Localization and radiofrequency catheter ablation of left-sided accessory pathways during atrial fibrillation Feasibility and electrogram criteria for identification of appropriate target sites

Abstract

Objectives. The purpose of the present study was to assess the feasibility of and electrophysiologic criteria for successful radio-frequency catheter ablation of left-sided accessory pathways during atrial fibrillation in patients with Wolff-Parkinson-White syndrome.Background. The onset of recurrent or sustained atrial fibrillation can complicate or significantly prolong accessory pathway catheter ablation procedures.Methods. We studied 19 consecutive patients (mean age [±SD] 44 ± 16 years) with Wolff-Parkinson-White syndrome who had ongoing atrial fibrillation with rapid anterograde conduction over the accessory pathway (mean ventricular rate [±SD] 173 ± 26 beats/min, range 130 to 220) at the beginning of the localization procedure during radiofrequency catheter ablation. Localization and ablation of the accessory pathway were performed with a 7F deflectable catheter (4-mm tip) that was placed underneath the mitral valve annulus. The electrophysiologic criteria from unipolar and bipolar local electrograms were compared for successful (n = 18) and unseccessful (n = 39) sites.Results. The accessory pathways were localized in the left posteroseptal (n = 6), posterior (n = 1), posterolateral (n = 7) and lateral (n = 5) regions and successfully ablated during atrial fibrillation in 18 (95%) of 19 patients with a mean of 3 ± 2 radiofrequency pulses (range 1 to 8, median 2). Presence of an accessory pathway potential (94% vs. 44%), early activation time of the ventricular electrogram (−3.2 ± 9.2 vs.−15.3 ± 12.6 ms) and recording of atrial activation (88% vs. 61%) from the ablation catheter were helpful in identifying successful sites (p < 0.001, p < 0.001 and p < 0.05, respectively, compared with unsuccessful sites). In addition, the ventricular activation time in relation to the intrinsic deflection of the unipolar electrogram was significantly earlier at successful than unsuccessful sites (18.1 ± 4.8 vs. 24.4 ± 6.6 ms, p < 0.01). A QS complex on the unipolar electrogram was observed at 96% of successful sites and at 94% of unsuccessful sites (p = 0.74). Multivariate logistic regression analysis revealed that the presence of an accessory pathway potential (p < 0.002) and early ventricular activation time in relation to the onset of the QRS complex (p < 0.001) were independent predictors of ablation success.Conclusions. Localization and radiofrequency catheter ablation of left-sided accessory pathways is possible in patients with sustained atrial fibrillation and rapid anterograde conduction over the accessory pathway during the ablation procedure. The electrophysiologic criteria described here can be used to reliably identify successful sites for radiofrequency ablation.