An anatomically and electrogram-guided stepwise approach for effective and safe catheter ablation of the fast pathway for elimination of atrioventricular node reentrant tachycardia

Abstract

We describe a new stepwise anatomically and electrogram-guided strategy for radiofrequency catheter ablation of the fast pathway. Anatomically and electrogram-guided approaches have been developed for slow pathway ablation in patients with atrioventricular (AV) node reentrant tachycardia; however, no stepwise systematic approaches exist for fast pathway ablation. Fifty-three patients (mean [+/- SD] age 43 +/- 11 years) with AV node reentrant tachycardia underwent attempted ablation of the fast pathway. The ablation catheter was initially positioned posterior and slightly superior to the site of the maximal His bundle recording region. At these sites, the amplitude of the local atrial potential was usually at least twice as high as the local ventricular potential, and a small proximal His bundle potential was recorded. When the first pulse was ineffective, the ablation catheter was repositioned stepwise slightly inferior to more midseptal sites. After a mean of 3.4 +/- 3.1 radiofrequency pulses (median 2, range 1 to 12), AV node reentrant tachycardia was noninducible in 51 patients (96%). No inadvertent complete AV block occurred. The AH interval was prolonged from 79 +/- 19 to 145 +/- 37 ms (p < 0.001). Thirty-eight patients (72%) developed complete ventriculoatrial block. Recording of a His bundle potential at the target site, stability of the local electrograms and occurrence of fast junctional rhythms during energy applications were more often observed at successful sites than transiently effective or noneffective sites. During a follow-up period of 12 +/- 7 months, 3 (6%) of 51 patients had a clinical recurrence of AV node reentrant tachycardia. Radiofrequency catheter ablation of the fast pathway using a combined anatomically and electrogram-guided stepwise approach is highly effective and safe. The safety of this approach seems to be due to the stable position of the ablation catheter at the interatrial septum, rather than across the tricuspid annulus, and the larger distance to the central body of the AV node and bundle of His.