Initial Experience Using the Radiofrequency Needle Visualization on the Electroanatomical Mapping System for Transseptal Puncture

Fluoroless left atrial access for radiofrequency and cryoballoon ablations using a novel radiofrequency transseptal wire

Purpose

Conventional catheter ablation for atrial fibrillation requires fluoroscopy, which has inherent risks of radiation exposure to patients and medical staff. Optimization of fluoroscopy parameters and use of three-dimensional electroanatomic mapping (EAM) and intracardiac echocardiography (ICE) have helped to reduce radiation exposure; however, despite growing evidence, there are still concerns about safety and added procedure time associated with fluoroless procedures, particularly in left-sided ablations, due to the potential risk of complications. Herein, we report our initial experience using a radiofrequency (RF) wire for completely fluoroless radiofrequency ablation (RFA) and cryoballoon ablation (CBA).

Methods

A retrospective analysis was conducted on ablation procedures for various cardiac arrhythmias performed non-fluoroscopically at two centers using the VersaCross RF wire transseptal system under EAM and ICE guidance.

Results

A total of 72 and 54 patients underwent RFA and CBA, respectively, successfully without any procedural complications. Transseptal access time for RFA was 14.5 ± 6.6 min from procedure start (including sheath and catheter placements ± right-sided ablation) or 2.8 ± 1.0 min from RF wire insertion into the femoral introducer. Transseptal access time for CBA was 19.2 ± 11.7 min from procedure start (including sheath and catheter placements ± right-sided ablation) or 3.5 ± 1.6 min from RF wire insertion into the femoral introducer. Average procedure time was 104.4 ± 38.0 min for RFA and 91.1 ± 22.1 min for CBA.

Conclusions

A RF wire can be used to achieve completely fluoroless transseptal puncture safely and effectively while improving procedural efficiency in both RFA and CBA.

Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia in Patients With Congenital Heart Disease

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.

Tachyarrhythmias in Congenital Heart Diseases: From Ion Channels to Catheter Ablation

Major advances in pediatric cardiology in recent decades, especially surgical techniques, have resulted in an increasing number of patients with congenital heart disease (CHD) surviving to adulthood. This has generated new challenges, particularly with regards to the late onset of complex arrhythmias. Abnormal anatomy, surgical scarring, chronic hypoxemia, hemodynamic compromise, neuro-hormonal abnormalities, and genetic factors can all contribute to creating a unique substrate for arrhythmia development. This review attempts to synthesize the current state of knowledge spanning the spectrum from underlying mechanisms of arrhythmias in patients with congenital heart disease to current ablative strategies. We discuss existing knowledge gaps and highlight important areas for future research.

Zero-Fluoroscopy Ablation for Atrial Re-Entry Via a Vein of Marshall Connection Using a Visible Sheath

We describe a zero-fluoroscopy ablation of a left atrial re-entry tachycardia in a patient with a previous atrial fibrillation ablation procedure. The critical isthmus was demonstrated to use an epicardial connection via the ligament of Marshall after failed endocardial and epicardial ablation along the mitral isthmus line. (Level of Difficulty: Intermediate.)

Catheter mapping and ablation during pregnancy

A substantial number of pregnant women at some point experience cardiac arrhythmia, which is mostly treated by antiarrhythmic medication. In some instances, arrhythmias can be drug-resistant and pose a relevant risk to both mother and unborn child as they can result in hemodynamic compromise. In recent years, invasive electrophysiology procedures have been carried out with ever reducing exposure to ionising radiation, and multiple techniques have been established to achieve ZERO exposure. Of course, these techniques should all be applied when contemplating an invasive mapping and ablation procedure during pregnancy. The role of the cardio-obstetrics team in planning and performing such procedures is paramount. Careful assessment of the pregnant mother and her unborn child is mandatory. Only with good preparation is a complete understanding of both cardiac anatomy and physiology achievable, which is a pre-requisite of a successful ablation outcome. Various aspects of the ablation procedure itself are discussed and evaluated from the perspective of all team members involved, including the obstetrician, the anaesthetist and the electrophysiologist. This review aims to inform the reader about the techniques available and reports on the published outcomes for ablations during pregnancy in the last decade.