Remote magnetic navigation shows superior long-term outcomes in pediatric atrioventricular (nodal) tachycardia ablation compared to manual radiofrequency and cryoablation

Cryoablation Versus Radiofrequency Ablation in the Management of Pediatric Supraventricular Tachyarrhythmia: A Systematic Review and Meta-Analysis

Supraventricular tachycardia (SVT) is a common arrhythmia in pediatric patients, often requiring catheter ablation for effective treatment. Two primary techniques, radiofrequency ablation (RFA) and cryoablation (CA), are widely used; however, their comparative safety and efficacy remain subjects of debate, with no clear consensus on the preferred approach. This systematic review and meta-analysis aimed to evaluate and compare the efficacy and safety of RFA and CA in pediatric patients with SVT, focusing on the primary outcomes of acute success and recurrence rates. The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included comparative analyses such as randomized controlled trials, non-randomized trials, and observational studies that specifically evaluated RFA and CA in pediatric populations with SVT. Exclusion criteria included studies involving adult populations, those without comparative groups, case reports, case series, and conference abstracts. Data extracted from the included studies encompassed acute success rates, recurrence rates, and complication rates, providing a comprehensive overview of the performance and safety profiles of RFA and CA in this patient group. Acute success rates were high for both techniques (RFA: 96.3%, CA: 94.9%; p = 0.137). However, RFA demonstrated a significantly lower recurrence rate (7.9% vs. 14.4%; odds ratio (OR): 0.408, 95% CI: 0.242-0.689, p < 0.001). CA was associated with longer procedure durations (mean difference: 9.684 minutes, p = 0.437) and significantly reduced fluoroscopy times (mean difference: 6.566 minutes, p = 0.032). Complication rates were comparable, with a non-significant trend favoring RFA (OR: 0.363, p = 0.112). Overall, both RFA and CA were found to be effective and safe for pediatric SVT. RFA offers durable results with lower recurrence rates, while CA minimizes fluoroscopy time, thereby reducing radiation exposure. Treatment selection should be individualized, considering factors such as the type and location of the arrhythmia as well as specific procedural risks.

Comparing Low-to-Zero Fluoroscopic Navigation Systems for AVNRT Catheter Ablation: A Network Meta-Analysis

BACKGROUND

Low-to-zero fluoroscopic navigation systems lower radiation exposure which improves health outcomes. Conventional x-ray fluoroscopy (CF) has long been the standard to guide to catheter location for cardiac ablation. With advancements in technology, alternative safety navigation systems have been developed. Three primary modalities commonly utilized are three-dimensional electroanatomic mapping (3D-EAM), magnetic navigation system (MNS), and intracardiac echocardiography (ICE), all of which can reduce radiation exposure during the procedure.

OBJECTIVE

We aim to compare the efficacy and safety among ICE, EAM, MNS, and CF in ablation of atrioventricular nodal reentrant tachycardia (AVNRT).

METHODS

This is a meta-analysis consisting of observational studies and randomized controlled trials, which evaluated the performance of navigation systems of catheter ablation in AVNRT patients. Primary endpoint was to access the AVNRT recurrence after the procedure during follow-up periods. Secondary endpoints were technical success, fluoroscopic time, fluoroscopic dose area product, radiofrequency ablation time, and adverse events. Random-effect model was applied for pooled estimated effects of included studies.

RESULTS

A total of 21 studies (21 CF, 2 ICE, 9 EAM, 11 MNS) including 1716 patients who underwent catheter ablation for AVNRT treatment were analyzed. Of these, 16 were observational studies and 5 were randomized controlled trials.

PRIMARY OUTCOME

Point estimation of AVNRT recurrence showed ICE exhibited a pooled odds ratio (ORs) of 1.06 (95% confidence interval [CI]: 0.064-17.322), MNS with ORs of 0.51 (95% CI: 0.214-1.219], and EAM with ORs of 0.394 (95% CI: 0.119-1.305) when compared to CF.

SECONDARY OUTCOMES

EAM had significant higher technical success with ORs of 2.781 (95% CI: 1.317-5.872) when compared to CF. Regarding fluoroscopy time, EAM showed the lowest time with mean differences (MD) of -10.348 min (95% CI: -13.385 to -7.3101) and P-score of 0.998. It was followed by MNS with MD of -3.712 min (95% CI: -7.128 to -0.295) and P-score of 0.586, ICE with MD of -1.150 min (95% CI: -6.963 to 4.662) with a P-score of 0.294 compared to CF, which has a P-score of 0.122. There were insignificant adverse events across the procedures.

CONCLUSION

AVNRT ablation navigated by low-to-zero fluoroscopic navigation systems achieves higher efficacy and comparable safety to conventional fluoroscopywhile also reducing risk of radiation exposure time.

Transcatheter ablation of atrioventricular nodal reentry tachycardia in children and congenital heart disease in the era of 3D mapping

Atrioventricular nodal reentrant tachycardia (AVNRT) is a common supraventricular tachycardia in children and congenital heart disease (CHD) patients. Nowadays, in large enough children, chronic treatment for symptomatic and recurrent AVNRT episodes relies on transcatheter ablation. Indeed, many three-dimensional (3D) mapping strategies and ablation techniques have been developed and it helped to increase success rates and to reduce complications. Therefore, this study aimed to perform an updated comprehensive review of the available literature regarding contemporary management of AVNRT in children. A literature search was performed using Google Scholar, PubMed, Springer, Ovid, and Science Direct. We found that in recent times many investigations have demonstrated that 3D mapping systems allow to localize more precisely the ablation substrate, with minimal use of fluoroscopy. The most frequently employed mapping strategies are the low-voltage bridge strategy together with the search for the SP potential and the Sinus Rhythm Propagation Map with the identification of areas of Wave Collision or Pivot Points. For transcatheter ablation in pediatric settings, radiofrequency (RF) ablation was first used in the 1990s, while cryoablation was introduced in 2003 and nowadays represents the most used energy for AVNRT ablation in this population. Indeed, its specific features, such as reversible cryomapping, cryoadhesion and the precision in lesion delivery, made this technique very appealing to decrease complications and fluoroscopy time. As regards AVNRT in CHD patients, it represents the third most common form of arrhythmia in children with CHD. However, in this subgroup ablation remains challenging and experience limited, since anatomy may be atypical and the areas of ablation less predictable or less accessible.

Best practices in robotic magnetic navigation-guided catheter ablation of cardiac arrhythmias, a position paper of the Society for Cardiac Robotic Navigation

Preamble

Robotic magnetic navigation (RMN)-guided catheter ablation (CA) technology has been used for the treatment of cardiac arrhythmias for almost 20 years. Various studies reported that RMN allows for high catheter stability, improved lesion formation and a superior safety profile. So far, no guidelines or recommendations on RMN-guided CA have been published.

Purpose

The aim of this consensus paper was to summarize knowledge and provide recommendations on management of arrhythmias using RMN-guided CA as treatment of atrial fibrillation (AF) and ventricular arrhythmias (VA).

Methodology

An expert writing group, performed a detailed review of available literature, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Recommendations on RMN-guided CA are presented in a guideline format with three levels of recommendations to serve as a reference for best practices in RMN procedures. Each recommendation is accompanied by supportive text and references. The various sections cover the practical spectrum from system and patient set-up, EP laboratory staffing, combination of RMN with fluoroscopy and mapping systems, use of automation features and ablation settings and targets, for different cardiac arrhythmias.

Conclusion

This manuscript, presenting the combined experience of expert robotic users and knowledge from the available literature, offers a unique resource for providers interested in the use of RMN in the treatment of cardiac arrhythmias.

Efficacy and safety between radiofrequency ablation and types of cryoablation catheters for atrioventricular nodal reentrant tachycardia: A Network Meta-analysis and Systematic Review

INTRODUCTION

Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common supraventricular tachycardia referred for ablation. Periprocedural conduction system damage was a primary concern during AVNRT ablation. This study aimed to assess the incidence of permanent atrioventricular (AV) block and the success rate associated with different types of catheters in slow pathway ablation.

METHOD

A literature search was performed to identify studies that compared various techniques, including types of radiofrequency ablation (irrigated and nonirrigated) and different sizes of catheter tip cryoablation (4, 6, and 8-mm), in terms of their outcomes related to permanent atrioventricular block and success rate. To assess and rank the treatments for the different outcomes, a random-effects model of network meta-analysis, along with p-scores, was employed.

RESULTS

A total of 27 studies with 5110 patients were included in the analysis. Overall success rates ranged from 89.78% to 100%. Point estimation showed 4-mm cryoablation exhibited an odds ratio of 0.649 (95%CI: 0.202-2.087) when compared to nonirrigated RFA. Similarly, 6-mm cryoablation had an odds ratio of 0.944 (95%CI: 0.307-2.905), 8-mm cryoablation had an odds ratio of 0.848 (95%CI: 0.089-8.107), and irrigated RFA had an odds ratio of 0.424 (95%CI: 0.058-3.121) compared to nonirrigated RFA.

CONCLUSION

Our study found no significant difference in the incidence of permanent AV block between the types of catheters. The success rates were consistently high across all groups. These findings emphasize the potential of both RF ablation (irrigated and nonirrigated catheter) and cryoablation as viable options for the treatment of AVNRT, with similar safety and efficacy profile.