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Leung LW, Evranos B, Gonna H, Harding I, Domenichini G, Gallagher MM. Multi-catheter cryotherapy for the treatment of resistant accessory pathways. Indian Pacing Electrophysiol J 2024; 24:1-5. [PMID: 37977548 PMCID: PMC10927982 DOI: 10.1016/j.ipej.2023.11.002] [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: 08/27/2023] [Revised: 10/25/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE To investigate the utility of simultaneous multi-catheter cryotherapy for the treatment of APs that were previously resistant to standard radiofrequency (RF) catheter ablation. BACKGROUND Catheter ablation is established in the treatment of accessory pathways (AP), with high rates of permanent procedural success with a single attempt. However, there are still instances of acute procedural failure and AP recurrences with standard RF and cryotherapy methods. METHODS Seven consecutive cases of pre-excitation syndromes with prior failed RF catheter ablation had the novel treatment. Cryotherapy was delivered using two 8 mm tip focal cryoablation catheters (Freezor® Max, Medtronic, Minneapolis, Minnesota, USA). RESULTS Accessory pathway localisation was septal in 5 cases, left posterolateral in 1, right lateral in 1. In all cases, ablation of the AP was acutely successful with no procedural complications. Median procedure and fluoroscopy durations were 199 and 35 min, sequentially. Median Procedure duration fell significantly in the second half of series (174 min) compared to the first half (233 min, P = 0.05). One patient had evidence of a recurring AP conduction with pre-excitation at 5-week follow up. After a median follow up of 66.8+-6.5 months, 6 out of 7 patients remained asymptomatic and free of pre-excitation. CONCLUSION Simultaneous multi-catheter cryotherapy is feasible, safe and can provide definitive cure of accessory pathways that were previously resistant to standard radiofrequency ablation. Further study is required in the assessment of this novel form of advanced cryotherapy to treat complex and resistant arrhythmias.
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Affiliation(s)
- Lisa Wm Leung
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Banu Evranos
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Hanney Gonna
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Idris Harding
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Giulia Domenichini
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Mark M Gallagher
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK.
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Buist TJ, Groen MHA, Wittkampf FHM, Loh P, Doevendans PAFM, van Es R, Elvan A. Feasibility of Linear Irreversible Electroporation Ablation in the Coronary Sinus. Cardiovasc Eng Technol 2023; 14:60-66. [PMID: 35710861 DOI: 10.1007/s13239-022-00633-3] [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: 02/03/2021] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Previous studies demonstrated that the coronary sinus (CS) is an important target for ablation in persistent atrial fibrillation. However, radiofrequency ablation in the CS is associated with coronary vessel damage and tamponade. Animal data suggest irreversible electroporation (IRE) ablation can be a safe ablation modality in vicinity of coronary arteries. We investigated the feasibility of IRE in the CS in a porcine model. METHODS Ablation and pacing was performed in the CS in six pigs (weight 60-75 kg) using a modified 9-French steerable linear hexapolar Tip-Versatile Ablation Catheter. Pacing maneuvers were performed from distal to proximal segments of the CS to assess atrial capture thresholds before and after IRE application. IRE ablations were performed with 100 J IRE pulses. After 3-week survival animals were euthanized and histological sections from the CS were analyzed. RESULTS A total of 27 IRE applications in six animals were performed. Mean peak voltage was 1509 ± 36 V, with a mean peak current of 22.9 ± 1.0 A. No complications occurred during procedure and 3-week survival. At 30 min post ablation 100% isolation was achieved in all animals. At 3 weeks follow-up pacing thresholds were significant higher as compared to baseline. Histological analysis showed transmural ablation lesions in muscular sleeves surrounding the CS. CONCLUSION IRE ablation of the musculature along the CS using a multi-electrode catheter is feasible in a porcine model.
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Affiliation(s)
- Thomas J Buist
- Heart Centre, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marijn H A Groen
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Fred H M Wittkampf
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Peter Loh
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Pieter A F M Doevendans
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Central Military Hospital, Utrecht, The Netherlands
| | - René van Es
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arif Elvan
- Heart Centre, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
- Department of Cardiology, Isala Heart Centre, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
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Marazzato J, Marazzi R, Angeli F, Vilotta M, Bagliani G, Leonelli FM, De Ponti R. Ablation of Accessory Pathways with Challenging Anatomy. Card Electrophysiol Clin 2020; 12:555-566. [PMID: 33162003 DOI: 10.1016/j.ccep.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although catheter ablation of accessory pathways is deemed highly safe and effective, peculiar location of these pathways might lead to complex and potentially hazardous procedures requiring ablation in anatomic regions such as para-Hisian area, coronary sinus, and epicardial surface. The electrophysiologist should know these possible scenarios to plan the best strategy for safe and effective ablation of these uncommon accessory pathways.
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Affiliation(s)
- Jacopo Marazzato
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
| | - Raffaella Marazzi
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS, Via Crotto Roncaccio, 16, Tradate, Varese 21049, Italy
| | - Manola Vilotta
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy
| | - Giuseppe Bagliani
- Arrhythmology Unit, Cardiology Department, Foligno General Hospital, Via Massimo Arcamone, Foligno, Perugia 06034, Italy; Cardiovascular Disease Department, University of Perugia, Piazza Menghini 1, Perugia 06129, Italy
| | - Fabio M Leonelli
- Cardiology Department, James A. Haley Veterans' Hospital, University of South Florida, 13000 Bruce B Down Boulevard, Tampa, FL 33612, USA; University of South Florida, 4202 East Fowler Avenue, Tampa, FL 33620, USA
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy.
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Romero J, Diaz JC, Alviz I, Bello J, Purkayastha S, Velasco A, Andrea Natale, Di Biase L. Methodology of Typical Accessory Pathway Catheter Ablation. Card Electrophysiol Clin 2020; 12:541-553. [PMID: 33162002 DOI: 10.1016/j.ccep.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Accessory pathways are abnormal electrical conductions between the atrial and ventricular myocardium, bypassing the atrioventricular node and as such are an important substrate for arrhythmias. Ablation is a curative treatment and should always be offered to symptomatic patients and asymptomatic patients with high risk professions. Adequate knowledge and understanding of different mapping and ablation techniques is pivotal to achieve successful outcomes.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Juan Carlos Diaz
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Isabella Alviz
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Juan Bello
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Sutopa Purkayastha
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Alejandro Velasco
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St Davids Medical Center, 919 East 32nd Street, Austin, TX 78705, USA
| | - Luigi Di Biase
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA; Texas Cardiac Arrhythmia Institute at St Davids Medical Center, 919 East 32nd Street, Austin, TX 78705, USA.
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Aguilar M, Tedrow UB. Epicardial Ablation of Supraventricular Tachycardias. Card Electrophysiol Clin 2020; 12:357-369. [PMID: 32771189 DOI: 10.1016/j.ccep.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Supraventricular arrhythmias are the most common cardiac arrhythmias encountered; however, it is uncommon that supraventricular tachycardias require percutaneous epicardial access for successful mapping and ablation. There are particular scenarios where epicardial access and ablation should be considered. Certain accessory pathways particularly in the posteroseptal region may require epicardial access for successful ablation. These pathways may also be approached from within the coronary sinus system. In addition, tachycardias near the phrenic nerve in the right atrium or left atrium may require epicardial access for successful ablation or to allow displacement of the phrenic nerve facilitating safe catheter ablation.
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Affiliation(s)
- Martin Aguilar
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Usha B Tedrow
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School; Clinical Cardiac Electrophysiology Fellowship; Ventricular Arrhythmia Program.
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Prochnau D, Fischer H, Mühlhammer D, Eggers R. Radiofrequency ablation of a concealed left-sided accessory pathway in the mid-coronary sinus after failed conventional ablation attempts. Herzschrittmacherther Elektrophysiol 2019; 30:316-321. [PMID: 31440898 DOI: 10.1007/s00399-019-00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 08/05/2019] [Indexed: 06/10/2023]
Abstract
The case of a 71-year-old female patient with recurrent supraventricular tachycardia is reported. During the initial electrophysiological study, an orthodromic atrioventricular reentrant tachycardia utilizing a concealed left-sided accessory pathway (AP) was induced. Radiofrequency (RF) ablation via a retrograde aortic approach was unsuccessful. A second ablation attempt 6 weeks later via a transseptal approach using the EnSite Precision three-dimensional (3-D) cardiac mapping system and an irrigated-tip RF ablation catheter also failed to ablate the AP. Therefore, mapping in the coronary sinus (CS) was performed. During right ventricular pacing, the earliest retrograde atrial activation was found in the mid-CS. Irrigated-tip RF ablation for 1.8 s at this region successfully ablated the AP permanently. In complicated cases after failed conventional ablation attempts via a transfemoral or transseptal approach, CS ablation is an effective alternative to percutaneous or surgical ablation of epicardial APs. In such cases, electroanatomical mapping systems may be useful in determining the location of the AP and reducing fluoroscopy time. Furthermore, ablation with irrigated-tip RF catheters can improve the treatment success rate due to larger and deeper lesion formation.
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Affiliation(s)
- D Prochnau
- Department of Internal Medicine I, Sophien- and Hufeland-Hospital Weimar, Henry-van-de-Velde-Straße 2, 99425, Weimar, Germany.
| | - H Fischer
- Department of Internal Medicine I, Sophien- and Hufeland-Hospital Weimar, Henry-van-de-Velde-Straße 2, 99425, Weimar, Germany
| | - D Mühlhammer
- Department of Internal Medicine I, Sophien- and Hufeland-Hospital Weimar, Henry-van-de-Velde-Straße 2, 99425, Weimar, Germany
| | - R Eggers
- Department of Internal Medicine I, Sophien- and Hufeland-Hospital Weimar, Henry-van-de-Velde-Straße 2, 99425, Weimar, Germany
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Utility of Echocardiography in Detecting Silent Complications After Pediatric Catheter Ablations. Pediatr Cardiol 2017; 38:1426-1433. [PMID: 28711964 DOI: 10.1007/s00246-017-1680-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
Although transcatheter arrhythmia ablation (TCA) has been performed in children for over two decades, guidelines for routine use of post-ablation transthoracic echocardiography (TTE) are absent. We sought to determine the efficacy of TTE after apparently uneventful TCA procedures in detecting adverse findings and identify predisposing factors. A retrospective review of clinical and procedural data on patients who underwent TCA for supraventricular arrhythmias from 2000 to 2015 was performed. Pre- and post-ablation TTE data were reviewed. All patients were followed at 1 week, 6 and 12 months post-TCA. A repeat TTE was performed at 12 months on patients in whom post-TCA abnormalities were found. Patients were divided into two groups: those with and without adverse TTE findings and comparative analysis between variables was performed. Data on 252 patients, 52% males, mean age 14 ± 3 years were analyzed. New onset or worsening atrioventricular valve regurgitation occurred in 17 (6.7%), a small pericardial effusion in 3 (1.2%) and worsened ventricular function in 2 patients (0.8%). Patients in the complication group had higher mean number of ablations (22.6 ± 15.3 vs. 16.8 ± 9.2, p 0.001) and required longer duration of ablation (sec) (254.6 ± 256.4 vs. 180.9 ± 158.9, p < 0.001). TCA location (including coronary sinus), energy source, arrhythmia substrate, and a trans-septal approach were noncontributory to any adverse findings. Routine post-ablation TTE uncovers asymptomatic self-resolving abnormalities that typically do not require any intervention.
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8
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Mito T, Takemoto M, Kang H, Kawano Y, Tanaka A, Aoki R, Antoku Y, Matsuo A, Hida S, Okazaki T, Yoshitake K, Tayama KI, Kosuga KI. A case of premature ventricular complexes/ventricular tachycardia from the left ventricular outflow tract successfully ablated from the distal great cardiac vein. J Cardiol Cases 2017; 16:85-88. [PMID: 30279804 DOI: 10.1016/j.jccase.2017.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/17/2017] [Accepted: 05/22/2017] [Indexed: 11/24/2022] Open
Abstract
We experienced a 41-year-old male with premature ventricular complexes/ventricular tachycardia from the left coronary cusp and distal great cardiac vein of the left ventricular outflow tract successfully treated by radiofrequency catheter ablation utilizing a 3D mapping system (EnSiteNavX/Velocity™ Cardiac Mapping System, St. Jude Medical, St. Paul, MN, USA) without any complications. <Learning objective: The approach from the distal great cardiac vein should be considered as a potential approach and may be one of the effective strategies for ablation of left ventricular outflow tract-premature ventricular complexes/ventricular tachycardia (PVC/VTs). Radiofrequency catheter ablation of frequent PVC/VTs may improve the clinical status and cardiac function.>.
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Affiliation(s)
- Takahiro Mito
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Masao Takemoto
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Honsa Kang
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Yuki Kawano
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Atsushi Tanaka
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Ryota Aoki
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Yoshibumi Antoku
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Atsutoshi Matsuo
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Satoru Hida
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Teiji Okazaki
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Kiyonobu Yoshitake
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Kei-Ichiro Tayama
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
| | - Ken-Ichi Kosuga
- Cardiovascular Center, Munakata Suikokai General Hospital, Fukutsu, Japan
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Sternick EB, Faustino M, Correa FS, Pisani C, Scanavacca MI. Percutaneous Catheter Ablation of Epicardial Accessory Pathways. Arrhythm Electrophysiol Rev 2017; 6:80-84. [PMID: 28835839 DOI: 10.15420/aer.2017.6.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Radiofrequency (RF) catheter ablation is the treatment of choice in patients with accessory pathways (APs) and Wolff-Parkinson-White syndrome. Endocardial catheter ablation has limitations, including the inability to map and ablate intramural or subepicardial APs. Some of these difficulties can be overcome using an epicardial approach performed through the epicardial venous system or by percutaneous catheterisation of the pericardial space. When a suspected left inferior or infero-paraseptal AP is refractory to ablation or no early activation is found at the endocardium, a transvenous approach via the coronary sinus is warranted because such epicardial pathways can be in close proximity to the coronary venous system. Associated congenital abnormalities, such as right atrial appendage, right ventricle diverticulum, coronary sinus diverticulum and absence of coronary sinus ostium, may also hamper a successful outcome. Percutaneous epicardial subxiphoid approach should be considered when endocardial or transvenous mapping and ablation fails. Epicardial mapping may be successful. It can guide and enhance the effectiveness of endocardial ablation. The finding of no epicardial early activation leads to a more persistent new endocardial attempt. When both endocardial and epicardial ablation are unsuccessful, open-chest surgery is the only option to eliminate the AP.
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Affiliation(s)
- Eduardo Back Sternick
- Arrhythmia Unit, Biocor Instituto, Nova Lima, Brazil.,Medical Sciences Faculty of Minas Gerais, Belo Horizonte, Brazil
| | - Mariana Faustino
- Cardiology Department, Hospital Fernando Fonseca, Amadora, Portugal
| | | | - Cristiano Pisani
- Arrhythmia Clinical Unit, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
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Diab OA, Amer MS, Salah El-Din RA. Effect of experimental coronary sinus ligation on myocardial structure and function in the presence or absence of structural heart disease: an insight for the interventional electrophysiologist. Europace 2016; 18:1897-1904. [PMID: 26850747 DOI: 10.1093/europace/euv431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 11/23/2015] [Indexed: 11/12/2022] Open
Abstract
AIMS To study the effect of coronary sinus (CS) occlusion on normal hearts and hearts with structural disease. METHODS AND RESULTS We included 32 dogs, divided into 4 groups: (1) CS ligation (CSL): subjected to CSL; (2) control group: no intervention; (3) MI-CSL group: subjected to myocardial infarction (MI) induction followed by CSL after 1 week; and (4) MI-control group: subjected to MI induction, then open thoracotomy after 1 week without CSL. Electrocardiography, echocardiography, histopathology, and immunohistochemistry were done before and after CSL. In CSL group, there were no significant electrocardiographic or echocardiographic changes after CSL, although there was interstitial oedema that decreased after 1 week with the appearance of Thebesian vessels and positive staining for vascular endothelial growth factor. In MI-CSL group, there was significant increase in left ventricular (LV) end-systolic diameter (P = 02), decrease in LV fractional shortening (P = 0.0001), and LV ejection fraction (P = 0.002) in comparison with MI-control group, associated with severe myocardial degeneration. CONCLUSION Acute CS occlusion could be compensated in normal hearts, but may be detrimental in the presence of structural heart disease.
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Affiliation(s)
- Osama Ali Diab
- Faculty of Medicine, Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Mohammed Said Amer
- Faculty of Veterinary Medicine, Department of Surgery, Cairo University, Cairo, Egypt
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Chan NY. Catheter ablation of peri-nodal and pulmonary veno-atrial substrates: should it be cool? Europace 2016; 17 Suppl 2:ii19-30. [DOI: 10.1093/europace/euv230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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12
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A detailed assessment of the human coronary venous system using contrast computed tomography of perfusion-fixed specimens. Heart Rhythm 2013; 11:282-8. [PMID: 24144884 DOI: 10.1016/j.hrthm.2013.10.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Access to the coronary venous system is required for the delivery of several cardiac therapies including cardiac resynchronization therapy, coronary sinus ablation, and coronary drug delivery. Therefore, characterization of the coronary venous anatomy will provide insights to gain improved access to these vessels and subsequently improved therapies. For example, cardiac resynchronization therapy has a 30% nonresponder rate, partially due to suboptimal lead placement within the coronary veins. OBJECTIVE To understand the implications of coronary venous anatomy for the development of devices deployed within these vessels. METHODS We cannulated the coronary sinus of 121 perfusion-fixed human hearts with a venogram balloon catheter and injected contrast into the venous system while obtaining computed tomographic images. For each major coronary vein, distance to the coronary sinus, branching angle, arc length, tortuosity, number of branches, and ostial diameter were assessed from the reconstructed anatomy. RESULTS Twenty-nine percent (35/121) specimens did not have a venous branch overlying the inferolateral side of the heart large enough to fit a 5F pacing lead. No significant differences in anatomy were found between subgroups with varying cardiac medical histories. CONCLUSION The anatomical approach employed in this study has allowed for the development of a unique database of human coronary venous anatomy that can be used for the optimization of design and delivery of cardiac devices.
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13
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Reentry mechanisms and ablation of ECG-typical atrial flutters involving the cavo-tricuspid isthmus and the proximal coronary sinus. Int J Cardiol 2013; 168:3728-35. [DOI: 10.1016/j.ijcard.2013.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 04/12/2013] [Accepted: 06/15/2013] [Indexed: 11/16/2022]
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Namgung J. Successful ablation of resistant left lateral accessory pathway and coexisting atypical atrioventricular nodal reentrant tachycardia. Korean Circ J 2013; 43:189-92. [PMID: 23613697 PMCID: PMC3629246 DOI: 10.4070/kcj.2013.43.3.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 08/01/2012] [Accepted: 08/23/2012] [Indexed: 11/11/2022] Open
Abstract
A 41-year-old male was presented with drug-resistant supraventricular tachycardia. Electrophysiological study confirmed that the supraventricular tachycardia was caused by dual atrioventricular nodal pathways and a left lateral accessory pathway (AP). The left lateral AP was resistant to traditional endocardial ablation, but was successfully eliminated by radiofrequency ablation via the intracoronary sinus approach.
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Affiliation(s)
- June Namgung
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
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15
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Spencer JH, Anderson SE, Iaizzo PA. Human coronary venous anatomy: implications for interventions. J Cardiovasc Transl Res 2013; 6:208-17. [PMID: 23307201 DOI: 10.1007/s12265-012-9443-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 12/19/2012] [Indexed: 11/29/2022]
Abstract
The coronary venous system is a highly variable network of veins that drain the deoxygenated blood from the myocardium. The system is made up of the greater cardiac system, which carries the majority of the deoxygenated blood to the right atrium, and the smaller cardiac system, which drains the blood directly into the heart chambers. The coronary veins are currently being used for several biomedical applications, including but not limited to cardiac resynchronization therapy, ablation therapy, defibrillation, perfusion therapy, and annuloplasty. Knowledge of the details of the coronary venous anatomy is essential for optimal development and delivery of treatments using this vasculature. This article is part of a JCTR special issue on Cardiac Anatomy.
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Affiliation(s)
- Julianne H Spencer
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN 55455, USA.
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Affiliation(s)
- Noel G Boyle
- UCLA Cardiac Arrhythmia Center, 100 UCLA Medical Plaza, Suite 660, Westwood Blvd, Los Angeles CA 90095-7392, USA.
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Houmsse M, Daoud EG. Biophysics and clinical utility of irrigated-tip radiofrequency catheter ablation. Expert Rev Med Devices 2012; 9:59-70. [PMID: 22145841 DOI: 10.1586/erd.11.42] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Catheter ablation by radiofrequency (RF) energy has successfully eliminated cardiac tachyarrhythmias. RF ablation lesions are created by thermal energy. Electrode catheters with 4-mm-tips have been adequate to ablate arrhythmias located near the endocardium; however, the 4-mm-tip electrode does not readily ablate deeper tachyarrhythmia substrate. With 8- and 10-mm-tip RF electrodes, ablation lesions were larger; yet, these catheters are associated with increased risk for coagulum, char and thrombus formation, as well as myocardial steam rupture. Cooled-tip catheter technology was designed to cool the electrode tip, prevent excessive temperatures at the electrode tip-tissue interface, and thus allow continued delivery of RF current into the surrounding tissue. This ablation system creates larger and deeper ablation lesions and minimizes steam pops and thrombus formation. The purpose of this article is to review cooled-tip RF ablation biophysics and outcomes of clinical studies as well as to discuss future technological improvements.
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Affiliation(s)
- Mahmoud Houmsse
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University, Columbus, USA.
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Radiofrequency ablation of coronary sinus-dependent atrial flutter guided by fractionated mid-diastolic coronary sinus potentials. J Interv Card Electrophysiol 2010; 29:97-107. [PMID: 20814733 PMCID: PMC2949572 DOI: 10.1007/s10840-010-9504-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Accepted: 06/20/2010] [Indexed: 11/12/2022]
Abstract
Background The efficacy of radiofrequency (RF) ablation of an uncommon coronary sinus (CS)-dependent atrial flutter (AFL) was evaluated using conventional electrophysiological criteria in a highly selected subset of patients with typical and atypical AFL. Methods Fourteen patients with atrial flutter (11 males, mean age 69 ± 9 years) without previous right or left atrial RF ablation were included. Heart disease was present in eight patients. Baseline ECG suggested typical AFL in 12 patients and atypical AFL in two. Mean AFL cycle length was 324 ± 64 ms at the time of RF ablation in the CS. Lateral right atrium activation was counterclockwise (CCW) in 13 patients and clockwise in one. CS activation was CCW in all. Criteria for CS ablation included the presence of CS mid-diastolic fractionated atrial potentials (APs) associated with concealed entrainment with a postpacing interval within 20 ms. Success was defined as termination of AFL and subsequent noninducibility. Results The initial target for ablation was the cavotricuspid isthmus (CTI) in 11 patients and the CS with further CTI ablation in three. AP duration at the CS target site was 122 ± 33 ms, spanning 40 ± 12% of the AFL cycle length. CS ablation site was located 1–4 cm from the CS ostium. Ablation was successful in all patients. Mean time to AFL termination during CS ablation was 39 ± 52 s (<20 s in eight patients). No recurrence of ablated arrhythmia occurred during a follow-up of 18 ± 8 months. Conclusions The CS musculature is a critical part of some AFL circuits in patients with typical and atypical AFL. AFL can be terminated in patients with CS or CTI/CS AFL reentrant circuits by targeting CS mid-diastolic fragmented APs.
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Guzzo G, Cosío FG, Pastor A, Núñez A. Electroanatomic study of the left atrial insertion of an epicardial accessory pathway integrating the coronary sinus. Europace 2010; 12:1022-4. [PMID: 20219752 DOI: 10.1093/europace/euq063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Endocardial electro-anatomic reconstruction of the left atrium and activation mapping defined a very large atrial accessory pathway insertion with a previously failed ablation attempt. Radiofrequency application inside the coronary sinus (CS), at a site with a sharp electrogram bridging atrial and ventricular electrograms abolished pathway conduction. The myocardium in the venous branches of the CS appeared to be responsible for this extraordinary atrial insertion area.
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Affiliation(s)
- Gonzalo Guzzo
- Cardiology Service, Hospital Universitario de Getafe, Ctra de Toledo, KM 12,5, 28905 Getafe, Madrid, Spain.
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20
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Schweikert RA. Epicardial Ablation of Supraventricular Tachycardia. Card Electrophysiol Clin 2010; 2:105-111. [PMID: 28770728 DOI: 10.1016/j.ccep.2009.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Epicardial catheter-based mapping and ablation of a variety of supraventricular tachycardias is feasible, safe, and effective. Supraventricular tachycardia substrates are not uncommonly epicardial, and approaches with percutaneous epicardial instrumentation or via the epicardial venous structures, such as the coronary sinus, are becoming more widely accepted. These techniques are an important treatment option as an alternative to a more invasive surgical approach or to allowing patients to suffer from an ongoing arrhythmia. New technologies and innovative techniques are being developed that hold great potential to improve the efficacy and safety of the epicardial catheter-based approach to these challenging arrhythmias.
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Affiliation(s)
- Robert A Schweikert
- Department of Cardiology, Akron General Medical Center, 400 Wabash Avenue, Akron, OH 44307, USA; Department of Internal Medicine, Northeast Ohio Universities College of Medicine, 4209 State Route 44, PO Box 95, Rootstown, OH 44272, USA
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Weiss C, Cappato R, Willems S, Meinertz T, Kuck KH. Prospective evaluation of the coronary sinus anatomy in patients undergoing electrophysiologic study. Clin Cardiol 2009; 22:537-43. [PMID: 10492844 PMCID: PMC6655875 DOI: 10.1002/clc.4960220810] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Previous retrospective studies could find a predominant incidence of coronary sinus (CS) anomalies in patients with accessory pathways and a characteristic anatomy of the CS ostium in patients with atrioventricular nodal reentrant tachycardias (AVNRT). HYPOTHESIS In the present prospective study, CS angiograms were prospectively performed to analyze the incidence of CS anomalies and to measure the diameters of the CS ostium. METHODS The study included patients referred for electrophysiologic study and catheter ablation of various tachyarrhythmias. The anatomy of the CS and its side branches was visualized [left anterior oblique (LAO) 30 degrees, right anterior oblique (RAO) 30 degrees] by retrograde angiography in 204 consecutive patients (82 women, 122 men, age 45 +/- 15 years); of these, 120 presented with 123 accessory pathways (45 left-sided, 33 right-sided, 45 septal). The diagnosis in the remaining patients was atrioventricular nodal reentrant tachycardia in 43 cases, atrial tachycardia or atrial fibrillation in 12, and ventricular tachycardia in 15. In 14 patients, the indication for the electrophysiologic study was an unexplained syncope. The CS angiogram was evaluated for anomalies and the size of the CS ostium was manually measured in both projections. RESULTS Anomalies of the CS defined as diverticula, persistent left superior vena cava, or enlarged CS ostia were found in 18 patients (9%). Of those, CS diverticula were found in nine patients, all with a posteroseptal or left posterior manifest accessory pathway, which was abolished within the neck of the diverticulum in seven patients and at the posteroseptal tricuspid annulus in two patients. Persistence of the left superior vena cava was found in five patients, four had atrioventricular reentrant tachycardia secondary to five accessory pathways (left free wall in four, right midseptal in one), and one patient had atrioventricular nodal reentrant tachycardia (AVNRT). Enlargement of the CS ostium of > 25 mm width was detected in nine patients (5%), of whom four had AVNRT. However, the width of the CS ostium generally did not differ significantly between patients with AVNRT (LAO: 14.4 +/- 5.6; RAO 9.3 +/- 2.4 mm) compared with the control group (LAO 13.4 +/- 4.1; 8.2 +/- 1.9 mm). CONCLUSIONS Anomalies of the CS as diverticula, persistent superior vena cava, or enlargement of the CS ostium are predominantly found in patients with accessory pathway-related tachycardias. Diverticula of the proximal CS were found in 7% of patients with accessory pathways; in these cases, ablation succeeded mostly by radiofrequency (RF) current delivery in the neck of the diverticulum. Enlargement of the CS ostium was more often seen in patients with AVNRT than in all other patients. However, in general the measurements of the coronary sinus ostium did not significantly differ in patients with AVNRT compared with the control group.
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MESH Headings
- Adult
- Atrial Fibrillation/diagnosis
- Atrial Fibrillation/physiopathology
- Atrial Fibrillation/therapy
- Catheter Ablation
- Coronary Angiography
- Coronary Vessel Anomalies/physiopathology
- Electrophysiology
- Female
- Heart Conduction System/physiopathology
- Humans
- Male
- Middle Aged
- Prospective Studies
- Tachycardia, Atrioventricular Nodal Reentry/diagnosis
- Tachycardia, Atrioventricular Nodal Reentry/physiopathology
- Tachycardia, Atrioventricular Nodal Reentry/therapy
- Tachycardia, Ectopic Atrial/diagnosis
- Tachycardia, Ectopic Atrial/physiopathology
- Tachycardia, Ectopic Atrial/therapy
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/therapy
- Vena Cava, Superior/abnormalities
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Affiliation(s)
- C Weiss
- Department of Cardiology University Hospital Eppendorf, Germany
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De Sisti A, Tonet J, Marrakchi S, Raguin D, Frank R. Effective cryoablation of a lateral accessory pathway within the distal coronary sinus. J Interv Card Electrophysiol 2008; 22:189-93. [DOI: 10.1007/s10840-008-9273-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 04/24/2008] [Indexed: 10/22/2022]
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23
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Characterization of the mitral isthmus for atrial fibrillation ablation using intracardiac ultrasound from within the coronary sinus. Heart Rhythm 2008; 5:19-27. [DOI: 10.1016/j.hrthm.2007.08.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 08/17/2007] [Indexed: 11/21/2022]
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24
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Karpawich PP. Catheter-Delivered Cryoablation in the Pediatric Coronary Sinus: Assessing Newer Arrhythmia Therapies. J Cardiovasc Electrophysiol 2007; 18:598-600. [PMID: 17472711 DOI: 10.1111/j.1540-8167.2007.00837.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Tada H, Yamada M, Naito S, Nogami A, Oshima S, Taniguchi K. Radiofrequency catheter ablation within the coronary sinus eliminates a macro-reentrant atrial tachycardia: importance of mapping in the coronary sinus. J Interv Card Electrophysiol 2007; 15:35-41. [PMID: 16680548 DOI: 10.1007/s10840-006-6310-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Accepted: 11/21/2005] [Indexed: 10/24/2022]
Abstract
We describe a patient who underwent radiofrequency (RF) catheter ablation of symptomatic atrial fibrillation. After left atrial (LA) catheter ablation and pulmonary vein isolation, a macro-reentrant atrial tachycardia (AT) with a critical isthmus at the mitral isthmus was induced by incremental atrial pacing from the coronary sinus. Extensive RF energy applications from endocardial sites using ablation catheters with 4 mm- and 8 mm- tips resulted in no discrete potentials being recorded from the endocardial sites of the isthmus, but the tachycardia could not be terminated. However, discrete potentials were recorded within the CS, and epicardial RF energy applications from the CS eliminated the tachycardia. Thus, mapping in the CS is useful for detecting residual conduction at epicardial sites along the mitral isthmus. RF catheter ablation within the CS should be considered when no distinct electrograms are recorded after extensive ablation from the endocardial sites and when distinct electrograms are recorded within the CS.
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Affiliation(s)
- Hiroshi Tada
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan.
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26
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Segal OR, Wong T, Chow AWC, Jarman JWE, Schilling RJ, Markides V, Peters NS, Wyn Davies D. Intra-coronary guidewire mapping–A novel technique to guide ablation of human ventricular tachycardia. J Interv Card Electrophysiol 2007; 18:143-54. [PMID: 17464557 DOI: 10.1007/s10840-007-9084-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2006] [Accepted: 01/29/2007] [Indexed: 11/28/2022]
Abstract
HYPOTHESIS Endocardial catheter ablation of ventricular tachycardia (VT) may fail if originating from epicardial or intramural locations. We hypothesized that mapping could be achieved using an angioplasty guidewire in the coronary circulation, to guide trans-coronary ablation. METHODS AND RESULTS Six patients (2 male), 64 +/- 14 years and previously unsuccessful endocardial VT ablation were studied. Using ECG and existing endocardial mapping data, a coronary artery supplying the predicted VT origin was selected. A 0.014-in angioplasty guidewire was advanced into branches of the artery and connected to an amplifier to record unipolar signals against an indifferent electrode within the inferior vena cava. An uninflated angioplasty balloon was advanced over the wire such that only the distal 5 mm was used for mapping. One VT per patient was mapped (CL 348 +/- 102.1 ms). Diastolic potentials were recorded from all (77.7 +/- 43.8 ms pre-QRS onset) and concealed entrainment demonstrated in 3. Pacemapping during sinus rhythm was used in the remainder due to failure of entrainment (n = 2) or degeneration to VF (n = 1). Following branch identification, cold saline injection causing VT termination was used for further confirmation. Five VTs were ablated using intra-coronary ethanol injection via the central lumen of the inflated over the wire balloon. The other was ablated using radiofrequency energy in a coronary vein adjacent to the target artery, which was too small for an angioplasty balloon. No complications or recurrence of ablated VT was seen over 19 +/- 17 months of follow up. CONCLUSIONS Intracoronary guidewire mapping is a novel method of electrophysiological epicardial mapping to help guide trans-coronary VT ablation.
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Affiliation(s)
- Oliver R Segal
- St. Mary's Hospital and Imperial College of Medicine, London, UK
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27
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Nezafat R, Han Y, Peters DC, Herzka DA, Wylie JV, Goddu B, Kissinger KK, Yeon SB, Zimetbaum PJ, Manning WJ. Coronary magnetic resonance vein imaging: Imaging contrast, sequence, and timing. Magn Reson Med 2007; 58:1196-206. [DOI: 10.1002/mrm.21395] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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28
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Callans DJ, Jacobson JT. Nonpharmacologic Treatment of Tachyarrhythmias. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50026-7] [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: 10/20/2022] Open
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29
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Obel OA, d'Avila A, Neuzil P, Saad EB, Ruskin JN, Reddy VY. Ablation of Left Ventricular Epicardial Outflow Tract Tachycardia From the Distal Great Cardiac Vein. J Am Coll Cardiol 2006; 48:1813-7. [PMID: 17084255 DOI: 10.1016/j.jacc.2006.06.006] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2005] [Revised: 07/12/2006] [Accepted: 07/18/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the feasibility and safety of ablation of idiopathic outflow tract ventricular tachycardia (OTVT) from the distal ramifications of the coronary sinus (CS). BACKGROUND A significant minority of patients presenting with idiopathic OTVT have an epicardial focus, the standard approach to which involves ablation from within one of the aortic valve cusps (AVCs). We describe the successful ablation of idiopathic epicardial OTVT from within the CS in the distal great cardiac vein (GCV). METHODS Ablation from the distal GCV was performed in 5 patients with idiopathic OTVT who had unfavorable mapping, in some cases unsuccessful ablation from various endocardial and epicardial sites including the AVCs, and in 1 patient via the direct epicardial approach. An electroanatomic mapping system (Carto) was used in 3 patients, and conventional mapping was performed in 2 patients, and in 3 patients cryothermal ablation was performed. RESULTS In all patients, the first ablation lesion in the GCV successfully eliminated the arrhythmia. All patients have remained free of VT after a mean follow-up of 24 (7 to 44) months. There were no immediate or long-term complications. CONCLUSIONS Idiopathic epicardial OTVT can be successfully ablated from the distal GCV, and should be seen as an alternative to ablation from the aortic valve cusps.
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Affiliation(s)
- Owen A Obel
- Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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30
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Amasyali B, Kose S, Aytemir K, Kilic A, Kursaklioglu H, Isik E. A permanent junctional reciprocating tachycardia with an atypically located accessory pathway successfully ablated from within the middle cardiac vein. Heart Vessels 2006; 21:188-91. [PMID: 16715194 DOI: 10.1007/s00380-005-0848-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 06/25/2005] [Indexed: 10/24/2022]
Abstract
Permanent form of junctional reciprocating tachycardia (PJRT) is an uncommon form of atrioventricular re-entrant tachycardia due to an accessory pathway characterized by slow and decremental retrograde conduction. The majority of accessory pathways in PJRT are localized in the posteroseptal zone. Despite the high success rate, failure may occur during endocardial radiofrequency catheter ablation due to epicardial insertion of the accessory pathway. We report a case of PJRT in a 25-year-old man in whom the accessory pathway was located epicardially in the posteroinferior region and ablated from within the middle cardiac vein by radiofrequency catheter ablation.
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Affiliation(s)
- Basri Amasyali
- Department of Cardiology, Gulhane GATA Military Medical School, 06018, Etlik, Ankara, Turkey.
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31
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Coronary Sinus Morphology in Patients with Posteroseptal Atrioventricular Accessory Pathways. J Arrhythm 2006. [DOI: 10.1016/s1880-4276(06)80012-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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32
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Aoyama H, Nakagawa H, Pitha JV, Khammar GS, Chandrasekaran K, Matsudaira K, Yagi T, Yokoyama K, Lazzara R, Jackman WM. Comparison of Cryothermia and Radiofrequency Current in Safety and Efficacy of Catheter Ablation within the Canine Coronary Sinus Close to the Left Circumflex Coronary Artery. J Cardiovasc Electrophysiol 2005; 16:1218-26. [PMID: 16302908 DOI: 10.1111/j.1540-8167.2005.50126.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION A canine model was used to compare cryoablation and radiofrequency ablation (RFA) within the coronary sinus (CS) in the ability to create a transmural CS myocardial (Trans-CSM) lesion and risk of coronary artery stenosis. METHODS After CS and left circumflex (LCx) coronary angiography, an intravascular ultrasound (IVUS) probe was placed in LCx in 29 dogs. An irrigated RFA catheter (8 dogs) or N(2)O cryoablation catheter (21 dogs) was inserted into the CS and positioned within 2 mm of LCx, confirmed by IVUS. RF (30-50W) was applied for 60 seconds at 10 CS sites. Cryoablation (-75 degrees C) was performed with one (n = 7) or two (n = 14) 4-minute applications. Dogs were sacrificed at 1 week (8 RFA and 13 cryoablation) or 3 months (8 cryoablation). RESULTS During RFA, IVUS showed wall thickening and LCx narrowing in 9 of 10 sites. Angiography at 5-minute post-RFA identified LCx narrowing (25-90%) at 6 of 10 sites and 25-75% narrowing at 4 of 9 sites at 1-week post-RFA. During cryoablation, IVUS showed reversible ice ball compression of LCx, and no LCx narrowing by angiography at 5 minutes, 1 week, or 3 months. Histology showed Trans-CSM lesion at 10 of 10 RFA sites and 20 of 21 cryoablation sites. RFA produced LCx medial necrosis at 7 of 10 sites, involving 20-50%(median 32.5%) of LCx circumference with loss of intima at 5 of 7 sites. Single and twice 4-minute cryoablation produced LCx medial necrosis at 2 of 7 and 8 of 14 sites (5-40%, median 25% circumference). Intima was preserved at 1 week (13/13) with minor proliferation (without narrowing) at 2 of 8 sites at 3 months. CONCLUSIONS Cryoablation in CS within 2 mm of LCx produces Trans-CSM lesions similar to RFA with lower risk of LCx stenosis than RFA.
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Affiliation(s)
- Hiroshi Aoyama
- Cardiac Arrhythmia Research Institute and Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
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Takahashi Y, Jaïs P, Hocini M, Sanders P, Rotter M, Rostock T, Sacher F, Jaïs C, Clémenty J, Haïssaguerre M. Acute Occlusion of the Left Circumflex Coronary Artery During Mitral Isthmus Linear Ablation. J Cardiovasc Electrophysiol 2005; 16:1104-7. [PMID: 16191121 DOI: 10.1111/j.1540-8167.2005.50124.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Occlusion of LCX During RF Catheter Ablation. We report a case of acute occlusion of the left circumflex coronary artery during catheter ablation in the coronary sinus to complete the linear lesion between the postero-lateral mitral annulus and the left inferior pulmonary vein for the treatment of atrial fibrillation.
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Affiliation(s)
- Yoshihide Takahashi
- Hôpital Cardiologique du Haut-Lévêque, Université Victor Segalen Bordeaux 2, France.
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Skanes AC, Jones DL, Teefy P, Guiraudon C, Yee R, Krahn AD, Klein GJ. Safety and Feasibility of Cryothermal Ablation Within the Mid‐ and Distal Coronary Sinus. J Cardiovasc Electrophysiol 2004; 15:1319-23. [PMID: 15574185 DOI: 10.1046/j.1540-8167.2004.04116.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The aim of this study was to assess the safety and feasibility of catheter-based cryothermal ablation lesions in the mid- and distal coronary sinus. METHODS AND RESULTS Cryothermal ablation lesions were delivered using a 7-French catheter at the mid- (n = 13) and distal (n = 12) coronary sinus in 14 swine under general anesthesia. Lesions were delivered for 2 or 4 minutes in a 1:2 randomized ratio such that seven 2-minute lesions and eighteen 4-minute lesions were delivered to a maximum negative temperature of -70 degrees C. Integrity of the circumflex artery was assessed by angiography before and after each lesion application. In five animals, arterial Doppler flow velocity was continuously monitored and coronary flow reserve assessed. Histologic assessment of the left AV ring was made after a 48-hour survival period and lesions graded for depth and transmurality. Eighteen of 25 lesions were >3 mm deep: five of seven 2-minute lesions and thirteen of eighteen 4-minute lesions. Lesions were transmural in 18 of 25 cases. Two transmural lesions were limited in depth due to their epicardial position. One 2-minute mid-coronary sinus lesion was not found. Adherent thrombus was seen grossly in the coronary sinus at one site and only on microscopic examination in three other lesions. Angiography demonstrated no arterial spasm or thrombosis. Continuous-flow Doppler remained unchanged throughout lesion production. Coronary flow reserve was unchanged (1.7 +/- 0.8 preablation vs 1.7 +/- 1.0 postablation, P = 0.6). The media and intima were preserved in all cases. Necrosis of the adventitia was seen in one arterial segment. CONCLUSION Catheter-based cryoablation can produce lesions in the musculature of the adjacent atrium and ventricle when accessed from the coronary sinus without significant injury to the coronary sinus or adjacent artery. This method has potential application as the ablation method of choice when such lesions are required.
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Affiliation(s)
- Allan C Skanes
- Department of Medicine, University of Western Ontario, London, Ontario, Canada.
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Hartung U, Trappe HJ, Weismüller P. [A 66-year old female patient with tachycardia and syncope]. Internist (Berl) 2004; 45:461-5. [PMID: 15152614 DOI: 10.1007/s00108-003-1134-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A 66-year old female patient suffered from paroxysmal tachycardias, palpitations, dizziness and once a short period of unconsciousness. The surface ECG showed preexcitation, and the clinical diagnosis of WPW syndrome was established. The electrophysiological study revealed the rare occurrence of an epicardial posteroseptal accessory pathway. Retrograde venous angiography of the coronary sinus showed a coronary sinus diverticulum. Ablation of the accessory pathway in the neck of the coronary sinus diverticulum was successful. Epicardial accessory pathways in a coronary sinus diverticulum are rare. However, successful ablation of accessory pathways at this site is safely possible.
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Affiliation(s)
- U Hartung
- Medizinische Klinik II, Friedrich-Alexander Universität Erlangen-Nürnberg, Germany
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36
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Affiliation(s)
- Fred Morady
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan 48109-0311, USA.
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37
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Abstract
The coronary sinus provides access to the epicardial space of the heart allowing ablation of epicardial accessory pathways, foci of ventricular arrhythmia, and arrhythmogenic areas such as the vein or ligament of Marshall. In addition, its musculature may form atrioventricular accessory connections, participate in macroreentrant atrial arrhythmias, and generate foci of microreentrant atrial tachycardia and fibrillation. Thus, the coronary sinus may serve both as a bystander to arrhythmia circuits as well as an original source of cardiac arrhythmia.
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38
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Gaita F, Montefusco A, Riccardi R, Giustetto C, Grossi S, Caruzzo E, Bianchi F, Vivalda L, Gabbarini F, Calabro R. Cryoenergy Catheter Ablation:. J Cardiovasc Electrophysiol 2004; 15:263-8. [PMID: 15030412 DOI: 10.1046/j.1540-8167.2004.03426.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Permanent junctional reciprocating tachycardia (PJRT) is an infrequent form of reciprocating tachycardia, almost incessant from childhood and usually refractory to drug therapy. Radiofrequency catheter ablation currently is the first-line therapy for PJRT, but its application in the septal region may be associated with complications. In contrast, cryoenergy has several advantages, such as the ability to test the effects of ablation while the lesion is still forming, thus reducing the number of ineffective, useless, and potentially harmful lesions. The aim of this study was to investigate the potential clinical utility of percutaneous cryoenergy catheter ablation for treatment of pediatric patients with PJRT. METHODS AND RESULTS Four patients (age 14 +/- 5 years; mean +/- SD) with a clinical diagnosis of PJRT underwent catheter cryoablation. The ablation was successfully accomplished in 4 (100%) of 4 patients. The mean +/- SD number of cryoapplications was 1.8 +/- 0.8, and from 1 to 6 cryomappings were performed for each permanent cryolesion. The successful site was in the mid-septal region (2 patients), at the coronary sinus orifice (1 patient), and in the middle cardiac vein (1 patient). No complications with cryoablation were reported, nor was there prolongation of the AH interval during cryomapping or cryoablation. No pain was reported by patients during the cryoenergy catheter ablation procedure. PJRT recurrence occurred in 1 patient who underwent a second successful cryoablation procedure. CONCLUSION The outcomes of cryoenergy catheter ablation in these 4 patients treated for PJRT suggest that cryoablation is a safe, effective, and pain-free technique for treating pediatric patients with PJRT.
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Affiliation(s)
- Fiorenzo Gaita
- Division of Cardiology, Ospedale Mauriziano di Torino, Italy.
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39
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Sanders P, Jaïs P, Hocini M, Haïssaguerre M. Electrical Disconnection of the Coronary Sinus by Radiofrequency Catheter Ablation to Isolate a Trigger of Atrial Fibrillation. J Cardiovasc Electrophysiol 2004; 15:364-8. [PMID: 15030429 DOI: 10.1046/j.1540-8167.2004.03300.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We report a case of radiofrequency catheter ablation for chronic atrial fibrillation, in which electrical disconnection of the coronary sinus was necessary to isolate a trigger initiating atrial fibrillation.
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Affiliation(s)
- Prashanthan Sanders
- Service de Rythmologie, Hôpital Cardologique du Haut-Lévêque, Bordeaux, France.
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40
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Morady F. Catheter Ablation of Supraventricular Arrhythmias:. State of the Art. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:125-42. [PMID: 14720171 DOI: 10.1111/j.1540-8159.2004.00401.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Fred Morady
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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Hwang C, Peter CT, Chen PS. Radiofrequency ablation of accessory pathways guided by the location of the ligament of Marshall. J Cardiovasc Electrophysiol 2003; 14:616-20. [PMID: 12875423 DOI: 10.1046/j.1540-8167.2003.03067.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION In humans, complex muscle connections are present near the junction between the coronary sinus (CS) and the ligament of Marshall. We hypothesize that these complex muscle connections participate in accessory pathway conduction. METHODS AND RESULTS Electrophysiologic studies and radiofrequency ablation were performed in four patients with refractory AV reciprocating tachycardia. Case 1 was a 19-year-old male. Marshall bundle potentials were recorded by a catheter in the vein of Marshall. Radiofrequency energy application from that catheter resulted in successful ablation. Case 2 was a 43-year-old male who had undergone two unsuccessful radiofrequency ablation procedures of a left free-wall accessory pathway by conventional techniques. Coronary sinus electrography during tachycardia and ventricular pacing showed a long V-A interval. Radiofrequency energy application directed toward the ligament of Marshall eliminated the pathway conduction. Case 3 was a 17-year-old male who had undergone three unsuccessful ablation procedures. Radiofrequency energy application directed toward the stump of the vein of Marshall successfully eliminated the pathway conduction. Case 4 was a 20-year-old female who underwent one unsuccessful ablation procedure. Successful ablation was achieved in the left atrial free wall, approximately 1 cm above the AV annulus, at a location near the ligament of Marshall. CONCLUSION We report four patients in whom successful accessory pathway ablation was achieved by targeting the ligament of Marshall. These findings suggest that the complex muscle connections among the coronary sinus, ligament of Marshall, and left atrium is important in accessory pathway conduction and maintenance of circus movement tachycardia in these patients.
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Affiliation(s)
- Chun Hwang
- Utah Valley Regional Medical Center, Provo, Utah, USA.
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Blaufox AD, Saul JP. Radiofrequency ablation of right-sided accessory pathways in pediatric patients. PROGRESS IN PEDIATRIC CARDIOLOGY 2001; 13:25-40. [PMID: 11413056 DOI: 10.1016/s1058-9813(01)00081-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Right free-wall and septal accessory pathways encompass the full spectrum of accessory pathway electrophysiology and are situated in complex anatomical arrangements. Understanding this diversity of physiology is necessary for the successful and safe elimination of these connections with transcatheter radiofrequency ablation. When radiofrequency catheter ablation of these pathways is attempted in children, anatomical relationships often become more complex, and spatial constraints require more adaptive techniques than in adults. It is clear that considerable progress has been made with radiofrequency catheter ablation, such that it is now first-line therapy for most children who have been diagnosed with one of the broad spectrum of clinical manifestations that result from the presence of these accessory connections. This review will discuss how accessory pathway electrophysiology and anatomy impact the clinical syndromes observed in children, and how these factors, as well as others particular to children, determine the approach, results and potential long-term consequences of radiofrequency catheter ablation of right-sided accessory pathways in the pediatric population.
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Affiliation(s)
- A D. Blaufox
- Medical University of South Carolina, Charleston, SC, USA
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43
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Moak JP, Moore HJ, Lee SW, Giglia TM, Sable CA, Furbush NC, Ringel RR. Case report: pulmonary vein stenosis following RF ablation of paroxysmal atrial fibrillation: successful treatment with balloon dilation. J Interv Card Electrophysiol 2000; 4:621-31. [PMID: 11141209 DOI: 10.1023/a:1026573816874] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Paroxysmal atrial fibrillation and atrial tachycardia may originate from a focal source in one or multiple pulmonary veins. A focal origin facilitates a potential cure amendable to radiofrequency ablation. Herein we report the case of a 16 year old adolescent male with a tachycardia induced cardiomyopathy who presented with very frequent paroxysmal episodes of atrial fibrillation, atrial flutter and atrial tachycardia. The origin of the arrhythmia was mapped to the secondary branches of the left lower pulmonary vein using an octapolar micro-mapping catheter. Immediately following application of three radiofrequency lesions, angiography of the left lower pulmonary vein revealed a region of focal stenosis at the site of energy application, with delayed pulmonary venous emptying. Attempts to relieve any element of spasm using direct administration of nitroglycerin were unsuccessful. Three months later repeat catheterization revealed an unchanged region of tight anatomical stenosis. Balloon dilation of two stenotic areas resulted in dramatic relief of the obstruction and improved venous drainage. Recatheterization 6 months later revealed mild restenosis that was successfully redilated. Intracardiac ultrasound demonstrated focal constriction. Care should be exercised in attempting RF ablation in distal arborization sites of the pulmonary veins in children, because of the small caliber compared to adult subjects. Radiofrequency induced focal areas of stenosis may be amenable to balloon catheter dilation.
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Affiliation(s)
- J P Moak
- Department of Cardiology, Children's National Medical Center, Washington, DC, USA.
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Lam C, Schweikert R, Kanagaratnam L, Natale A. Radiofrequency ablation of a right atrial appendage-ventricular accessory pathway by transcutaneous epicardial instrumentation. J Cardiovasc Electrophysiol 2000; 11:1170-3. [PMID: 11059983 DOI: 10.1111/j.1540-8167.2000.tb01765.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Epicardial location of accessory AV pathways may be responsible for the failure of conventional endocardial radiofrequency catheter ablation. Transcutaneous epicardial instrumentation provides access to the normal pericardium with no need for invasive thoracotomy or thoracoscopy. We report the case of successful epicardial mapping and ablation of a right atrial appendage-ventricular connection using a percutaneous epicardial approach, after repeated failure of endocardial ablation attempts.
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Affiliation(s)
- C Lam
- Department of Cardiology, The Cleveland Clinic Foundation, Ohio 44195, USA
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45
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Abstract
After its introduction in 1987, radiofrequency catheter ablation became established as a safe and effective therapy for the cure of many cardiac arrhythmias in people. The possibility of assessing the relationship between the anatomical target and the electrophysiologic changes produced by radiofrequency pulse delivery has also provided significant improvement in the physician's knowledge of the pathophysiology of the underlying rhythm disturbance. Nowadays, using this therapy, success rates well above 90% with recurrence rates lower than 5% are expected after treatment of most regular supraventricular arrhythmias. As catheter ablation techniques develop, success rates in the range of those obtained for regular supraventricular arrhythmias are expected in the future in the treatment of regular ventricular and irregular supraventricular arrhythmias.
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Affiliation(s)
- R Cappato
- Department of Clinical Arrhythmology, Istituto Policlinico S. Donato, Milan, Italy
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46
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Liu J, Dole LR. Late complete atrioventricular block complicating radiofrequency catheter ablation of a left posteroseptal accessory pathway. Pacing Clin Electrophysiol 1998; 21:2136-8. [PMID: 9826868 DOI: 10.1111/j.1540-8159.1998.tb01135.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A patient with AV reentrant tachycardia underwent radiofrequency catheter ablation for interruption of a left posteroseptal accessory pathway (AP). During the RF current application, he developed transient complete left bundle branch block which lasted for 2 minutes. The following day the patient developed permanent complete AV block. This case indicates that great care should be taken when performing RF ablation for this AP site.
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Affiliation(s)
- J Liu
- Division of Medicine, Royal Brisbane Hospital, Herston Queensland, Australia
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47
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Cooke PA, Wilber DJ. Radiofrequency catheter ablation of atrioventricular nodal reentry tachycardia utilizing nonfluoroscopic electroanatomical mapping. Pacing Clin Electrophysiol 1998; 21:1802-9. [PMID: 9744446 DOI: 10.1111/j.1540-8159.1998.tb00282.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The advent of catheter ablation stimulated extensive research into anatomical localization of the pathways involved in atrioventricular nodal reentrant tachycardia (AVNRT). Conventional electrophysiological methods that attempt to correlate intracardiac electrograms with two-dimensional fluoroscopic anatomy are limited by the relative inaccuracy and poor reproducibility of this technique, and the requirement for high levels of radiation exposure. A new method of nonfluoroscopic electroanatomical mapping utilizes magnetic field sensing with a specialized catheter to construct three-dimensional electroanatomical endocardial maps of selected heart chambers with spatial resolution of < 1 mm. This system can be used in patients undergoing catheter ablation for AVNRT to create accurate maps of Koch's triangle and to guide application of radiofrequency energy. Initial experience in 14 patients suggests efficacy and safety comparable to conventional mapping and ablation techniques. Further evaluation may confirm the potential benefits of this system with respect to success rates, complications, procedure time, and radiation exposure.
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Affiliation(s)
- P A Cooke
- University of Chicago Hospitals, Illinois 60637, USA
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Sopher SM, Grace AA, Heald SC, Rowland E. Entrapment of an ablation catheter in the cardiac venous system: a case report. Pacing Clin Electrophysiol 1998; 21:1306-8. [PMID: 9633075 DOI: 10.1111/j.1540-8159.1998.tb00192.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cannulation of the coronary sinus is a common procedure with infrequent complications. We report an unusual case of a steerable "dumb-bell" catheter passed through the ostium of the coronary sinus prior to an intended radiofrequency ablation procedure becoming stuck and requiring general anesthesia for extraction. We caution against the use of such catheters with a "waist" for the cannulation of the coronary sinus.
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Affiliation(s)
- S M Sopher
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, United Kingdom
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Shinbane JS, Lesh MD, Stevenson WG, Klitzner TS, Natterson PD, Wiener I, Ursell PC, Saxon LA. Anatomic and electrophysiologic relation between the coronary sinus and mitral annulus: implications for ablation of left-sided accessory pathways. Am Heart J 1998; 135:93-8. [PMID: 9453527 DOI: 10.1016/s0002-8703(98)70348-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To determine whether precise left-sided accessory pathway localization is possible from the coronary sinus, electrocardiogram (ECG) characteristics from the coronary sinus pair demonstrating earliest activation via the accessory pathway were compared to simultaneous mitral annular ablation catheter ECGs at successful ablation sites in 48 patients. To define the coronary sinus-mitral annular relation, the coronary sinus to mitral annulus distance (D) was measured at sequential distances from the coronary sinus os in 10 cadaver hearts. Mitral annular ECGs demonstrated earliest activation via the accessory pathway more frequently than the earliest coronary sinus pair (p < 0.001), more frequent continuous electrical activity (p < 0.001), and more frequent accessory pathway potentials (p < 0.01). D was >10 mm at 20, 40, and 60 mm, respectively, from the coronary sinus os. Coronary sinus ECGs do not precisely localize left-sided accessory pathways, which may be due in part to an average anatomic separation of more than 10 mm between the coronary sinus and accessory pathways bridging the mitral annulus.
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Affiliation(s)
- J S Shinbane
- Department of Medicine, University of California, San Francisco, 94143-1354, USA
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de Paola AA, Melo WD, Távora MZ, Martinez EE. Angiographic and electrophysiological substrates for ventricular tachycardia mapping through the coronary veins. Heart 1998; 79:59-63. [PMID: 9505921 PMCID: PMC1728572 DOI: 10.1136/hrt.79.1.59] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To study the value of epicardial mapping through the coronary venous system in patients with sustained ventricular tachycardia. DESIGN 20 consecutive patients with sustained ventricular tachycardia who were candidates for radiofrequency ablation. SETTING Electrophysiological laboratory. INTERVENTIONS Coronary venous angiography was performed with a catheter, which provided coronary sinus occlusion during injection of contrast media. Multipolar microelectrode catheters were then manoeuvred into the tributaries of coronary sinus, using an over-wire system or an on-wire system. An endocardial ablation catheter was positioned in the left ventricle. Conventional programmed ventricular stimulation was performed for sustained ventricular tachycardia induction. Endocardial radiofrequency ablation was performed using impedance or temperature monitoring. RESULTS Coronary veins were catheterised in all patients; 20 had induction of sustained ventricular tachycardia, 14 were stable. Presystolic epicardial electrograms were recorded in six patients and concealed entrainment in two, helping as a landmark for endocardial ablation. After simultaneous epicardial and endocardial mapping, successful endocardial radiofrequency ablation was achieved in nine of 14 patients with stable ventricular tachycardia (64%). CONCLUSIONS Epicardial mapping through the coronary veins in patients with ventricular tachycardia is feasible, safe, and can be a useful landmark for endocardial catheter mapping and ablation.
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Affiliation(s)
- A A de Paola
- Clinical Cardiac Electrophysiology Section, Paulista School of Medicine, Federal University of S Paulo, Brazil
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