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Przybylski R, DeWitt ES, Meziab O, Gauvreau K, Dionne A, O'Leary ET, Alexander ME, Walsh EP, Mah DY. Retroflexed catheter course reduces the risk of right free wall accessory pathway recurrence. J Cardiovasc Electrophysiol 2023; 34:1828-1834. [PMID: 37449445 DOI: 10.1111/jce.16003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/18/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Accessory atrioventricular pathways (APs) may mediate atrioventricular reciprocating tachycardia and, in some cases, have the potential to conduct atrial tachycardia rapidly, which can be life threatening. While catheter ablation can be curative, ablation of right free wall APs is associated with a high rate of recurrence, likely secondary to reduced catheter stability along the right free wall atrioventricular groove. We sought to identify characteristics associated with a lower rate of recurrence and hypothesized ablation lesions placed on the ventricular side of the atrioventricular groove using a retroflexed catheter approach would decrease rates of recurrence. METHODS AND RESULTS Retrospective chart review of patients who underwent catheter ablation of a right free wall AP from January 1, 2008 through June 1, 2021 with >2 months follow up. Cox proportional hazards regression was used to identify relationships between predictor variables and AP recurrence. We identified 95 patients who underwent ablation of 98 right free wall APs. Median age was 13.1 years and median weight at ablation was 52.3 kg. Overall, 23/98 (23%) APs recurred. Use of a retroflexed catheter course approaching the atrioventricular groove from the ventricular aspect was associated with reduced risk of AP recurrence with (univariable hazard ratio of 0.10 [95% confidence interval: 0.01-0.78]), which remained significant in multiple two variable Cox proportional hazards models. CONCLUSION Use of a retroflexed catheter course is associated with a reduced likelihood of AP recurrence. This approach results in improved catheter stability and should be considered for ablation of right free wall APs.
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Affiliation(s)
- Robert Przybylski
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth S DeWitt
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Omar Meziab
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark E Alexander
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Dong ZY, Shao W, Yuan Y, Lin L, Yu X, Cui L, Zhen Z, Gao L. Transseptal approach for catheter ablation of left-sided accessory pathways in children with Marfan syndrome: A case report. World J Clin Cases 2023; 11:2084-2090. [PMID: 36998966 PMCID: PMC10044966 DOI: 10.12998/wjcc.v11.i9.2084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/20/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Left-sided accessory pathways (APs) can be accessed with either a transaortic (TA) or transseptal approach (TS). For children with Marfan syndrome (MFS) who have aortic disease, the use of TA can aggravate the disease, making TS the best choice for these patients.
CASE SUMMARY A 10-year-old girl was hospitalized because of intermittent heart palpitations and chest tightness. She was diagnosed with MFS, supraventricular tachycardia, Wolff-Parkinson-White syndrome, and left-sided AP was detected by cardiac electrophysiological. Catheter ablation was successfully performed via TS under the guidance of the Ensite system. During the follow-up, no recurrence or complications occurred.
CONCLUSION The TS for catheter ablation of left-sided APs can be considered in children with MFS. Adequate evaluation and selection of the appropriate puncture site are particularly important.
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Affiliation(s)
- Zi-Yan Dong
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Wei Shao
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Yue Yuan
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Li Lin
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Xia Yu
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Lang Cui
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Zhen Zhen
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Lu Gao
- National Center for Children’s Health, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
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Nikoo MH, Khorshidifar M, Nasrollahi E, Bahramvand Y, Nouri F, Attar A. Ventricular versus atrial side ablation for treatment of atrioventricular accessory pathways: a randomized controlled clinical trial. J Interv Card Electrophysiol 2022; 64:103-110. [PMID: 35013893 DOI: 10.1007/s10840-021-01100-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The earliest atrial (A)/ventricular (V) activation potentials, or fused A/V potentials, are commonly used as ablation targets for atrioventricular (AV) accessory pathways (APs). However, these targets can be achieved in a relatively wide area of the heart around AV rings at both atrial and ventricular sides. The aim of this study is to analyze the height of intracardiac A and V waves and their correlation to find the most appropriate side for successful delivery of radiofrequency energy, atrial or ventricular edge. METHODS Ninety patients diagnosed with orthodromic AV re-entrant tachycardia (AVRT) or Wolff-Parkinson-White syndrome were enrolled. Local atrial/ventricular (A/V) amplitude potentials with the earliest activation or fused AV potentials were measured. Patients were randomly assigned into two groups with a 2:1 ratio. In group 1, ablation was done at the site where A was greater than V. In group 2, V was greater than A. Primary endpoint was success at first attempt, achieving antegrade AP conduction block, AV block during right ventricle pacing, or AVRT termination with no AP conduction. RESULTS Fifty-one patients (56.7%) were male. Thirty patients had an ablation at an atrial site (A > V) and 60 at a ventricular site (V > A). Ablation was more successful at the ventricular site (87% vs 100%, P = 0.011). All 30 patients in the atrial arm and 71% of the ventricular group underwent ablation via the antegrade method. CONCLUSIONS Success of catheter ablation of APs is higher where V > A (ventricular site of AP), indicating the priority of the ventricular edge of the mitral ring for a better outcome.
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Affiliation(s)
- Mohammad Hossein Nikoo
- Department of Cardiovascular Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Non-Communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Meghdad Khorshidifar
- Students' Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Nasrollahi
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Yaser Bahramvand
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Nouri
- Students' Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Armin Attar
- Department of Cardiovascular Medicine, TAHA Clinical Trial Group, School of Medicine, Shiraz University of Medical Sciences, 71344-1864, Shiraz, Iran.
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Yu X, Dong Z, Gao L, Lin L, Cui L, Shao W, Yu W, Zhen Z, Yuan Y. Transseptal Approach Versus Transaortic Approach for Catheter Ablation of Left-Sided Accessory Pathways in Children. Front Pediatr 2022; 10:888029. [PMID: 35783318 PMCID: PMC9247647 DOI: 10.3389/fped.2022.888029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Catheter ablation is recommended to eradicate supraventricular tachycardia caused by left-sided accessory pathways (APs) in children. This study aims to compare the safety and efficacy of the transseptal approach (TS) and aortic approach (TA) for catheter ablation of left-sided APs in a pediatric cohort. METHODS Patients < 18 years of age with left-sided APs who had undergone ablation at Beijing Children's Hospital between 13 January 2018 and 7 January 2020 were included and randomly categorized into either TS or TA group (follow-up for 22 months). In all, 60 patients in TS group and 41 patients in TA group were included in this study. Principal endpoints were success rate, recurrence rate, complications, procedure time, and radiation dose. RESULTS For TS group versus TA group, success rate was observed in 100 versus 97.56% (p = 0.402). The procedure time was 27.0 (32.0-23.0) versus 29.0 (38.0-24.5) min (p = 0.092). The rate of success or the procedure time was similar, but for the patients with Aps located in left posterior septum (LPS) or left posterior lateral (LPL), the TS group had a shorter procedure time compared with TA group (p < 0.01). The radiation dose was 28.0 (20.0-41.75) versus 0 mGy (p < 0.001). After successful ablation, no recurrence and complication were observed in either group. CONCLUSION Both TS and TA for catheter ablation of left-sided Aps were shown to be safe and effective in children. Zero radiation and ease of mastery make TA the preferred choice. TS is recommended to be used by properly trained medical professionals, especially for patient with AP localized in the LPL or LPS. However, TS is a good alternative where patients have aortic lesions or when TA fails.
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Affiliation(s)
- Xia Yu
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Ziyan Dong
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lu Gao
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Li Lin
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lang Cui
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wei Shao
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wen Yu
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhen Zhen
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yue Yuan
- Department of Cardiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
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Anselmino M, Matta M, Saglietto A, Calò L, Giustetto C, Scaglione M, Gaita F. Transseptal or retrograde approach for transcatheter ablation of left sided accessory pathways: a systematic review and meta-analysis. Int J Cardiol 2018; 272:202-7. [PMID: 29954668 DOI: 10.1016/j.ijcard.2018.06.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/08/2018] [Accepted: 06/11/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Transcatheter ablation is the most effective treatment for patients with symptomatic or high-risk accessory pathways (AP). At present, no clear recommendations have been issued on the optimal approach for left sided AP ablation. We performed this meta-analysis to compare the safety and efficacy of transaortic retrograde versus transseptal approach for left sided AP ablation. METHODS AND RESULTS MEDLINE/PubMed and Cochrane database were searched for pertinent articles from 1990 until 2016. Following inclusion/exclusion criteria application, 29 studies were selected including 2030 patients (1013 retrograde, 1017 transseptal) from 28 observational single Centre studies and one randomized trial. Patients approached by transseptal puncture presented a significantly higher acute success (98% vs. 94%, p = 0.040). The incidence of late recurrences (p = 0.381) and complications (p = 0.301) did not differ among the two groups, but the pattern of complications differed: vascular complications were more frequent with transaortic retrograde approach, while cardiac tamponade was the main transseptal complication. No difference was noted in terms of procedural duration and fluoroscopy time (p = 0.230 and p = 0.980, respectively). Meta-regression analysis showed no relation between year of publication and acute success (p = 0.325) or incidence of complications (p = 0.795); additionally, no direct relation was found between age and acute success (p = 0.256) or complications (p = 0.863). CONCLUSIONS Left sided AP transcatheter ablation is effective in around 95% of the cases, with a very limited incidence of complications. Transseptal access provides higher acute success in achieving AP ablation; late recurrences are rare but observed similarly following both approaches. Retrograde approach is affected by a relatively high incidence of vascular complications.
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Pass RH, Liberman L, Silver ES, Janson CM, Blaufox AD, Nappo L, Ceresnak SR. The "hidden" concealed left-sided accessory pathway: An uncommon cause of SVT in young people. Pacing Clin Electrophysiol 2018; 41:368-371. [PMID: 29327439 DOI: 10.1111/pace.13279] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 12/03/2017] [Accepted: 12/26/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Concealed left-sided accessory pathways (CLAP) are a cause of supraventricular tachycardia (SVT) in the young. Most are mapped with right ventricular (RV) apical/outflow pacing. Rarely, alternative means of mapping are required. We review our experience from three pediatric electrophysiology (EP) centers with a rare form of "hidden" CLAP. METHODS All patients <21 years undergoing EP study from 2008 to 2014 with a "hidden" CLAP (defined as an accessory pathway [AP] for which RV pacing at cycle lengths [CL] stable for mapping did not demonstrate eccentric retrograde conduction) were included. EXCLUSION CRITERIA preexcitation. Demographic, procedural, and follow-up data were collected. RESULTS A total of 23 patients met the criteria (median age, 14.3 years [range 7-21], weight, 51 kg [31-99]). 21 (96%) had SVT and one AFIB (4%). APs were adenosine sensitive in 7/20 patients (35%) and VA conduction was decremental in six (26%). CLAP conduction was demonstrable with orthodromic reentrant tachycardia in all patients, with RV extrastimulus testing in seven (30%) and with rapid RV pacing (<CL 300) in three (13%). Left ventricular (LV) pacing demonstrated CLAP conduction in 17/17 (100%) patients in whom it was used. All 23 CLAPs were successfully ablated (100%) via transseptal approach with radiofrequency energy. Specific ablation techniques included: 16 (70%) during LV paced rhythm, four (17%) during orthodromic reciprocating tachycardia (ORT; 3/4 ventricular entrained), and three (13%) with brief rapid RV pacing. There were no complications. At 18 months (range 3-96), there was one recurrence (4%). CONCLUSIONS Some CLAPs are only demonstrable with LV pacing, entrained ORT, or rapid RV pacing. LV pacing facilitated preferential AP conduction, allowing for mapping while maintaining stable hemodynamics.
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Affiliation(s)
- Robert H Pass
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Leonardo Liberman
- New York Presbyterian Hospital, Children's Hospital of NY, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Eric S Silver
- New York Presbyterian Hospital, Children's Hospital of NY, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Christopher M Janson
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Andrew D Blaufox
- Cohen's Children's Hospital, Hofstra-Northwell School of Medicine, New Hyde Park, NY, USA
| | - Lynn Nappo
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Scott R Ceresnak
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
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