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Wakamatsu Y, Nagashima K, Watanabe R, Hirata S, Hirata M, Okumura Y. Beyond the lens: Unveiling the invisible atrioventricular node in the era of high-density mapping. J Cardiol 2024:S0914-5087(24)00099-6. [PMID: 38834137 DOI: 10.1016/j.jjcc.2024.05.010] [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: 01/10/2024] [Revised: 05/21/2024] [Accepted: 05/29/2024] [Indexed: 06/06/2024]
Abstract
Numerous studies have clarified the histological characteristics of the area surrounding the atrioventricular (AV) node, commonly referred to as the triangle of Koch (ToK). Although it is suggested that the conduction of electric impulses from the atria to the ventricles via the AV node involves myocytes possessing distinct conduction properties and gap junction proteins, a comprehensive understanding of this complex conduction has not been fully established. Moreover, although various pathways have been proposed for both anterograde and retrograde conduction during atrioventricular nodal reentrant tachycardia (AVNRT), the reentrant circuits of AVNRT are not fully elucidated. Therefore, the slow pathway ablation for AVNRT has been conventionally performed, targeting both its anatomical location and slow pathway potential obtained during sinus rhythm. Recently, advancements in high-density three-dimensional (3D) mapping systems have facilitated the acquisition of more detailed electrophysiological potentials within the ToK. Several studies have indicated that the activation pattern, the low-voltage area within the ToK obtained during sinus rhythm, and the fractionated potentials acquired during tachycardia may be optimal targets for slow pathway ablation. This review provides an overview of the tissue surrounding the AV node as reported to date and summarizes the current understanding of AV conduction and AVNRT circuits. Furthermore, we discuss recent findings on slow pathway ablation utilizing high-density 3D mapping systems, exploring strategies for optimal slow pathway ablation.
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Affiliation(s)
- Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shu Hirata
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Moyuru Hirata
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Takahashi K, Kuwahara T, Makita T, Ito Y, Oyagi Y, Kadono K, Oshio T, Takahashi R. A novel approach to typical atrioventricular nodal reentrant tachycardia with high-resolution mapping using the CARTO 3 cardiac mapping system. J Interv Card Electrophysiol 2024; 67:807-816. [PMID: 37930505 DOI: 10.1007/s10840-023-01688-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND We hypothesized that high-resolution activation mapping during sinus rhythm (SR) in Koch's triangle (KT) can be used to describe the most delayed atrial potential around the atrioventricular node and evaluated whether ablation targeting of this potential is safe and effective for the treatment of patients with typical atrioventricular nodal reentrant tachycardia (AVNRT). METHODS We conducted a prospective, non-randomized, observational study using high-resolution activation mapping from the sinus node to KT with a PENTARAY or OCTARAY catheter using the CARTO 3 cardiac mapping system (Biosense Webster) during SR in 62 consecutive patients (22 men; age [mean ± standard deviation] = 55 ± 14 years) treated for typical AVNRT at our institution from August 2021 to March 2023. RESULTS In all cases, the most delayed atrial potential was observed near the His potential within KT. Ablation targeting of this potential helped successfully treat each case of AVNRT, with a junctional rhythm observed at the ablation site. Initial ablation was deemed successful in 55/62 patients (89%); in the remaining seven patients, lesion expansion resolved AVNRT. One procedural complication occurred, namely, a transient atrioventricular block lasting 45 s. One patient experienced a transient tachycardic episode by the 1-month follow-up, but no further episodes were noted up to the 1-year follow-up. CONCLUSION Activation mapping at KT during SR with the high-resolution CARTO system clearly revealed the most delayed atrial potential near the His potential within KT. Targeting this potential was a safe and effective treatment method for patients with typical AVNRT in our study.
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Affiliation(s)
- Kenta Takahashi
- Department of Cardiology, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan.
| | - Taishi Kuwahara
- Department of Cardiology, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Toshio Makita
- Department of Cardiology, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Yayoi Ito
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Yoshimi Oyagi
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Kenta Kadono
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Takuya Oshio
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Ryo Takahashi
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
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Takahashi M, Yamaoka K, Kujiraoka H, Arai T, Hojo R, Fukamizu S. Peak Frequency Annotation Algorithm Guided Slow Pathway Ablation in Typical Atrioventricular Nodal Re-entrant Tachycardia. Heart Rhythm 2024:S1547-5271(24)02631-6. [PMID: 38797307 DOI: 10.1016/j.hrthm.2024.05.037] [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: 03/19/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The slow-pathway potential is difficult to annotate because it is buried within the atrial potential. Omnipolar technology Near Field (OTNF) in Ensite X can automatically annotate the peak frequency potential associated with acquired intracardiac electrograms. OBJECTIVE This study aimed to visualize the junction between the transitional cells and the slow pathway using a peak frequency map with OTNF and evaluate whether the high-frequency site around the tricuspid annulus (TA) is an effective target for slow pathway ablation. METHODS This prospective observational study enrolled 37 patients with typical atrioventricular nodal re-entrant tachycardia. Patients underwent slow pathway ablation using peak frequency map (n = 17) and the conventional approach based on anatomical and electrophysiological findings (n = 20). RESULTS High-frequency sites were distributed at the TA side of 4-5 o'clock in all peak frequency map-guided patients. The distance to His bundle from successful ablation site was farther (24.0 ± 4.8 vs. 12.7 ± 4.0 mm, p < 0.0001), junctional rhythm was slower (88 ± 17 vs. 115 ± 12 bpm, p < 0.0001), time to junctional rhythm after radiofrequency application was shorter (3.4 ± 1.4 vs. 8.2 ± 4.6 sec, p < 0.0001), and elimination rate of jump up (71 vs. 30%, p = 0.02) was higher in the peak frequency map-guided group. CONCLUSION The high-frequency site of the TA at 4-5 o'clock in the peak frequency map could be a novel target of slow pathway ablation with high safety, efficiency, and efficacy.
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Affiliation(s)
- Masao Takahashi
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan.
| | - Koichiro Yamaoka
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Hirofumi Kujiraoka
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Tomoyuki Arai
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Rintaro Hojo
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
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Devecchi C, Matta M, Magnano M, Dell'Era G, Galiffa VA, Renaudo D, Negro A, Occhetta E, Patti G, Rametta F. Voltage and propagation mapping: New tools to improve successful ablation of atrioventricular nodal reentry tachycardia. J Cardiovasc Electrophysiol 2024; 35:942-949. [PMID: 38462681 DOI: 10.1111/jce.16234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/25/2024] [Accepted: 02/19/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Mapping system is useful in ablation of atrioventricular nodal reentry tachycardia (AVNRT) and localization of anatomic variances. Voltage mapping identifies a low voltage area in the Koch triangle called low-voltage-bridge (LVB); propagation mapping identifies the collision point (CP) of atrial wavefront convergence. We conducted a prospective study to evaluate the relationship between LVB and CP with successful site of ablation and identify standard value for LVB. MATERIALS AND METHODS Three-dimensional (3D) maps of the right atria were constructed from intracardiac recordings using the ablation catheter. Cut-off values on voltage map were adjusted until LVB was observed. On propagation map, atrial wavefronts during sinus rhythm collide in the site representing CP, indicating the area of slow pathway conduction. Ablation site was selected targeting LVB and CP site, confirmed by anatomic position on fluoroscopy and atrioventricular ratio. RESULTS Twenty-seven consecutive patients were included. LVB and CP were present in all patients. Postprocedural evaluation identified standard cut-off of 0.3-1 mV useful for LVB identification. An overlap between LVB and CP was observed in 23 (85%) patients. Procedure success was achieved in all patient with effective site at first application in 22 (81%) patients. There was a significant correlation between LVB, CP, and the site of effective ablation (p = .001). CONCLUSION We found correlation between LVB and CP with the site of effective ablation, identifying a voltage range useful for standardized LVB identification. These techniques could be useful to identify ablation site and minimize radiation exposure.
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Affiliation(s)
- Chiara Devecchi
- Division of Cardiology, Ospedale Sant'Andrea, Vercelli, Italy
- Division of Cardiology, AOU Maggiore della Carità, Novara, Italy
| | - Mario Matta
- Division of Cardiology, AOU Città della Salute e della Scienza, Torino, Italy
| | - Massimo Magnano
- Division of Cardiology, Ospedale Sant'Andrea, Vercelli, Italy
| | | | | | | | | | - Eraldo Occhetta
- Division of Cardiology, Ospedale Sant'Andrea, Vercelli, Italy
| | - Giuseppe Patti
- Division of Cardiology, AOU Maggiore della Carità, Novara, Italy
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
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Johnsrude CL, Dasgupta S. Catheter cryoablation guided by propagation mapping to treat dual atrioventricular nodal nonreentrant tachycardia in an adult with postoperative congenital heart disease. HeartRhythm Case Rep 2024; 10:330-334. [PMID: 38799598 PMCID: PMC11116949 DOI: 10.1016/j.hrcr.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Affiliation(s)
- Christopher L. Johnsrude
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - Soham Dasgupta
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
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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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7
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Nakahara S. Editorial comment to "Relationship between the atrial-activation pattern around the triangle of Koch and successful ablation sites in slow-fast atrioventricular nodal reentrant tachycardia". J Arrhythm 2024; 40:222-223. [PMID: 38586853 PMCID: PMC10995592 DOI: 10.1002/joa3.13021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/27/2024] [Indexed: 04/09/2024] Open
Affiliation(s)
- Shiro Nakahara
- Department of CardiologyDokkyo Medical University Saitama Medical CenterKoshigayaSaitamaJapan
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Somasundaram N, Von Bergen NH. High-density "APLE" Mapping-Activation, Propagation, Low Voltage, and Electrogram Evaluation with the HD Grid for Atrioventricular Nodal Re-entry Tachycardia Ablation. J Innov Card Rhythm Manag 2024; 15:5787-5793. [PMID: 38584748 PMCID: PMC10994155 DOI: 10.19102/icrm.2024.15034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/02/2023] [Indexed: 04/09/2024] Open
Abstract
This is the first case series to evaluate high-density mapping of the triangle of Koch (TOK) using the HD Grid to guide slow-pathway ablation integrating activation, propagation (with wave collision), low-voltage signals, and atrial electrogram appearance. We will describe our technique and the results in this case series. Using three-dimensional mapping and the HD Grid, patients underwent high-density voltage mapping of the TOK. Ablation site selection was based on properties during sinus rhythm with late activation, at or above the propagation wave collision, over low voltage, and with appropriate electrogram appearance. Five patients underwent mapping of the slow pathway using the HD Grid. Their median age was 14 years, their median weight was 54.1 kg, and their median height was 161.5 cm. The TOK was mapped with the HD Grid for a median of 3 min. The procedure was successful in all patients using this technique. The median lesion number to the site of success was 3, with a median total number of cryotherapy lesions of 11. No radiation was used. There were no recurrences. Using activation, propagation wave, low voltage, and electrogram appearance when mapping for slow-pathway localization and ablation with the HD Grid can be successful, results in high-density maps, and is relatively faster.
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Affiliation(s)
| | - Nicholas H. Von Bergen
- Department of Pediatrics, The University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Fogarty IV WM, Kamp AN, Eisner M, Kertesz NJ, Kumthekar RN. Beyond Anatomy: Use of Sinus Propagation Mapping to Identify the Slow Pathway for Cryoablation in Pediatric Patients. J Innov Card Rhythm Manag 2023; 14:5682-5688. [PMID: 38155723 PMCID: PMC10752429 DOI: 10.19102/icrm.2023.14124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/09/2023] [Indexed: 12/30/2023] Open
Abstract
Slow pathway modification via cryoablation is a common treatment of atrioventricular nodal re-entrant tachycardia (AVNRT) in pediatric patients. Sinus propagation mapping (SPM) is a tool that has been used to augment identification of the AVNRT slow pathway. We hypothesize that the use of SPM will decrease the total number of ablations performed and decrease the number of ablations until the slow pathway is successfully modified without a significant increase in procedure time. We conducted a retrospective review of patients who underwent cryoablation for AVNRT from August 2016 through March 2021. We excluded patients >21 years of age, those who underwent radiofrequency ablation; those with prior AVNRT ablation, additional pathways, or arrhythmias; and those with congenital heart disease. Out of 122 patients identified by the IMPACT database query, 103 met the inclusion criteria. Fifty-two patients (50.5%) had SPM completed during their procedures. The median number of ablations needed until successful slow pathway modification was two ablations in patients who underwent SPM and four ablations in the non-SPM group (P = .03). There was no significant difference in the total number of ablations between groups. The median total procedural time was longer in the SPM group (152 vs. 125 min; P = .01). SPM can be utilized to further improve the successful treatment of AVNRT with cryotherapy by lowering the number of ablations needed until successful slow pathway modification. However, the technique requires some additional time to collect sufficient data points to create the sinus map.
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Affiliation(s)
| | - Anna N. Kamp
- Division of Cardiology, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mariah Eisner
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Naomi J. Kertesz
- Division of Cardiology, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Rohan N. Kumthekar
- Division of Cardiology, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Chieffo E, D’Amore S, De Regibus V, Dossena C, Frigerio L, Taravelli E, Ferrazzano C, De Iuliis P, Cacucci M, Landolina ME. Atrioventricular nodal reentry tachycardia treatment using CARTO 3 V7 activation mapping: a new era of slow pathway radiofrequency ablation is under coming. Front Cardiovasc Med 2023; 10:1144988. [PMID: 37840959 PMCID: PMC10570829 DOI: 10.3389/fcvm.2023.1144988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 08/28/2023] [Indexed: 10/17/2023] Open
Abstract
Background Slow pathway (SP) ablation is the cornerstone for atrioventricular nodal reentry tachycardia (AVNRT) treatment, and a low-voltage bridge offers a good target during mapping using low x-ray exposure. We aimed to assess a new tool to identify SP by activation mapping using the last CARTO3® version, i.e., CARTO PRIME® V7 (Biosense Webster, Diamond Bar, CA, USA). Methods and results Right atrial septum and triangle of Koch 3D-activation map were obtained from intracardiac contact mapping during low x-ray CARTO 3® procedure. In 60 patients (mean age 60.3 ± 14.7, 61% females) undergoing ablation for AVNRT, an automatic activation map using a DECANAV® mapping catheter and CARTO® Confidense™, Coherent, and FAM DX software modules were obtained. The SP was identified in all patients as the latest atrioventricular node activation area; RF catheter ablation (RFCA) in that region elicited junctional beats. The mean procedural time was 150.3 ± 48.3 min, the mean fluoroscopy time exposure was 2.9 ± 2 min, the mean dose-area product (DAP) was 16.5 ± 2.7 cGy/cm2. The mean number of RF applications was 3.9 ± 2, the mean ablation index was 428.6 ± 96.6, and the mean contact force was 8 ± 2.8 g. There were no adverse event during the procedure, and no AVNRT recurrences occurred during a mean follow-up of 14.3 ± 8.3 months. Conclusion Ablation of the SP by automatic mapping using Confidense™, Coherent, and FAM DX software modules is an innovative, safe, and effective approach to AVNRT ablation. The CARTO3® V7 system shows on a 3D map the latest AV node activation area during sinus rhythm allowing low fluoroscopy time and highly effective RFCA.
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Affiliation(s)
- Enrico Chieffo
- Department of Cardiology, ASST Ospedale Maggiore, Crema, Italy
| | - Sabato D’Amore
- Department of Cardiology, ASST Ospedale Maggiore, Crema, Italy
| | | | - Cinzia Dossena
- Department of Cardiology, ASST Ospedale Maggiore, Crema, Italy
| | - Laura Frigerio
- Department of Cardiology, ASST Ospedale Maggiore, Crema, Italy
| | - Erika Taravelli
- Department of Cardiology, S. Croce e Carle Hospital, Cuneo, Italy
| | | | | | - Michele Cacucci
- Department of Cardiology, ASST Ospedale Maggiore, Crema, Italy
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Drago F, Raimondo C, Tamborrino PP, Silvetti MS, Alberio AMQ, Annibali R, Fanti V, Raponi M. AVNRT cryoablation in children <26 kg: efficacy and safety of electrophysiologically guided low-voltage bridge strategy. Pacing Clin Electrophysiol 2023; 46:543-547. [PMID: 36815543 DOI: 10.1111/pace.14660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/14/2022] [Accepted: 12/30/2022] [Indexed: 02/24/2023]
Abstract
The recently published "electrophysiologically guided low-voltage bridge (LVB) strategy" is effective in the ablation of atrioventricular nodal re-entry tachycardia (AVNRT) in children. This study aimed to evaluate its efficacy and safety in children <26 kgs. Fourteen children [64% males, median age 6.5 years (IQR 6-8 years), median weight 25.5 kg (IQR 24-26 kg)] with AVNRT were treated. In all patients, we detected a LVB associated to a typical slow pathway potential. The acute success rate was 100% with a mean of 5.5 cryoablation deliveries. All procedures were performed with near-zero fluoroscopic exposure (median time 0.15 min, IQR 0-0.7 min), in six patients fluoroscopy was 0 min. There were no complications or recurrences during the follow-up (median 20.91 months, IQR 11.7-26.7 months).
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Affiliation(s)
- Fabrizio Drago
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Cristina Raimondo
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Paolo Tamborrino
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Massimo Stefano Silvetti
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonino Maria Quintilio Alberio
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Tseng WC, Wu MH, Lu CW, Wu KL, Wang JK, Lin MT, Chen CA, Chiu SN. Combination of Slow Pathway Late Activation Maps and Voltage Gradient Maps in Guidance of Atrioventricular Nodal Reentry Tachycardia Cryoablation. Heart Rhythm 2023:S1547-5271(23)02105-7. [PMID: 37075960 DOI: 10.1016/j.hrthm.2023.04.006] [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: 02/12/2023] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND The optimal strategy for electroanatomic mapping-guided cryoablation of atrioventricular nodal reentry tachycardia (AVNRT) remains unclear. OBJECTIVE To investigate the effectiveness of slow pathway late activation mapping (SPLAM) and voltage gradient mapping for AVNRT cryoablation. METHODS From June 2020 to February 2022, all consecutive patients with AVNRT underwent SPLAM to define the wave collision point and voltage gradient mapping to define the low voltage bridge (LVB). Conventional procedures performed from August 2018 to May 2020 served as control. RESULTS The study and control groups comprised 36 (aged 16.5±8.2 years) and 37 patients (aged 15.5±7.3 years), respectively. Total procedural times were comparable, and acute success rates were 100% in both groups. Compared to controls, number of cryomapping attempts (median 3 vs. 5, p=0.012) and cryoablation applications (median 1 vs. 2, p<0.001) were significantly lower in the study group. At a median follow-up of 14.6 and 18.3 months, recurrence rates were 5.6% (2 patients) and 10.8% (4 patients) in the study and control groups (p=0.402), respectively. Mapping of Koch's triangle took 11.8±3.6 min, in which 1562±581 points were collected. In SPLAM, wave collision points were defined and compatible with the final successful lesion sites in all patients, including those with multiple slow pathways. LVB could not be defined in 6 patients (16.7%), and LVB was not compatible with the final successful lesion in another 6 (16.7%). CONCLUSIONS For AVNRT cryoablation, SPLAM could effectively guide the localization of slow pathway ablation sites and was particularly beneficial in patients with multiple slow pathways.
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Affiliation(s)
- Wei-Chieh Tseng
- Department of Emergency Medicine, National Taiwan University Hospital/National Taiwan University Children's Hospital. No 7 & 8, Chun-Shan South Road, Taipei 100, Taiwan; Department of Pediatrics, National Taiwan University Hospital/National Taiwan University Children's Hospital. No 7 & 8, Chun-Shan South Road, Taipei 100, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital/National Taiwan University Children's Hospital. No 7 & 8, Chun-Shan South Road, Taipei 100, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital/National Taiwan University Children's Hospital. No 7 & 8, Chun-Shan South Road, Taipei 100, Taiwan
| | - Kun-Lang Wu
- Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan. No. 320, Xuguang Rd., Changhua City, Changhua County 500, Taiwan
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital/National Taiwan University Children's Hospital. No 7 & 8, Chun-Shan South Road, Taipei 100, Taiwan
| | - Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Hospital/National Taiwan University Children's Hospital. No 7 & 8, Chun-Shan South Road, Taipei 100, Taiwan
| | - Chun-An Chen
- Department of Pediatrics, National Taiwan University Hospital/National Taiwan University Children's Hospital. No 7 & 8, Chun-Shan South Road, Taipei 100, Taiwan
| | - Shuenn-Nan Chiu
- Department of Pediatrics, National Taiwan University Hospital/National Taiwan University Children's Hospital. No 7 & 8, Chun-Shan South Road, Taipei 100, Taiwan.
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13
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Gerontitis D, Pope MT, Elmowafy M, Sadagopan S, Yue AM. High-density electro-anatomical activation mapping to guide slow pathway modification in patients with persistent left superior vena cava. Heart Rhythm 2023:S1547-5271(23)02025-8. [PMID: 37019166 DOI: 10.1016/j.hrthm.2023.03.1537] [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: 02/18/2023] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Slow pathway (SP) mapping and modification can be challenging in patients with persistent left superior vena cava (PLSVC) due to anatomical variance of Koch's triangle (KT) and coronary sinus (CS) dilatation. There is a lack of studies using detailed 3-dimensional (3D) electro-anatomical mapping (EAM) to investigate conduction characteristics and guide ablation targets in this condition. OBJECTIVES To describe a novel technique of slow pathway mapping and ablation in sinus rhythm using 3D EAM in patients with PLSVC after validation in a cohort with normal coronary sinus anatomy. METHODS Seven patients with PLSVC and dual AV node physiology who underwent slow pathway modification with the use of 3D EAM were included. Twenty-one normal heart patients with AV nodal re-entrant tachycardias formed the validation group. High-resolution, ultra-high-density local activation timing (LAT) mapping of the right atrial septum and proximal coronary sinus in sinus rhythm was performed. RESULTS SP ablation targets were consistently identified by an area in the right atrial septum with the latest activation time and multi-component atrial electrogram (EGM) adjacent to a region with isochronal crowding (deceleration zone). In PLSVC patients, these targets were located at or within 1 cm of the mid anterior CS ostium. Ablation in this area led to successful SP modification reaching standard clinical endpoints with a median of 43 sec of radio frequency energy or 14 mins of cryoablation without complications. CONCLUSION High-resolution activation mapping of Koch's triangle in sinus rhythm can facilitate localisation and safe slow pathway ablation in patients with PLSVC.
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Affiliation(s)
- Dimitrios Gerontitis
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Michael Tb Pope
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Mahmoud Elmowafy
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Shankar Sadagopan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Arthur M Yue
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
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14
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Costa A, Marinelli A, Rauhe W, Martignani C, Ignatiuk B, Sabbatani P, Nangah R, Basso F, Molon G. Voltage mapping of Koch’s triangle in atrioventricular nodal reentrant tachycardia ablation. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01432-5. [DOI: 10.1007/s10840-022-01432-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
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15
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von Alvensleben JC, Sandhu A, Chang S, Runciman DM, Wehrmann M, Tzou DW, Schäfer M, Collins KK. High-density electroanatomic mapping with grid catheter in pediatrics and congenital heart disease. J Interv Card Electrophysiol 2022; 66:611-619. [PMID: 36104612 DOI: 10.1007/s10840-022-01364-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/29/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The Advisor™ HD Grid mapping catheter (Abbott Laboratories; Chicago, IL) allows for bipolar electrogram collection in both orthogonal and perpendicular planes, unique when compared to traditional and branch catheters. Experience in pediatric patients and congenital heart disease (CHD) is limited. The purpose of this work was to evaluate the utility and safety of the Advisor™ HD Grid mapping catheter in pediatric and CHD populations. METHODS Retrospective review of all pediatric patients and those with CHD (regardless of age) at Children's Hospital Colorado and University of Colorado undergoing electrophysiologic study in which the Advisor™ HD Grid mapping catheter was utilized. RESULTS Sixty-five procedures in 60 patients (N = 31 female (47.6%), median age 17 years (15-24.1)) were included. Patients had CHD in 30 procedures (46.1%). Eight-eight arrhythmia substrates were mapped including atrial flutter/intra-atrial reentrant tachycardia (N = 33), focal atrial tachycardia (N = 20), isolated PVCs (N = 10), accessory pathways (N = 9), atrioventricular nodal reentrant tachycardia (N = 7), right ventricular substrate mapping (N = 7), and ventricular tachycardia (N = 2). Median time per map was 11.8 (7.5-20.1) min with 3.2 (± 1.7) maps per procedure and a median of 2634 (1767-7654) points used per map. Patients with CHD required more maps (p < 0.001) and points per map (p < 0.001). Ablation was successful in 92.4% of procedures. CONCLUSIONS The Advisor™ HD Grid mapping catheter is safe and effective in the pediatric and congenital heart disease population. A wide variety of arrhythmia substrates can be mapped with high point density and low mapping time.
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16
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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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17
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Howard TS, Valdes SO, Zobeck MC, Lam WW, Miyake CY, Rochelson E, Dan Pham T, Kim JJ. Ripple Mapping: A precise tool for atrioventricular nodal reentrant tachycardia ablation. J Cardiovasc Electrophysiol 2022; 33:1183-1189. [PMID: 35419906 DOI: 10.1111/jce.15491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/16/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Ablation for atrioventricular nodal reentrant tachycardia (AVNRT) classically utilizes evaluation of signal morphology within the anatomic region of the slow pathway (SP), which involves subjectivity. Ripple Mapping (RM) (CARTO-3© Biosense Webster Inc, Irvine, CA) displays each electrogram at its 3-dimensional coordinate as a bar changing in length according to its voltage-time relationship. This allows prolonged, low-amplitude signals to be displayed in their entirety, helping identify propagation in low-voltage areas. We set out to evaluate the ability of RM to locate the anatomic site of the slow pathway and assess its use in guiding ablation for AVNRT. METHODS Patients ≤18 yrs with AVNRT in the EP laboratory between 2017 and 2021 were evaluated. RM was performed to define region of SP conduction in patients from 2019-2021, whereas standard electro-anatomical mapping was used from 2017-2019. All ablations were performed using cryo-therapy. Demographics, outcomes and analysis of variance in number of test lesions until success were compared between groups. RESULTS A total 115 patients underwent AVRNT ablation during the study; 46 patients were in the RM group and 69 were in the control group. There were no demographic differences between groups. All procedures, in both groups, were acutely successful. In RM group, 89% of first successful lesions were within 4mm of the predicted site. There was significantly reduced variability in number of test lesions until success in the RM group (p=0.01). CONCLUSIONS RM is a novel technique that can help identify slow pathway location, allowing for successful ablation of AVNRT with decreased variability. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Taylor S Howard
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Santiago O Valdes
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Mark C Zobeck
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Wilson W Lam
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Christina Y Miyake
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.,Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Tx, USA
| | - Ellis Rochelson
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Tam Dan Pham
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jeffrey J Kim
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Waldmann V, Hebe J, Walsh EP, Khairy P, Ernst S. Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia in Patients With Congenital Heart Disease. Circ Arrhythm Electrophysiol 2022; 15:e010631. [PMID: 35089803 DOI: 10.1161/circep.121.010631] [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] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Victor Waldmann
- Electrophysiology and Adult Congenital Heart Disease Medico-Surgical Unit, European Georges Pompidou Hospital, Paris, France (V.W.).,Pediatric and Congenital Heart Disease Department, Necker Hospital, Paris, France (V.W.)
| | - Joachim Hebe
- Center for Electrophysiology Bremen at Heart Center Bremen, Germany (J.H.)
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (E.P.W.)
| | - Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Quebec, Canada (P.K.)
| | - Sabine Ernst
- Royal Brompton Hospital, Guys and St. Thomas' NHS Foundation Trust, London, United Kingdom (S.E.).,National Heart and Lung Institute, Imperial College, London, United Kingdom (S.E.)
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19
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Drago F, Tamborrino PP, Porco L, Campisi M, Fanti V, Annibali R, Silvetti MS. Koch's triangle voltage mapping for cryoablation of slow pathway in children: preliminary data of a novel high-density technique. J Interv Card Electrophysiol 2021; 63:621-628. [PMID: 34697756 DOI: 10.1007/s10840-021-01081-0] [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: 06/15/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Different authors have described three-dimensional (3D) voltage mapping of the Koch's triangle (KT) in order to find low-voltage bridges (LVB) as targets for a successful transcatheter ablation (TCA) of the slow pathway (SP) in children. Recently, the Advisor High Density (HD) Grid™ mapping catheter was introduced as new multipolar catheter for HD mapping. The aim of the study was to describe our preliminary experience with the use of HD Grid™ catheter in LVB and electrophysiologically guided cryoablation of SP in children. METHODS Twenty-one children (mean age 13±3 years) with atrioventricular nodal re-entrant tachycardia (AVNRT) underwent cryoablation of SP guided by voltage HD mapping of the KT using HD Grid™ catheter. In order to better highlight the differences with conventional mapping, point collection was performed in each patient with this new multipolar catheter and with a quadripolar catheter. RESULTS The conventional mapping collected 871±262 points and used 211±80 points in 887±275 s, whereas HD mapping collected 7468±2947 points, using 604±165 points in 513±181 s (p<0.001). Moreover, the LVB area mapped with HD Grid™ was about one-half smaller and clearly delineated. Cryoablation acute success rate was 100%. Overall median fluoroscopy exposure was 0.08 (0.01-5.42) μGy/m2, with a median fluoroscopy time of 0.1 (0.0-0.6) min. During the follow-up (4.8 ± 3.7 months), there were no recurrences. No complications occurred. CONCLUSIONS Our preliminary experience shows that HD mapping is faster and offers higher spatial resolution and definition. Procedural time can be reduced maintaining the TCA safe, with reduced fluoroscopy use and success.
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Affiliation(s)
- Fabrizio Drago
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart - ERN-Guard Heart), Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy.
| | - Pietro Paolo Tamborrino
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart - ERN-Guard Heart), Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Luigina Porco
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart - ERN-Guard Heart), Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Marta Campisi
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart - ERN-Guard Heart), Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Veronica Fanti
- Abbott, St Jude Abbott Medical Italia, Milan, Sesto San Giovanni, Italy
| | - Roberta Annibali
- Abbott, St Jude Abbott Medical Italia, Milan, Sesto San Giovanni, Italy
| | - Massimo Stefano Silvetti
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart - ERN-Guard Heart), Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
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20
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Physiology of slow pathway conduction during sinus rhythm: evidence from high density mapping within the triangle of Koch. J Interv Card Electrophysiol 2021; 63:573-580. [PMID: 34518928 DOI: 10.1007/s10840-021-01061-4] [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: 12/08/2020] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate nature of AV nodal activation in patients with AVNRT using high density electro-anatomic mapping (HD-EAM). METHODS HD-EAM was created in 30 patients with AVNRT from the triangle of Koch (ToK) in sinus rhythm (SR). Isochronal late activation maps (ILAM) were created. EAMs were analyzed for slow pathway (SPW) and fast pathway (FPW) activation. A pivot point (PP) was defined where FPW and SPW collided and pivoted back to the AV node (AVN). Conduction was assessed with programmed extrastimulus (PES) in 9 patients until FPW refractory period (ERP). The change in PP distance from the HIS (ΔPP) was measured in SR and PES. The ΔPP was compared to ΔAH. The PP was ablated and SR re-mapped. RESULTS The FPW activates the His and moves inferiorly toward the coronary sinus (CS). Activation also enters the ToK near the CS and collides with the FPW which then pivots around a functional line of block (LOB) within the ToK and moves superiorly along the septal tricuspid annulus. PP electrograms are fractionated, low amplitude, and consistent with SPW potentials (Haissaguerre et al. in Circulation 85:2162-2175, 1992). During PES the PP moved superiorly until FPW ERP when only SPW activation occurs. Normalized ΔAH and ΔPR vs ΔPP was highly correlated p < 0.0001. Ablation at the PP was successful and associated with loss of SPW fusion and pivot. CONCLUSION We conclude HD-EAM/ILAM provide a novel method for localizing the SPW in SR. This study provides further understanding of dual AV nodal physiology and may aid in targeting the SPW for ablation of AVNRT.
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21
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Drago F, Calvieri C, Russo MS, Remoli R, Pazzano V, Battipaglia I, Gimigliano F, Allegretti G, Silvetti MS. Low-voltage bridge strategy to guide cryoablation of typical and atypical atrioventricular nodal re-entry tachycardia in children: mid-term outcomes in a large cohort of patients. Europace 2021; 23:271-277. [PMID: 33038208 DOI: 10.1093/europace/euaa195] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/18/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS In the current literature, results of the low-voltage bridge (LVB) ablation strategy for the definitive treatment of atrioventricular nodal re-entry tachycardia (AVNRT) seem to be encouraging also in children. The aims of this study were (i) to prospectively evaluate the mid-term efficacy of LVB ablation in a very large cohort of children with AVNRT, and (ii) to identify electrophysiological factors associated with recurrence. METHODS AND RESULTS One hundred and eighty-four children (42% male, mean age 13 ± 4 years) with AVNRT underwent transcatheter cryoablation guided by voltage mapping of the Koch's triangle. Acute procedural success was 99.2% in children showing AVNRT inducibility at the electrophysiological study. The overall recurrence rate was 2.7%. The presence of two LVBs, a longer fluoroscopy time and the presence of both typical and atypical AVNRT, were found to be significantly associated with an increased recurrence rate during mid-term follow-up. Conversely, there was no significant association between recurrences and patient's age, type of LVB, lesion length, number of cryolesions or catheter tip size. CONCLUSION The LVB ablation strategy is very effective in AVNRT treatment in children. Recurrences are related to the complexity of the arrhythmogenic substrate.
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Affiliation(s)
- Fabrizio Drago
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Palidoro-Rome, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Camilla Calvieri
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Palidoro-Rome, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Mario Salvatore Russo
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Palidoro-Rome, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Romolo Remoli
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Palidoro-Rome, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Vincenzo Pazzano
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Palidoro-Rome, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Irma Battipaglia
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Palidoro-Rome, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Fabrizio Gimigliano
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Palidoro-Rome, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | | | - Massimo Stefano Silvetti
- Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Palidoro-Rome, Piazza Sant'Onofrio 4, 00165 Rome, Italy
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J Bailin S, Shantha G, Doshi H, Hoffman C. Substrate Targeted Ablation of Atrial Fibrillation Guided by High Density Voltage Mapping: Long-Term Results. J Atr Fibrillation 2020; 13:2270. [PMID: 34950289 DOI: 10.4022/jafib.2270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 12/26/2019] [Accepted: 01/05/2020] [Indexed: 11/10/2022]
Abstract
Background Long-term ablation results for atrial fibrillation (AF) have been disappointing, particularly for non-paroxysmal AF (NPAF). We hypothesize fibrosis in paroxysmal AF (PAF) and NPAF would be reflected in voltage fragmentation and visualized by high density mapping. Targeted ablation of discrete low voltage bridges (LVB) would eliminate endocardial fragmentation and should have a positive effect on long-term sinus rhythm (SR) survival. Objective To assess the efficacy of LVB ablation on SR survival in patients with PAF and NPAF, as well as, determine its impact on P wave duration (PWD) and LA volume (LAV). Methods 56 patients (29PAF/26NPAF) had a voltage gradient map (VGM) created, high and low voltage limits were adjusted to image LVB. Ablation was performed until no LVB were observed. Baseline PWD and LAV were obtained and reassessed 6 months' post ablation. Patients were followed for 5 years with intermittent monitors. Results Termination of AF in NPAF was 88%. PWD normalized in PAF and were normal in NPAF post ablation. LAV decreased significantly in NPAF. At 5 years, SR was observed in 89% of PAF and 67% of NPAF. Conclusions 1. LVB ablation terminates AF in NPAF 88%; 2. Both PWD and LAV were improved; 3. Maintenance of SR was observed in 89% and 67% (PAF vs NPAF); 4. The present study demonstrates efficacy of a simplified, individualized, and unified methodology for AF ablation.
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Affiliation(s)
- Steven J Bailin
- Department of electrophysiology, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Ghanshyam Shantha
- Department of electrophysiology, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Hardik Doshi
- Department of electrophysiology, University of Iowa Hospital and Clinics, Iowa City, Iowa
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23
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Young M, Niu J. Using coronary sinus ostium as the reference for the slow pathway ablation of atrioventricular nodal reentrant tachycardia in children. J Arrhythm 2020; 36:712-719. [PMID: 32782644 PMCID: PMC7411203 DOI: 10.1002/joa3.12379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/13/2020] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful slow pathway (SP) ablation sites for atrioventricular nodal reentrant tachycardia (AVNRT) are usually located inside the Koch's triangle (KT). This study aimed to determine the ablation site of SP using the coronary sinus (CS) ostium (CSO) as the reference and to evaluate the efficacy of the CSO-guided SP ablation. METHODS A regional geometry around the KT was constructed by 3D mapping in 52 consecutive patients under age 18 with AVNRT. SP cryoablation was performed. If initial cryoablation was unsuccessful or cryoablation was deemed not suitable, then radiofrequency (RF) ablation was performed. The successful ablation site direction relative to the CSO was expressed as o'clock with the CSO viewed as a clock. RESULTS Cryoablation was used as the primary energy source in 40 patients. Of which, 32 were successful and eight required additional RF ablation. Direct RF ablation was performed in 11 patients. Using the CSO as reference, the successful site with cryoablation was at its 2.2 ± 0.6 o'clock; the RF ablation success site was at CSO 2.7 ± 0.5 o'clock (P = .006). During a median follow-up of 12 month, there was 98% success of SP ablation in these patients, with one patient with RF ablation had a tachycardia recurrence. CONCLUSIONS Using CSO as reference, the cryoablation site at its 2:00 o'clock and RF ablation at its 3:00 o'clock are highly efficacious for SP ablation with good short-term outcomes, and may be a useful tool in guiding the ablation target for AVNRT.
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Affiliation(s)
- Ming‐Lon Young
- Heart InstituteJoe DiMaggio Children’s Hospital, Memorial Healthcare SystemHollywoodFLUSA
| | - Jianli Niu
- Office of Human ResearchMemorial Healthcare SystemHollywoodFLUSA
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24
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Hale ZD, Greet BD, Burkland DA, Greenberg S, Razavi M, Rasekh A, Molina Razavi JE, Saeed M. Slow-pathway visualization by using voltage-time relationship: A novel technique for identification and fluoroless ablation of atrioventricular nodal reentrant tachycardia. J Cardiovasc Electrophysiol 2020; 31:1430-1435. [PMID: 32270564 DOI: 10.1111/jce.14481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrioventricular nodal reentrant tachycardia (AVNRT) is treatable by catheter ablation. Advances in mapping-system technology permit fluoroless workflow during ablations. As national practice trends toward fluoroless approaches, easily obtained, reproducible methods of slow-pathway identification, and ablation become increasingly important. We present a novel method of slow-pathway identification and initial ablation results from this method. METHODS AND RESULTS We examined AVNRT ablations performed at our institution over a 12-month period. In these cases, the site of the slow pathway was predicted by latest activation in the inferior triangle of Koch during sinus rhythm. Ablation was performed in this region. Proximity of the predicted site to the successful ablation location, complication rates, and patient outcomes were recorded. Junctional rhythm was seen in 40/41 ablations (98%) at the predicted site (mean, 1.3 lesions and median, 1 lesion per case). One lesion was defined as 5 mm of ablation. The initial ablation was successful in 39/41 cases (95%); in two cases, greater or equal to 2 echo beats were detected after the initial ablation, necessitating further lesion expansion. In 8/41 cases (20%), greater than one lesion was placed during initial ablation before attempted reinduction. Complications included one transient heart block and one transient PR prolongation. During follow-up (median, day 51), one patient had lower-extremity deep-vein thrombosis and pulmonary embolus, and one had a lower-extremity superficial venous thrombosis. There was one tachycardia recurrence, which prompted a redo ablation. CONCLUSIONS Mapping-system detection of late-activation, low-amplitude voltage during sinus rhythm provides an objective, and fluoroless means of identifying the slow pathway in typical AVNRT.
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Affiliation(s)
- Zachary D Hale
- Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas
| | - Brian D Greet
- Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas.,Department of Cardiology, University of Texas, Houston, Texas
| | - David A Burkland
- Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas.,Texas Cardiac Arrhythmia, Houston, Texas
| | - Scott Greenberg
- Department of Cardiology, Baylor College of Medicine, The Woodlands, Texas
| | - Mehdi Razavi
- Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas
| | - Abdi Rasekh
- Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas
| | - Joanna E Molina Razavi
- Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas
| | - Mohammad Saeed
- Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas
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25
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Catheter ablation of atrioventricular nodal re-entrant tachycardia: Humans versus machines? Rev Port Cardiol 2019; 38:193-194. [PMID: 30992175 DOI: 10.1016/j.repc.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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26
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Creta A, Providência R. Catheter ablation of atrioventricular nodal re-entrant tachycardia: Humans versus machines? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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27
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The low specificity of low voltage bridges associating atrioventricular nodal reentry in pediatric patients. J Interv Card Electrophysiol 2018; 54:277-281. [PMID: 30032471 DOI: 10.1007/s10840-018-0382-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/15/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Patients with atrioventricular nodal reentry tachycardia (AVNRT) often are managed successfully by ablation of the slow pathway with success rates reported as high as 99%. Low voltage bridges (LVBs) have been demonstrated to be helpful in guiding AVNRT ablation. Patients may present to the electrophysiology lab without evidence of inducible arrhythmia. In these scenarios, the demonstration of LVBs may be diagnostic and guide catheter ablation treatment. The purpose of our study was to prospectively investigate the specificity of LVBs as a diagnostic marker of AVNRT. METHODS Patients aged < 19 years with narrow complex tachycardia prospectively underwent electrophysiology study with intention to perform catheter ablation. In each patient, the primary objective was the collection of right atrial voltage data that was then used to identify LVBs. RESULTS Twenty-four patients were included after exclusion criteria were applied. Final diagnosis was 11 AVNRT and 13 non-AVNRT (nAVNRT). LVBs were identified in 11/11 AVNRT patients and 9/13 non-AVNRT patients (p = 0.09). CONCLUSIONS LVBs are not specific to patients with AVNRT and cannot solely be used for diagnosis. However, in patients with documented AVNRT, the LVB can be used to identify the location of the slow pathway.
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28
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Moak JP. Look and you shall find: Perils along the road after slow pathway ablation for AV nodal reentry tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:194-196. [PMID: 29266362 DOI: 10.1111/pace.13261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 12/05/2017] [Accepted: 12/10/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Jeffrey P Moak
- Division of Cardiology, Children's National Health System, Washington, DC, USA
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29
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Reddy CD, Ceresnak SR, Motonaga KS, Avasarala K, Feller C, Trela A, Hanisch D, Dubin AM. Bridge to success: A better method of cryoablation for atrioventricular nodal reentrant tachycardia in children. Heart Rhythm 2017; 14:1649-1654. [DOI: 10.1016/j.hrthm.2017.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Indexed: 10/19/2022]
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30
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Cryoablation for atrioventricular nodal reentry tachycardia: Role of "mapping" and "pseudo-mapping". Indian Pacing Electrophysiol J 2017; 17:91-94. [PMID: 29067914 PMCID: PMC5527815 DOI: 10.1016/j.ipej.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 07/06/2017] [Indexed: 11/20/2022] Open
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31
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Van Aartsen A, Law IH, Maldonado JR, Von Bergen NH. Propagation Mapping Wave Collision Correlates to the Site of Successful Ablation During Voltage Mapping in Atrioventricular Nodal Reentry Tachycardia. J Innov Card Rhythm Manag 2017; 8:2836-2842. [PMID: 32494469 PMCID: PMC7252827 DOI: 10.19102/icrm.2017.080905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/02/2017] [Indexed: 11/06/2022] Open
Abstract
Voltage mapping has been used previously for slow-pathway localization for atrioventricular nodal reentrant tachycardia (AVNRT) ablation. However, propagation mapping may be a technique to further improve the localization of the slow pathway. This retrospective study aimed to evaluate the relationship of the propagation map to both the voltage mapping and successful site of ablation in patients who underwent ablation for AVNRT. All patients ≤20 years of age who underwent voltage mapping for AVNRT were included in this study. Patients were excluded if they had congenital heart disease or inadequate voltage point density within the triangle of Koch (TK). During the study, a propagation map was evaluated from the prior voltage map, marking a "wave collision" at the site of atrial wave convergence. Patient and procedural information, the location of the wave collision, the site of successful ablation, and the appearance of the voltage map were evaluated. Ultimately, 39 patients aged from four years of age to 20 years of age were evaluated. Success was achieved in 100% of patients, with a recurrence rate of 2.8% and no long-term complications observed. The average procedure time was 127 min. Follow-up length averaged seven months post operation. Low-voltage areas, and a wave collision, were present in all patients. This wave collision was typically located within the TK. The median number of ablations required for successful outcome was two. The successful ablation lesion was typically located over a low-voltage area within 4 mm of the wave collision within the TK. In conclusion, we found in this retrospective evaluation that propagation mapping resulted in a wave collision within the TK, and that the successful ablation site in the majority of patients was near a low-voltage area within 4 mm, typically superiorly, to the wave collision within the TK.
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Affiliation(s)
- Amy Van Aartsen
- Division of Cardiology, Department of Pediatrics, The University of Wisconsin-Madison, Madison, WI
| | - Ian H Law
- Division of Cardiology, Department of Pediatrics, The University of Iowa, Iowa City, IA
| | - Jennifer R Maldonado
- Division of Cardiology, Department of Pediatrics, The University of Iowa, Iowa City, IA
| | - Nicholas H Von Bergen
- Division of Cardiology, Department of Pediatrics, The University of Wisconsin-Madison, Madison, WI
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32
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Pang BJ, Redpath CJ, Green MS. Crossing the slow pathway bridge: A better method for decreasing long-term recurrences after cryoablation of atrioventricular nodal reentrant tachycardia? Heart Rhythm 2017; 14:1655-1656. [PMID: 28765089 DOI: 10.1016/j.hrthm.2017.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Benjamin J Pang
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Calum J Redpath
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martin S Green
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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33
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Choe WC, Sundaram S, Boorman C, Mullins N, Shamszad P, Plat F. High-density mapping of the slow pathway in a patient with atrioventricular nodal reentry given intranasal Etripamil during the NODE-1 study. HeartRhythm Case Rep 2017; 3:479-482. [PMID: 29062702 PMCID: PMC5643855 DOI: 10.1016/j.hrcr.2017.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- William C Choe
- Section of Cardiac Electrophysiology, South Denver Cardiology Associates, Littleton, Colorado
| | - Sri Sundaram
- Section of Cardiac Electrophysiology, South Denver Cardiology Associates, Littleton, Colorado
| | | | | | | | - Francis Plat
- Milestone Pharmaceuticals Inc, Montreal, Quebec, Canada
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34
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Papagiannis J, Beissel DJ, Krause U, Cabrera M, Telishevska M, Seslar S, Johnsrude C, Anderson C, Tisma-Dupanovic S, Connelly D, Avramidis D, Carter C, Kornyei L, Law I, Von Bergen N, Janusek J, Silva J, Rosenthal E, Willcox M, Kubus P, Hessling G, Paul T. Atrioventricular Nodal Reentrant Tachycardia in Patients With Congenital Heart Disease. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004869. [DOI: 10.1161/circep.116.004869] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 06/08/2017] [Indexed: 11/16/2022]
Abstract
Background—
The relationship of atrioventricular nodal reentrant tachycardia to congenital heart disease (CHD) and the outcome of catheter ablation in this population have not been studied adequately.
Methods and Results—
A multicenter retrospective study was performed on patients with CHD who had atrioventricular nodal reentrant tachycardia and were treated with catheter ablation. There were 109 patients (61 women), aged 22.1±13.4 years. The majority, 86 of 109 (79%), had CHD resulting in right heart pressure or volume overload. Patients were divided into 2 groups: group A (n=51) with complex CHD and group B (n=58) with simple CHD. There were no significant differences between groups in patients’ growth parameters, use of 3-dimensional imaging, and type of ablation (radiofrequency versus cryoablation). Procedure times (251±117 versus 174±94 minutes;
P
=0.0006) and fluoroscopy times (median 20.8 versus 16.6 minutes;
P
=0.037) were longer in group A versus group B. There were significant differences between groups in the acute success of ablation (82% versus 97%;
P
=0.04), risk of atrioventricular block (14 versus 0%;
P
=0.004), and need for chronic pacing (10% versus 0%;
P
=0.008). There was no permanent atrioventricular block in patients who underwent cryoablation. After 3.2±2.7 years of follow-up, long-term success was 86% in group A and 100% in group B (
P
=0.004).
Conclusions—
Atrioventricular nodal reentrant tachycardia can complicate the course of patients with CHD. This study demonstrates that the outcome of catheter ablation is favorable in patients with simple CHD. Patients with complex CHD have increased risk of procedural failure and atrioventricular block.
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Affiliation(s)
| | | | - Ulrich Krause
- For the author affiliations, please see the Appendix
| | | | | | | | | | | | | | | | | | | | | | - Ian Law
- For the author affiliations, please see the Appendix
| | | | - Jan Janusek
- For the author affiliations, please see the Appendix
| | | | | | - Mark Willcox
- For the author affiliations, please see the Appendix
| | - Peter Kubus
- For the author affiliations, please see the Appendix
| | | | - Thomas Paul
- For the author affiliations, please see the Appendix
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Catheter ablation of atypical atrial flutter: a novel 3D anatomic mapping approach to quickly localize and terminate atypical atrial flutter. J Interv Card Electrophysiol 2017; 49:307-318. [PMID: 28664343 DOI: 10.1007/s10840-017-0269-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aims to describe a novel method of High Density Activation Sequence Mapping combined with Voltage Gradient Mapping Overlay (HD-VGM) to quickly localize and terminate atypical atrial flutter. METHODS Twenty-one patients presenting with 26 different atypical atrial flutter circuits after a previous catheter or surgical AF ablation were studied. HD-VGM was performed with a commercially available impedance-based mapping system to locate and successfully ablate the critical isthmus of each tachycardia circuit. The results were compared to 21 consecutive historical control patients who had undergone an atypical flutter ablation without HD-VGM. RESULTS Twenty-six different atypical flutter circuits were evaluated. An average 3D anatomic mapping time of 12.39 ± 4.71 min was needed to collect 2996 ± 690 total points and 1016 ± 172 used mapping points. A mean of 195 ± 75 s of radiofrequency (RF) energy was needed to terminate the arrhythmias. The mean procedure time was 135 ± 46 min. With a mean follow-up 16 ± 9 months, 90% are in normal rhythm. In comparison to the control cohort, the study cohort had a shorter procedure time (135 ± 46 vs. 210 ± 41 min, p = 0.0009), fluoroscopy time (8.5 ± 3.7 vs. 17.7 ± 7.7 min, p = 0.0021), and success in termination of the arrhythmia during the procedure (100 vs. 68.2%, p = 0.0230). CONCLUSIONS Ablation of atypical atrial flutter is challenging and time consuming. This case series shows that HD-VGM mapping can quickly localize and terminate an atypical flutter circuit.
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Drago F, Battipaglia I, Russo MS, Remoli R, Pazzano V, Grifoni G, Allegretti G, Silvetti MS. Voltage gradient mapping and electrophysiologically guided cryoablation in children with AVNRT. Europace 2017; 20:665-672. [DOI: 10.1093/europace/eux021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/25/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Fabrizio Drago
- Paediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165 Rome, Italy
| | - Irma Battipaglia
- Paediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165 Rome, Italy
| | - Mario Salvatore Russo
- Paediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165 Rome, Italy
| | - Romolo Remoli
- Paediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165 Rome, Italy
| | - Vincenzo Pazzano
- Paediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165 Rome, Italy
| | - Gino Grifoni
- Paediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165 Rome, Italy
| | | | - Massimo Stefano Silvetti
- Paediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165 Rome, Italy
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Abstract
OPINION STATEMENT Our approach to the ablation of atrioventricular nodal reciprocating tachycardia (AVNRT), the most common supraventricular tachycardia, is as follows: We first attempt ablation in the right atrial posteroseptum anterior to the coronary sinus ostium with a 4-mm non-irrigated tip catheter. If ablation within the triangle of Koch is unsuccessful with radiofrequency (RF), we switch to cryoablation and target a more superior (mid septal) region. We also utilize cryoablation if RF ablation produces transient VA block (absence of retrograde conduction during junctional rhythm) or a fast junctional rhythm (<350 msec). If cryoablation were to fail, or is not available, we would then suggest ablation within the coronary sinus targeting the roof (2-4 cm from the os) using a 3.5-mm irrigated tip catheter. If tachycardia were still inducible despite these measures, we would then proceed with transseptal puncture (given our greater experience with this over a retrograde aortic approach) and perform RF ablation along the posteroseptal left atrium and inferoseptal mitral annulus utilizing an irrigated tip catheter. In our experience, cryoablation reliably results in elimination of the slow pathway. The only left atrial ablation for AVNRT at our institution in the past year was performed because a patent foramen ovale allowed for rapid left atrial access, facilitating left atrial ablation of the slow pathway.
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Kirsh JA. When Is a "Pathway" Not a Pathway? Explaining Late Recurrences After Successful Ablation of Pediatric Atrioventricular Nodal Reentrant Tachycardia. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.004650. [PMID: 27784740 DOI: 10.1161/circep.116.004650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joel A Kirsh
- From the Labatt Family Heart Centre, and Department of Pediatrics, Hospital for Sick Children & University of Toronto, Canada.
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39
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An integrative approach to slow pathway modulation in AVNRT using a novel ultra high-density electroanatomical mapping system. Clin Res Cardiol 2015; 104:697-9. [DOI: 10.1007/s00392-015-0847-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/19/2015] [Indexed: 11/25/2022]
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40
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Bearl DW, Mill L, Kugler JD, Prusmack JL, Erickson CC. Visualization of Atrioventricular Nodal Reentry Tachycardia Slow Pathways Using Voltage Mapping for Pediatric Catheter Ablation. CONGENIT HEART DIS 2015; 10:E172-9. [DOI: 10.1111/chd.12252] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2014] [Indexed: 11/28/2022]
Affiliation(s)
- David W. Bearl
- Department of Pediatrics; Children's Hospital and Medical Center; Omaha Neb USA
- University of Nebraska Medical Center; Omaha Neb USA
| | - LuAnn Mill
- Department of Pediatrics; Children's Hospital and Medical Center; Omaha Neb USA
- University of Nebraska Medical Center; Omaha Neb USA
| | - John D. Kugler
- Department of Pediatrics; Children's Hospital and Medical Center; Omaha Neb USA
- University of Nebraska Medical Center; Omaha Neb USA
| | | | - Christopher C. Erickson
- Department of Pediatrics; Children's Hospital and Medical Center; Omaha Neb USA
- University of Nebraska Medical Center; Omaha Neb USA
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Voltage mapping for slow-pathway visualization and ablation of atrioventricular nodal reentry tachycardia in pediatric and young adult patients. Pediatr Cardiol 2014; 35:103-7. [PMID: 23872907 DOI: 10.1007/s00246-013-0748-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
Abstract
Voltage guidance for the ablation of the slow pathway in atrioventricular nodal reentry tachycardia (AVNRT) is a dramatic shift from the traditional anatomy-guided approach within the triangle of Koch. The use of voltage gradient mapping has been evaluated in adults as an aid to identification of the slow pathway guiding placement of ablation applications. This study aimed to evaluate this technique of voltage-guided ablation of AVNRT in pediatric and young adult patients, who have a smaller, more compact triangle of Koch. A retrospective cohort study evaluated patients 20 years of age or younger with AVNRT who underwent voltage mapping. Using NavX, three-dimensional voltage maps of the right atrium were created during sinus rhythm, focusing primarily on the triangle of Koch. The voltage map gradients were adjusted to uncover a "voltage bridge" of lower voltage signals. This bridge was used as a surrogate of the slow pathway to guide cryoablation at this site. Of the 31 patients who underwent voltage mapping, three were excluded from the study due to inadequate mapping. All the patients experienced procedural success. In 86 % of the patients, there was an adequate voltage bridge to allow guided ablation. The successful ablation site was within the first three lesions for 60 % of the patients. Two patients experienced recurrence during a median follow-up period of 14 months. It appears that voltage-guided ablation of a voltage bridge in AVNRT can be used effectively and safely in the pediatric population.
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Bailin SJ, Ben Johnson W, Jumrussirikul P, Sorentino D, West R. A new methodology for atrial flutter ablation by direct visualization of cavotricuspid conduction with voltage gradient mapping: a comparison to standard techniques. ACTA ACUST UNITED AC 2013; 15:1013-8. [DOI: 10.1093/europace/eus416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Von Bergen NH, Law IH. AV nodal reentrant tachycardia in children: Current approaches to management. PROGRESS IN PEDIATRIC CARDIOLOGY 2013. [DOI: 10.1016/j.ppedcard.2012.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Pintarić H, Zeljković I, Babić Z, Vrsalović M, Pavlović N, Bosnjak H, Petrac D. Electrophysiological predictors of propafenone efficacy in prevention of atrioventricular nodal re-entrant and atrioventricular re-entrant tachycardia. Croat Med J 2013; 53:605-11. [PMID: 23275326 PMCID: PMC3541586 DOI: 10.3325/cmj.2012.53.605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Aim To assess the efficacy of propafenone in prevention of atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic atrioventricular tachycardia (AVRT) based on the clinical results of arrhythmia recurrence and find the electrophysiological predictor of propafenone effectiveness. Methods This retrospective study included 44 participants in a 12-month period, who were divided in two groups: group A – in which propafenone caused complete ventriculo-atrial block and group B – in which propafenone did not cause complete ventriculo-atrial block. Results Group A had significantly lower incidence of tachycardia than group B (95% vs 70.8%, P = 0.038), and complete ventriculo-atrial block predicted the efficacy of propafenone oral therapy in the prevention of tachycardia (sensitivity 87.5%, specificity 52.8%, positive predictive value 95%, negative predictive value 29.2%). Patients with AVNRT in group B who did not experience the recurrences of tachycardia had significantly shorter echo zone before intravenous administration of propafenone than the patients who experienced episodes of sustained tachycardia (median 40 ms [range 15-60 ms] vs 79 ms [range 50-180 ms], P = 0.008). Conclusion In patients with non-inducible tachycardia, complete ventriculo-atrial block can be used as an electrophysiological predictor of the efficacy of propafenone oral therapy in the prevention of tachycardia. In patients with non-inducible AVNRT, but without complete ventriculo-atrial block, propafenone was more effective in patients with shorter echo zone of tachycardia.
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Affiliation(s)
- Hrvoje Pintarić
- Department of Internal Medicine, Sestre milosrdnice University Hospital Centre, Vinogradska cesta 29, 10 000 Zagreb, Croatia.
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