) various forms of valvular heart disease; (3) heart failure, heart transplant, and left ventricular assist device situations; (4) arrhythmia syndromes; (5) implantable devices; (6) syncope history; and (7) congenital heart disease. We suggest appropriate waiting times after cardiac interventions or acute illnesses before driving resumption. When short-term driving cessation is recommended, recommendations are on the basis of expert consensus rather than the Risk of Harm formula because risk elevation is expected to be transient. These recommendations, although not a substitute for clinical judgement or governmental regulations, provide specialists, primary care providers, and allied health professionals with a comprehensive list of a wide range of cardiac conditions, with guidance provided on the basis of the level of risk of impairment, along with recommendations about ability to drive and the suggested duration of restrictions.

Iatrogenic Atrioventricular Block

Iatrogenic atrioventricular (AV) block can occur in the context of cardiac surgery, percutaneous transcatheter, or electrophysiologic procedures. In cardiac surgery, patients undergoing aortic and/or mitral valve surgery are at the highest risk for developing perioperative AV block requiring permanent pacemaker implantation. Similarly, patients undergoing transcatheter aortic valve replacement are also at increased risk for developing AV block. Electrophysiologic procedures, including catheter ablation of AV nodal re-entrant tachycardia, septal accessory pathways, para-Hisian atrial tachycardia, or premature ventricular complexes, are also associated with risk of AV conduction system injury. In this article, we summarize the common causes for iatrogenic AV block, predictors for AV block, and general management considerations.

Miniseries 2-septal and paraseptal accessory pathways-part III: mid-paraseptal accessory pathways-revisiting bypass tracts crossing the pyramidal space

The mid-paraseptal region corresponds to the portion of the pyramidal space whose right atrial aspect is known as the triangle of Koch. The superior area of this mid-paraseptal region is also para-Hisian, and is close to the compact atrioventricular node and the His bundle. The inferior sector of the mid-paraseptal area is unrelated to the normal atrioventricular conduction pathways. It is, therefore, a safe zone in which, if necessary, to perform catheter ablation. The middle part of the mid-paraseptal zone may, however, in some patients, house components of the compact atrioventricular node. This suggests the need for adopting a prudent attitude when considering catheter ablation in this area. The inferior extensions of the atrioventricular node, which may represent the substrate for the slow atrioventricular nodal pathway, take their course through the middle, and even the inferior, sectors of the mid-paraseptal region. In this review, we contend that the middle and inferior areas of the mid-paraseptal region correspond to what, in the past, was labelled by most groups as the 'midseptal' zone. We describe the electrocardiographic patterns observed during pre-excitation and orthodromic reciprocating tachycardia in patients with pathways ablated in the middle or inferior sectors of the region. We discuss the modification of the ventriculo-atrial conduction times during tachycardia after the development of bundle branch block aberrancy. We conclude that the so-called 'intermediate septal' pathways, as described in the era of surgical ablation, were insufficiently characterized. They should not be considered the surrogate of the 'midseptal' pathways defined using endocardial catheter electrode mapping.

Iatrogenic Atrioventricular Block

Iatrogenic atrioventricular (AV) block can occur in the context of cardiac surgery, percutaneous transcatheter, or electrophysiologic procedures. In cardiac surgery, patients undergoing aortic and/or mitral valve surgery are at the highest risk for developing perioperative AV block requiring permanent pacemaker implantation. Similarly, patients undergoing transcatheter aortic valve replacement are also at increased risk for developing AV block. Electrophysiologic procedures, including catheter ablation of AV nodal re-entrant tachycardia, septal accessory pathways, para-Hisian atrial tachycardia, or premature ventricular complexes, are also associated with risk of AV conduction system injury. In this article, we summarize the common causes for iatrogenic AV block, predictors for AV block, and general management considerations.

Fluoroless catheter ablation of accessory pathways in adult and pediatric patients: a single centre experience

Catheter radio-frequency ablation (RFA) and cryo-ablation (CRA) procedures are an effective and safe treatment options for adult and pediatric patients with accessory pathway (AP) mediated tachycardias. Non-fluoroscopic techniques during catheter ablation (CA) procedures reduce potentially harmful effects of radiation. Our aim was to investigate the efficacy and safety of completely fluoroless RFA and CRA procedures in pediatric and adult patients with APs. Consecutive patients with AP-related tachycardia and high risk asymptomatic ventricular pre-excitation were assessed in retrospective analysis. Three-dimensional (3D) electro-anatomical mapping (EAM) and intra-cardiac echocardiography (ICE) were used as principal imaging modalities. Fluoroscopy was not used during any stage of the procedures. Among 116 included patients (22.76 ± 16.1 years, 68 patients < 19 years), 60 had left-sided APs, 16 right-sided APs and 40 septal APs. Altogether, 96 had RFA and 20 CRA procedures. The acute success rates (ASR) of RFA and CRA were 97.9% and 95%, respectively (p = 0.43), with recurrence rates (RR) of 8.33% and 40%, respectively (p < 0.0001). The outcome difference was principally driven by lower RR with RFA in septal APs (9.1% vs. 38.9%, p = 0.025). Pediatric patients with APs (12.21 ± 3.76 years) had similar procedural parameters and outcomes compared to adult patients. There were no procedure-related complications. In adult and pediatric patients with AP-related tachycardias, both CRA and RFA can be effectively and safely performed without the use of fluoroscopy. In addition, RFA resulted in better outcomes compared to CRA.

Ablation of Accessory Pathways with Challenging Anatomy

Although catheter ablation of accessory pathways is deemed highly safe and effective, peculiar location of these pathways might lead to complex and potentially hazardous procedures requiring ablation in anatomic regions such as para-Hisian area, coronary sinus, and epicardial surface. The electrophysiologist should know these possible scenarios to plan the best strategy for safe and effective ablation of these uncommon accessory pathways.

Ablation of Accessory Pathways with Uncommon Electrophysiologic Properties

In rare cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic features that may be related to their specific anatomy. Most of these bundles show decremental nodelike conduction properties and sustain peculiar forms of arrhythmias that require careful differential diagnosis. On the other hand, some pathways do not actively sustain any reentrant circuit and should nevertheless be promptly recognized to avoid unnecessary ablation attempts. Although rare, these variants of accessory pathway should be known to warrant a safe and effective catheter ablation procedure.

[Catheter ablation of supraventricular tachycardia]

Supraventricular tachycardias (SVT) are common, with atrioventricular nodal reentry tachycardias (AVNRT) being the most common paroxysmal supraventricular tachycardia. The pathophysiological understanding and the catheter ablation of SVTs have developed steadily in recent years. For example, dividing AVNRT into "typical" and "atypical" depending on the HA-, VA-interval and AH/HA ratio is recommended. Because of higher rates of recurrences after cryoablation, radiofrequency ablation has prevailed in AVNRT. The current ESC guidelines for SVTs recommend the ablation of accessory pathways in asymptomatic high-risk patients and it is now a Class I recommendation. There is no recommendation for the access in left-sided accessory pathways. However, a transseptal compared to transaortic approach seems more promising in acute success. The use of a three-dimensional (3D) mapping system leads to a reduction of the fluoroscopy times and procedure duration. Ablation of focal atrial tachycardia remains challenging despite the use of 3D electroanatomical mapping systems. However, new technologies such as high-density (HD) multipoint mapping systems can be helpful. HD mapping systems also allow a better understanding of left and right atrial macroreentry tachycardia after previous ablation or cardiac surgery and in primary nature. However, in all technological advances, a proficient understanding of the basic techniques in electrophysiology, such as entrainment mapping, is mandatory.