ATRIOVENTRICULAR NODAL RE‐ENTRANT TACHYCARDIA ABLATION IN A CENTENARIAN

Abstract

To the Editor: A 107-year-old independently living woman with no known cardiac disease presented with lightheadedness and frequent falls. She underwent an extensive examination, and eventually an electrophysiology (EP) study was performed that revealed easily inducible typical atrioventricular (AV) nodal re-entrant tachycardia (AVNRT). Slow pathway ablation was successfully performed. To the best of our knowledge, the patient described here is the oldest reported patient to undergo successful AVNRT ablation (Figure 1). Twelve-lead electrocardiogram of patient's supraventricular tachycardia. Findings suggest a short RP tachycardia. Arrows point to retrograde p waves seen particularly in leads aVL and V1. A 107-year-old independently living woman with no known cardiac disease presented to a cardiologist with complaints of lightheadedness and frequent falls over the previous 5 months. A transthoracic echocardiogram showed normal left ventricular function and mild mitral and aortic valve stenosis. Holter monitoring revealed nonsustained episodes of a narrow-complex tachycardia, with heart rates as high as 170 beats per minute. She was treated with a beta-blocker, which was later discontinued due to symptomatic bradycardia with heart rates as low as 35 beats per minute. One day while walking out of her home, without any prodrome, she had a syncopal event resulting in facial trauma. Because of the sudden nature of her collapse, an arrhythmia was thought to be the likely cause of her symptoms, so an electrophysiology (EP) study was performed. EP study showed dual AV nodal physiology and easily inducible typical AV nodal re-entrant tachycardia (AVNRT) (Figure 2), and slow pathway ablation was successfully performed. To further understand her reported syncopal episodes, and especially to evaluate for a bradycardic etiology, an implantable loop recorder (ILR) was also implanted. She had an uncomplicated postprocedural course and was eventually discharged to home. During 14 months of outpatient follow-up, no tachy- or bradyarrhythmias were noted on ILR interrogation, and no further syncope was noted. Intracardiac tracing tracing showing inducible typical atrioventricular nodal re-entrant tachycardia during electrophysiology study. AVNRT is the most common cause of supraventricular tachycardia. Catheter ablation of AVNRT is a class I recommendation of the American College of Cardiology and the American Heart Association for the long-term treatment of AVNRT.1 The safety and high efficacy of catheter ablation of AVNRT in patients aged 75 and older has been demonstrated.2 A case of AVNRT ablation in a 96-year-old woman has been reported.3 To the best of the authors' knowledge, the patient described here is the oldest reported patient to undergo successful AVNRT ablation. The ILR further served to exclude other dysrhythmias as a possible cause of her presyncopal symptoms. Clinicians often consider older patients to be poor candidates for invasive but potentially curative procedures based solely on their age. These patients are treated conservatively, resulting in suboptimal symptom control, which may then translate to greater morbidity and mortality. Medications may have a higher incidence of adverse effects in elderly people.4 Slow-pathway catheter ablation in an attempt to cure AVNRT should always be considered an option in elderly patients. Tachyarrhythmias less amenable to curative ablation, such as atrial tachycardia of a nonunifocal source or atrial fibrillation, are frequent in this age group. Furthermore, patients of all ages with unexplained symptoms of presyncope or syncope may benefit from continuous cardiac monitoring using an ILR. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. James P. Daubert: Boston Scientific, honoraria for speaking; CV Therapeutics, advisory board; Medtronic, equity interest; Cryocor, consultant. Mehmet K. Aktas: Boston Scientific, honoraria. Author Contributions: Mehmet K. Aktas: acquisition of data, case report preparation and review. Stephen R. Tokarz: case report preparation and submission. James P. Daubert: acquisition of data, case report preparation and review. Sponsors' Role: None.