Comparison of minimal versus zero-fluoroscopic catheter ablation in gestational supraventricular arrhythmias

BACKGROUND

The management of symptomatic gestational supraventricular tachycardia (SVT) is challenging and requires a multidisciplinary approach for optimal management. Catheter ablation during pregnancy has traditionally been considered a last option due to procedural safety and ionizing radiation risks. Recent advances including intracardiac echocardiography and multi-electrode electroanatomic mapping have greatly enhanced the safety and efficacy profile to successfully perform ablations with minimal to no fluoroscopy even during pregnancy. This is the first review to compare the efficacy, safety, and aggregate outcomes of purely zero-fluoroscopic and minimal fluoroscopic approaches in gestational SVT.

METHODS

A literature search was performed for catheter ablations in the past 15 years for gestational arrhythmias that used minimal or no fluoroscopy. Sixteen cases describing catheter ablations with zero-fluoroscopy were compared to twenty-four cases using minimal fluoroscopy, defined as total documented exposure time of less than 10 min.

RESULTS

Analysis of both groups demonstrated that zero-fluoroscopic approaches have comparable efficacy and procedural safety outcomes with the utilization of earlier trimester ablations and in older maternal ages. The utilization of electroanatomic mapping with or without concomitant intracardiac echocardiography in the zero-fluoroscopy group further demonstrated equal efficacy rates of successful ablation when compared to the control group. Furthermore, there were no reported immediate or long-term periprocedural complications in either group, including delivery outcomes.

CONCLUSION

Our review demonstrates that zero-fluoroscopy catheter ablation for SVT in pregnancy is both effective and safe when compared to minimal fluoroscopy ablations while eliminating the theoretical risks of ionizing radiation.

Supraventricular Tachycardia in Pregnancy: Gestational and Labor Differences in Treatment

Supraventricular tachycardia (SVT) is a tachyarrhythmia characterized by a heart rate above 120 beats per minute (BPM). Patients with SVT exhibit the following symptoms: palpitations, shortness of breath, chest pain, hemodynamic instability, or possibly asymptomatic. The increase in cardiac output and the increase in resting heart rate during pregnancy predispose pregnant women to SVT. The management of SVT in pregnancy, although remarkably similar, varies slightly based on the trimester of pregnancy. Atenolol and verapamil are effective methods of treating SVT, which can be used during the second and third trimesters. Both medications are contraindicated in the first trimester. At the same time, intravenous adenosine can be used in all three trimesters, including labor. Electrical cardioversion is an effective treatment method for hemodynamically unstable or drug-refractory patients, which has proven to be safe in all three trimesters, including labor but can result in pre-term labor in the third trimester. Non-fluoroscopic ablation proved to be the only treatment method that definitively resolved SVT without recurrence.

State of Fluoroless Procedures in Cardiac Electrophysiology Practice

In the past decade, the use of interventional electrophysiological (EP) procedures for the diagnosis and treatment of cardiac arrhythmias has exponentially increased. These procedures usually require fluoroscopy to guide the advancement and frequent repositioning of intracardiac catheters, resulting in both the patient and the operator being subjected to a considerable degree of radiation exposure. Although shielding options such as lead gowns, glasses, and pull-down shields are useful for protecting the operator, they do not lessen the patient’s level of exposure. Furthermore, the prolonged use of lead gowns can exponentiate the onset of orthopedic problems among operators. Recent advancements in three-dimensional cardiac mapping systems and the use of radiation-free imaging technologies such as magnetic resonance imaging and intracardiac ultrasound allow operators to perform EP procedures with minimal or even no fluoroscopy. In this review, we sought to describe the state of fluoroless procedures in EP practice.

Zero-fluoroscopy catheter ablation of severe drug-resistant arrhythmia guided by Ensite NavX system during pregnancy: Two case reports and literature review

BACKGROUND

Cardiac arrhythmias can occur during pregnancy. Owing to radiation exposure and other uncertain risks for the mother and fetus, catheter ablation has rarely been performed and is often delayed until the postpartum period. We reported 2 pregnant women who were experiencing severe arrhythmias and were successfully ablated without fluoroscopic guidance. We also carried out a literature review of cases of pregnant women who underwent zero-fluoroscopy ablation.

METHODS AND RESULTS

One woman had drug-resistant and poorly tolerated frequent premature ventricular contraction (PVC) and ventricular tachycardia (VT). The other one had persistent and hardly terminated supraventricular tachycardia (SVT) via a right accessory pathway. The 2 patients were successfully underwent zero-fluoroscopy ablation guided by Ensite NavX system. The procedure time was 42 and 71 minutes, respectively.

CONCLUSION

Catheter ablation of SVT or PVC/VT in pregnant patients can be safely and effectively performed with a completely zero-fluoroscopy approach guided by the Ensite NavX system. In the case of a drug refractory, life-threatening arrhythmia during pregnancy, catheter ablation may be considered.

Ablation of severe drug-resistant tachyarrhythmia during pregnancy

AIMS

The goal of this study was to describe mapping and ablation of severe arrhythmias during pregnancy, with minimum or no X-ray exposure. Treatment of tachyarrhythmia in pregnancy is a clinical problem. Pharmacotherapy entails a risk of adverse effects and is unsuccessful in some patients. Radiofrequency ablation has been performed rarely, because of fetal X-ray exposure and potential maternal and fetus complications. GROUP AND METHOD: Mapping and ablation was performed in 9 women (age 24-34 years) at 12-38th week of pregnancy. Three had permanent junctional reciprocating tachycardia, and 2 had incessant atrial tachycardia. Four of them had left ventricular ejection fraction < or =45%. One patient had atrioventricular nodal reciprocating tachycardia requiring cardioversion. Three patients had Wolff-Parkinson-White syndrome. Two of them had atrial fibrillation with ventricular rate 300 bpm and 1 had atrioventricular tachycardia 300 bpm. Fetal echocardiography was performed before and after the procedure.

RESULTS

Three women had an electroanatomic map and ablation done without X-ray exposure. The mean fluoroscopy time in the whole group was 42 +/- 37 seconds. The mean procedure time was 56 +/- 18 minutes. After the procedure, all women and fetuses were in good condition. After a mean period of 43 +/- 23 months follow up (FU), all patients were free of arrhythmia without complications related to ablation either in the mothers or children.

CONCLUSION

Ablation can be performed safely with no or minimal radiation exposure during pregnancy. In the setting of malignant, drug-resistant arrhythmia, ablation may be considered a therapeutic option in selected cases.