Atrioventricular Nodal Reentrant Tachycardia Research Articles

RF catheter ablation of AVNRT in a patient with interrupted inferior vena cava anomaly with hemiazygos continuity with persistent left superior vena cava

Intrahepatic interruption of the inferior vena cava (IVC) with continued hemizygous is a very rare abnormality and sometimes it may be accompanied by other cardiovascular abnormalities. Continuation of the hemizygous vein draining into the right atrium through the left superior vena cava (LSVC) is much rarer. In this paper, we have presented a patient who had simultaneous IVC interrupted with persistent LSVC and suffered from Atrioventricular nodal reentrant tachycardia (AVNRT). Finally, radiofrequencies (RF) catheter ablation for AVNRT was successfully performed through a left subclavian vein access.

SVT quest: The adventure diagnosing narrow QRS tachycardia.

In the field of cardiac electrophysiology, there is a universal desire: the discovery of a flawless diagnostic maneuver for supraventricular tachycardias (SVTs). This is not merely a wish but a shared odyssey. To improve diagnostic accuracy and achieve sufficient sensitivity and specificity, numerous diagnostic maneuvers have been proposed. However, each has its limitations and prompts a search for new diagnostic techniques. This continuous cycle of discovery and refinement, which we titled "SVT Quest" is reviewed in chronological sequence. This adventure in diagnosing narrow QRS tachycardia unfolds in 3 steps: Step 1 involves differentiating atrial tachycardia from other SVTs based on the observations such as V-A-V or V-A-A-V response, ΔAA interval, VA linking, the last entrainment sequence, and response to the atrial extrastimulus. Step 2 focuses on differentiating orthodromic reciprocating tachycardia from atrioventricular nodal reentrant tachycardia based on the observations such as tachycardia reset upon the premature ventricular contraction during His refractoriness, uncorrected/corrected postpacing interval, differential ventricular entrainment, orthodromic His capture, transition zone analysis, and total pacing prematurity. Step 3 characterizes the concealed nodoventricular/nodofascicular pathway and His-ventricular pathway-related tachycardia based on observations such as V-V-A response, ΔatrioHis interval, and paradoxical reset phenomenon. There is no single diagnostic maneuver that fits all scenarios. Therefore, the ability to apply multiple maneuvers in a case allows the operator to accumulate evidence to make a likely diagnosis. Let's embark on this adventure!

High-density visualization of antegrade fast pathway activation during atypical fast/slow atrioventricular nodal reentrant tachycardia in two cases.

High-density visualization of antegrade fast pathway activation during atypical fast/slow atrioventricular nodal reentrant tachycardia in two cases.

Incidence of atrial fibrillation in patients with atrioventricular nodal re-entrant tachycardia and its association with long-term outcome

Atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common paroxysmal supraventricular tachycardia. We sought to investigate the incidence of atrial fibrillation in patients with electrophysiologically confirmed/ablated AVNRT and its association with transient ischemic attack (TIA)/stroke as well as mortality during long-term follow-up. From the Karolinska Ablation Registry, 2855 consecutive patients with a first-time ablation for AVNRT between 2005 and 2018 were analyzed. Patients were 52.1±15.9 years old and 59.3% were women. During follow-up of up to 10 years (median 6.0 years; interquartile range 3.3 to 9.2 years), new onset or recurrence of atrial fibrillation occurred in 317 (11.1%) patients (incidence rate 19 cases per 1000 person-years). Excluding those with history of atrial fibrillation, new onset of atrial fibrillation occurred in 153 (6.1%) patients. In multivariable analysis, history of atrial fibrillation, arterial hypertension, history of TIA/stroke, and heart failure remained independently associated with new onset or recurrence of atrial fibrillation during follow-up. Death of any cause and TIA/stroke occurred in 141 (4.9%) patients and 107 (3.7%) patients, respectively. In multivariable analysis, occurrence of atrial fibrillation during follow-up remained independently associated with both outcomes. The prevalence of atrial fibrillation according to age at the end of follow-up was high among young patients (<60 years of age: 12.7%; 60-69 years of age: 10.6%). In this large cohort of patients with diagnosed AVNRT, the incidence of atrial fibrillation was high (11.1%) during long-term follow-up. Occurrence of atrial fibrillation during follow-up remained independently associated with death for any cause as well as with TIA/stroke. Therefore, a closer monitoring for atrial fibrillation in patients with AVNRT including those at young age is advisable.

Effect of Ablation Energy Source on Outcomes of Slow Pathway Modification for AVNRT in Children

BackgroundSelection of radiofrequency ablation (RF) or cryoablation (Cryo) for atrioventricular nodal re-entrant tachycardia (AVNRT) in children remains controversial due to a lack of contemporary comparison studies in this population. ObjectivesThis study sought to compare outcomes of RF and Cryo for AVNRT in the pediatric population. MethodsAVNRT ablation outcomes were retrospectively analyzed utilizing the National Cardiovascular Data Registry IMPACT (Improving Pediatric and Adult Congenital Treatment) Registry from April 2016 to March 2019. Data from subjects 1 to 21 years of age undergoing elective first-time slow pathway (SP) modification for AVNRT were included. Exclusion criteria included <1 year of age, congenital heart disease, and >1 ablation target. Cases were analyzed by ablation energy: 1) RF only; 2) Cryo only; 3) radiofrequency ablation switching to cryoablation (RF→Cryo); and 4) cryoablation switching to radiofrequency ablation (Cryo→RF). The primary outcome was acute ablation failure. Secondary outcomes included in-hospital adverse events. ResultsAmong 2,448 patients (mean age 13.6 ± 3.4 years, 60% female), RF only was employed in 43% (n = 1,046), Cryo only in 49% (n = 1,201), RF→Cryo in 6% (n = 135), and Cryo→RF in 66 (3%). Acute ablation failure occurred in 1.3% (n = 33), with no difference by energy source (1% in RF only, 1.5% in Cryo only, 1.5% in RF→Cryo, 3% in Cryo→RF; P = 0.5). Atrioventricular (AV) block requiring permanent pacemaker did not occur in any group; transient AV block occurred in 0.4% of the cohort, with no difference by group. ConclusionsIn this largest pediatric study of AVNRT ablation, RF and Cryo demonstrated comparable high acute success and rare documentation of AV block that did not result in temporary or permanent pacing. Longitudinal data are important for further comparison of these modalities with regard to recurrence risk and late complications.

Analysis of ST segment depression in supraventricular tachycardia and its relationship with underlying mechanism

BackgroundElectrocardiographic diagnosis of causes of supraventricular tachycardia (SVT) is sometimes difficult and application of routine algorithms can lead to misdiagnosis in as many as 37 % of patients. ST segment depression may be useful in diagnosing the nature of SVT. MethodsWe reviewed surface electrocardiogram (ECG) characteristics of 300 patients having SVT with 1:1 AV relationship and correlated findings with electrophysiology study (EPS) findings. Final diagnosis of AVNRT (Atrioventricular nodal reentrant tachycardia), Orthodromic AVRT (atrioventricular reentrant tachycardia) and atrial tachycardia (AT) was correlated with ECG parameters like heart rate, ST segment depressions and QRS morphology. ResultsOut of 300 patients, majority patients included in study, were having AVNRT or AVRT. ST depression predicted AVRT if the ST depression was ≥ 2 mm (overall sensitivity of 38.3 % and specificity of 93.8 % to predict AVRT) and was downsloping in morphology (sensitivity of 36.9 % and specificity of 94.7 % to predict AVRT). At heart rates ≥214 beats per minute (bpm) as measured by 7 small squares of ECG at 25 mm/s, downsloping ST depression ≥2 mm had a sensitivity 37.9 % of and specificity of 89.2 % to predict AVRT. At heart rate <214 bpm, downsloping ST depression ≥2 mm had sensitivity of 37.2 % and specificity of 96.5 % to predict AVRT. Downsloping ST depression of ≥2 mm helps to differentiate AVNRT from AVRT. ConclusionA downsloping ST segment depression ≥2 mm predicted SVT being an AVRT and can be used as a useful criteria in diagnosing the tachycardia.

Valsalva Aneurysm of Right Sinus: A Case Report and Review of Literature

In this case report, we describe the diagnostic modality of sinus of Valsalva aneurysm (SOVA) in combination with congenital cardiac defect, aortic valve involvement, and conduction abnormality in a 19-year-old patient. Aim of article was to understand the importance of clinicians being cautious about SOVA presenting in young patients, despite cases being rare, and that SOVA requires a thorough SOVA diagnostic approach. We further provide a review of literature highlighting and comparing the treatment options for both unruptured and ruptured SOVAs. The patient presented for examination due to tachycardia and palpitations. A murmur was heard, and the patient was found to have an atrioventricular nodal reentry tachycardia. Echocardiographic evaluation, magnetic resonance imaging, and computed tomography angiography confirmed an aneurysmally dilated aortic root, aortic regurgitation, and ventricular septal defect. Surgical intervention was indicated; however, the patient refused to undergo surgery.

Evaluation of pediatric patients with palpitations via cardiac event recorder, Holter monitoring and transesophageal electrophysiologic study in detecting arrhythmia

Objective: Palpitations are a common reason for referral to pediatric cardiologists, the diagnostic workup involves ambulatory, non-invasive recording devices and invasive procedures. We aimed to evaluate arrhythmic symptoms of pediatric patients with a cardiac event recorder, Holter monitoring and transesophageal electrophysiologic study (TEEPS) results. Materials and Methods: Retrospective evaluation of pediatric patients who fitted an event recorder at tertiary University Hospital between January 2002 and August 2012. The data obtained from the same patients’ as cardiac event recorder, Holter monitoring and TEEPS results were studied for comparison. Results: During the study period, 40 patients who had all data of cardiac event recorder, Holter monitoring and TEEPS were included. The median age of the patients included in the study was 12 [interquartile range, 7-15] years. Using the Holter monitoring, supraventricular extrasystoles (SVEs) were detected in six (15%) patients and ventricular extrasystoles (VESs) in three (7.5%). According to the event recorder data of the 40 patients, there was sinus tachycardia in 20 (50%), supraventricular tachycardia (SVT) in three (7.5%), and SVEs in two (5%) patients. The event recorder data of the remaining 15 patients were assessed as normal. The analysis of the TEEPS results revealed atrioventricular nodal reentrant tachycardia in four (10%), atrioventricular reentry tachycardia in three (7.5%), and normal results in the remaining 33 (82.5%) patients. Conclusions: This study demonstrated that a cardiac event recorder may also be considered as an important diagnostic tool in the diagnosis and ruling out of SVT in pediatric patients for whom the cause of arrhythmia cannot be identified with the Holter monitor, in patients who do not accept the use of TEEPS method following the use of Holter monitor, and in patients in whom SVT cannot be stimulated by TEEPS yet complaints persist.

Benefits from catheter ablation in patients with pulmonary hypertension: Recent advances.

Supraventricular tachycardia (SVT) is a frequent complication of pulmonary hypertension (PH). The most prevalent SVTs are atrial fibrillation (AF) and typical atrial flutter (AFL), followed by focal and macroreentrant atrial tachycardia (AT) and nodal arrhythmia (AV nodal reentry tachycardia or AV reentry tachycardia). SVT is frequently associated with functional deterioration and right ventricular failure in PH patients. According to some data, reestablishing sinus rhythm is associated with clinical improvement. Catheter ablation of typical AFL, nodal tachyarrhythmias, or other less complex focal ATs have been shown to be feasible, acutely effective, and safe in patients with PH. However, the long-term clinical outcome is modified by the recurrence of index arrhythmia and the onset of a new SVT. Due to right atrial dilatation, technical issues can arise when ablation is carried out. The role of catheter ablation in patients with AF or more complex AT is even less effective. The results mirror the success rate in the general AF population with non-paroxysmal AF. However, the data is limited, and electrophysiological procedures are also more often complicated by specific adverse events in a severely frail population. Despite these limitations, catheter ablation is the treatment of choice in less complex SVT, but the indications for AF ablation must be more individualized.

Authors reply regarding "A-V-V-A response to single atrial premature depolarization in a narrow QRS tachycardia: What is the mechanism?"

We respond to a letter by Dr. A. Goyal. If the tachycardia were junctional ectopic tachycardia (JET), the occurrence of the ventriculoatrial block following an atrial premature depolarization could not be explained. Therefore, we conclude that atrioventricular nodal reentrant tachycardia was more likely than JET.

Aberrancy masquerading as ventricular tachycardia: Importance of invasive electrophysiology study for diagnosis of wide complex tachycardias

BackgroundDifferentiation between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) with aberrancy based on the 12‑lead ECG alone can be imprecise. Implantable cardiac defibrillators (ICD) may be inserted for presumed VT, particularly in patients with syncopal presentation or atypical aberrancy patterns. Accurate diagnosis of these patients facilitated by an electrophysiology study (EPS) may alter diagnosis and management. MethodsWe present a prospective collection of cases across 3 cardiac centers of consecutive patients with WCT presumed to be VT who were referred for consideration of an ICD, and in whom further evaluation including an EPS ultimately demonstrated SVT with aberrancy as the culprit arrhythmia. Results22 patients were identified (17 male, mean age 50±13 years. Available rhythm data at the time of referral was presumptively diagnosed as monomorphic VT in 16 patients and polymorphic VT in 6 patients. Underlying structural heart disease was present in 20 (91%). EPS resulted in a diagnosis of SVT with aberrancy in all cases: comprising AV nodal re-entry tachycardia (n=10), orthodromic reciprocating tachycardia (n=3), focal atrial tachycardia (n=3), AF/AFL (n=3) and 'double fire' tachycardia (n=2). 21 (95%) patients underwent successful ablation. All patients remained free of arrhythmia recurrence at a median of 3.4 years of follow-up. ICD insertion was obviated in 18 (82%) patients, with 1 patient proceeding to ICD extraction. ConclusionSVT with atypical aberrancy may mimic monomorphic or polymorphic VT. Careful examination of all available rhythm data and consideration of an EPS can confirm SVT and obviate the need for ICD therapy.

Prevalence and characteristics of atrioventricular nodal reentrant tachycardia with a bystander concealed nodoventricular/nodofascicular pathway

BackgroundThe concealed nodoventricular/nodofascicular (NV/NF) pathway is mostly a bystander, retrograde bypass tract connecting the right ventricle/right bundle branch (RBB) and slow pathway that is observed in patients with atrioventricular nodal reentrant tachycardia (AVNRT). However, its prevalence and characteristics in response to pacing maneuvers have not been fully evaluated. ObjectiveThis study investigated the prevalence and characteristics of AVNRT with a bystander NV/NF pathway. MethodsWe retrospectively reviewed 153 consecutive patients undergoing catheter ablation of AVNRT. After exclusion of 52 patients with inadequate electrophysiologic data, 101 patients composed the study population. ResultsThree patients (3.0%) had bystander concealed NV/NF pathways, all of which were connected to the slow pathway. The tachycardia was typical slow pathway/fast pathway AVNRT in 2 patients and atypical fast pathway/slow pathway AVNRT in 1 patient. In all cases, His-refractory ventricular extra-stimuli (VES) reset the AVNRTs with delay through the NV/NF pathways. Ventricular overdrive pacing (VOP) in the early phase also reset the AVNRT with delay. Earlier VES and middle phase of VOP did not reset the tachycardia, and further earlier VES and late phase of VOP reset the tachycardia with advance through the RBB-His conduction. ConclusionA bystander NV/NF pathway was not rare in patients with AVNRT. The VES and VOP for the AVNRTs with the bystander NV/NF pathways were characterized by the 2-phase resetting phenomenon: initial transient resetting with delay through the NV/NF pathway, and late resetting with advance through the RBB-His conduction.

Meta-Analysis of Genome-Wide Association Studies Reveals Genetic Mechanisms of Supraventricular Arrhythmias.

Substantial data support a heritable basis for supraventricular tachycardias, but the genetic determinants and molecular mechanisms of these arrhythmias are poorly understood. We sought to identify genetic loci associated with atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular accessory pathways or atrioventricular reciprocating tachycardia (AVAPs/AVRT). We performed multiancestry meta-analyses of genome-wide association studies to identify genetic loci for AVNRT (4 studies) and AVAP/AVRT (7 studies). We assessed evidence supporting the potential causal effects of candidate genes by analyzing relations between associated variants and cardiac gene expression, performing transcriptome-wide analyses, and examining prior genome-wide association studies. Analyses comprised 2384 AVNRT cases and 106 489 referents, and 2811 AVAP/AVRT cases and 1,483 093 referents. We identified 2 significant loci for AVNRT, which implicate NKX2-5 and TTN as disease susceptibility genes. A transcriptome-wide association analysis supported an association between reduced predicted cardiac expression of NKX2-5 and AVNRT. We identified 3 significant loci for AVAP/AVRT, which implicate SCN5A, SCN10A, and TTN/CCDC141. Variant associations at several loci have been previously reported for cardiac phenotypes, including atrial fibrillation, stroke, Brugada syndrome, and electrocardiographic intervals. Our findings highlight gene regions associated with ion channel function (AVAP/AVRT), as well as cardiac development and the sarcomere (AVAP/AVRT and AVNRT) as important potential effectors of supraventricular tachycardia susceptibility.

Activation map of koch triangle: a novel approach to AVNRT ablation using CARTO 3 v7

Abstract Background Ablation of slow pathway (SP) is the standard approach for atrioventricular nodal reentry tachycardia (AVNRT) treatment (1). Low-voltage bridge is an optimal target during mapping using low x-ray exposure (2,3). Purpose We want to assess a new tool to identify SP by activation mapping of Koch’s triangle using CARTO PRIME V7 Methods Triangle of Koch 3D-activation map were obtained from intracardiac contact mapping during low x-ray CARTO 3 procedures (Figure 1). In 60 patients (39 % males, mean age 60.3 ± 14.7 years) undergoing ablation for AVNRT, an automatic activation map using a DECANAV mapping catheter and CARTO Confidense, Coherent, and FAM DX software modules were obtained. Results We indentified SP in all patients as the latest atrioventricular node activation area; RF catheter ablation (RFCA) elicited junctional beats. The mean dose-area product (DAP) was 16.5 ± 2.7 cGy/cm2, the mean fluoroscopy time exposure was 2.9 ± 2 min, the mean ablation index was 428.6 ± 96.6, and the mean contact force was 8 ± 2.8 g. There were no adverse event during the procedure and no AVNRT recurrences during a mean follow-up of 14.3 ± 8.3 months. Conclusions Ablation of the SP by automatic mapping using Confidense, Coherent, and FAM DX software modules is a new approach to AVNRT ablation. The CARTO3 V7 system defines a 3D map of the latest AV node activation area during sinus rhythm allowing a highly effective RFCA under low fluoroscopy time exposure without recurrences or AV blocks.Figure 1

Atrioventricular nodal reentrant tachycardia ablation (avnrt), a female disease. insights from the german ablation registry

Abstract Background The German Ablation registry is a multi-centre prospective registry for electrophysiologic ablation procedures. Purpose We herein report on catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT) according to underlying gender. Methods From January 2007 until January 2010 a total of 2918 patients [64.4% female, 55 (43; 67) years] undergoing catheter ablation of AVNRT were enrolled in this registry and followed for at least one year. Results Female patients undergoing ablation for AVNRT were significantly younger than male patients [52 (41; 66) versus 60 (47; 70); p&amp;lt;0.001] and had less structural heart disease than male patients [12,1 % (228/1880) versus 30,8 % (320/1038)]. Female patients more often had ≥ one arrhythmia episode per month [73,7 % versus 68,1 %; p&amp;lt;0.001], nevertheless arrhythmia documentation was less often present in female patients [81,7 % versus 85,4 %; p=0.012]. Success rate was high (98,9 %) and major complications prior to discharge (death, myocardial infarction, stroke) were rare (1/2917) without significant difference between female and male patients. During a follow-up period of 682.9 ± 172,9 days, female patients more often experienced arrhythmia recurrences [19,1 % versus 13,8 %; p&amp;lt;0.001]. Conclusions Almost two-thirds of patients undergoing ablation for AVNRT included in the German ablation registry were female. Female patients were younger and less often had structural heart disease or other comorbidities than male patients undergoing AVNRT ablation. Success rates and complication rates were similar. During follow-up female patients more often experienced arrhythmia recurrences.

Simplification of resetting response in slow/fast atrioventricular nodal reentrant tachycardia: the 3 catheters approach

Abstract Background The resetting response is a maneuver that helps identify the anterograde limb of slow/fast atrioventricular nodal reentrant tachycardia (AVNRT). The actual described maneuver involved a 5 catheters approach, and the related complications are poorly described.(1) Purpose We describe a simplified approach with 3 catheters and the related complications of the maneuver. Methods A quadripolar catheter was placed in the His bundle region; a decapolar catheter in the coronary sinus (CS) and a 4 mm tip non irrigated or irrigated catheter was used for pacing and ablation. An 8.5 French Sl0 sheath was used to ensure contact and stability. In confirmed slow/fast AVNRT using the fast pathway as the retrograde limb (earliest retrograde atrial activity located in the parahisian region), a single decremental atrial extrastimulus was delivered at the lower part of the triangle of Koch and 2-3 cm inside the CS on the roof. Pacing maneuver was started near the end of the QRS complex and decremented by 10 ms per interval. The higher atrial signal with the best A/V ratio on the CS catheter was used as sense reference for resetting response. The end point of ablation was non inducibility. Results Ten patients were included in a 4-month period, comprising 2 redo procedures. The maneuver was not performed in 4 patients (40%) due to non-sustained tachycardia. Atrial fibrillation was induced in 2 patients (20%) during the maneuver systematically due to an atrial extrastimulus preceding the H potential (negative HA interval). In the 4 remaining patients with successful resetting response, the HA interval in successful ablation spot varies between 31 to 82 ms. The involved anterograde limb was the right extension in 3 (75%) and the left extension in 1 (25%). Conclusion Resetting response can be performed with a 3 catheters approach, the main limitation is non sustained tachycardia, and atrial fibrillation induced by short coupled extrastimulus.Resseting response in LIE and RIE

Impact of induced atrial fibrillation during atrioventricular nodal reentrant tachycardia ablation

Abstract Ablation is the treatment of choice for atrioventricular nodal reentrant tachycardia (AV NRT). Atrial fibrillation (AF) can incidentally occur during this procedure, labeling these patients (P) as susceptible for AF in the future. Our aim was to assess the presence of new onset AF in P who presented this arrhythmia during the electrophysiological study (EPS). Methods We retrospectively analyzed 580 P that underwent AV NRT ablation between November 2008 and August 2020. Patients with previous AF were excluded. After having AF induced during the EPS, 62 P were identified as susceptible for developing AF. Data were collected by contacting P and consulting medical records. Results The studied population had 64.5% (n=40) females, 35.5% (n=22) males, with ages between 15 and 81years old (median 52.3, mean 50.1). At ablation date, 33.9% (n=21) had hypertension, 3.2% (n=2) diabetes, 6.5% (n=4) chronic kidney disease, 3.2% (n=2) obstructive sleep apnea, 6.5% (n=4) coronary artery disease and 6.5% (n=4) structural heart disease. Previously to ablation, 46.8% (n=29) were on beta-blocker, 1.6% (n=1) on amiodarone and 3.2% (n=2) on flecainide. When admitted to the procedure, 98.4% (n=61) were in sinus rhythm and 1.6% (n=1) had a pacemaker. "Slow-fast" was the most common AVNRT type (96.8%). During the EPS, other arrhythmias were induced: in 12.9% (n=8) atrial flutter and in 9.7% (n=6) atrial tachycardia. After AF induction, 12.9% (n=8) needed electrical cardioversion and 3.2% (n=2) needed both electrical and pharmacological. At the time of ablation, transient complete atrioventricular block was noted in 6.5% (n=4) P. When contacted, 100% (n=62) had 1 year of follow-up, 69.4% (n=43) 5 years and 25.8% (n=16) 10 years, with a mean follow-up of 6.6 years. It was not possible to contact 12.9% (n=8) of the P, of those, 6.5% (n=4) died and 6.5% (n=4) did not reply. Recurrence of AV NRT was documented in 6.4% (n=4) P and all underwent a successful second ablation. Almost one third, 32.3% (n=20), were symptomatic, mainly with palpitations, and 27.4% (n=17) maintained follow up with a Cardiologist. New-onset AF was documented in 1 P only (1.6%), diagnosed 9 years after the procedure. Conclusion In our cohort, the induction of AF during EPS did not translate into clinical AF during follow-up. Whether this is a nonspecific finding related to catheter manipulation or pacing maneuvers on pharmacological provocation deserves further investigation.

Innovations in arrhythmia management in pregnant woman: catheter ablation without using fluoroscopy

Abstract Background The latest data of effectiveness and safety of catheter ablation without using fluoroscopy in general population suppose wide using of this technology. However, data on pregnant population is limited. Purpose To investigate efficacy and safety of catheter ablation without using fluoroscopy in pregnant women with analyzing obstetric and neonatal outcomes. Methods We studied 47 cases of catheter ablation in pregnant (mean age 25.3±3.9 years, mean gestation age 23.7 ±3.1 weeks) within 24 month follow-up. Ablation was performed under the guidance of CARTO (n=21; 44.7%) and Ensite Precision systems (n=26; 55.3%) without using fluoroscopy in all cases. Results The most common arrhythmia was atrioventricular nodal reentrant tachycardia (n=21; 44.7%), which was followed by Wolff–Parkinson–White syndrome (n=15; 31.9%). Cases of combination of accessory pathways with slow conduction ways (n=3, 6.4%), ventricular tachycardia (n=3, 6.4%) and premature ventricular contraction (n=5; 10.6%) were rare. Ablation without using fluoroscopy was successful in all cases, mean procedural time was 71.9±14.5 minutes. There was one case of complication after ablation procedure: ileofemoral thrombosis, which was treated successfully without termination of gestation (2.1%). We found increased uterine contractile activity and placental abruption in pregnant after ablation in 4.54% and 2.3% cases respectively. Cases of uterine blood flow violation was more frequent: in 15.9% cases. Obstetric outcomes characterized by prevalence of vaginal delivery and delivery in term: in 76.6% and 95.7% cases. There were live births in all pregnant women with normal range of fetal birth weight and Apgar score (3207.4±485 grams and 8.4±1.6 respectively). There were no incidence of mortality and arrhythmia recurrence at follow up. Conclusions Catheter ablation without using fluoroscopy can be effectively and safety performed during gestation with good neonatal and obstetric outcomes.

The best practices for safety and effectiveness in pregnant: zero-fluoroscopy arrhythmias catheter ablation

Abstract Background Arrhythmias are common during gestation. While the safety and effectiveness of zero-fluoroscopy arrhythmias catheter ablation has been studied, the effects of it in pregnant poorly understood. Purpose The aim of our single-center, prospectively study is explore feasibility, efficacy and safety of zero-fluoroscopy catheter ablation in pregnant. Methods Characteristic, obstetric and neonatal outcomes of 47 cases of zero-fluoroscopy catheter ablation during gestation (main group) within 24 month follow-up were compared with group of pregnant with antiarrhythmic therapy (control group, p=54). Ablation was performed under the guidance of CARTO (n=21; 44.7%) and Ensite Precision systems (n=26; 55.3%) and intracardiac echocardiography without using fluoroscopy in all cases. Results Mean age of pregnant and mean gestation age were comparable in both groups (25.3±3.9 vs. 27.3±3.9 years, p=0.093 and 23.7 ±3.1 vs. 23.8 ±3.2 weeks, p=0.123). Atrioventricular nodal reentrant tachycardia was the most common indications for ablation during gestation (n=21; 44.7%), which was followed by Wolff–Parkinson–White syndrome (n=15; 31.9%). Cases of combination of accessory pathways with slow conduction ways (n=3, 6.4%), ventricular tachycardia (n=3, 6.4%) and premature ventricular contraction (n=5; 10.6%) were rare. Acute procedural success of zero-fluoroscopy ablation was in 100% with mean procedural time 71.9±14.5 minutes. Complication (ileofemoral thrombosis) was in one pregnant (2.1%). Further course of pregnancy characterized by occurring increased uterine contractile activity and placental abruption only in main group (4.54%, p=0.464 and 2.3%, p=0.414 respectively), while uterine blood flow violation and preeclampsia were in both groups (15.9% vs. 13%, p=0.234 and 4.55% vs. 3.7%, p=0.730 respectively). Obstetric outcomes characterized by prevalence of vaginal delivery and delivery in term in both groups (76.6% vs.81.5%, p=0.241 and 95.7% vs. 96.3%, p=0.743). There were live births in all cases with normal range of fetal birth weight in both groups (3207.4±485 vs 3142.2±214.1 grams and 8.4±1.6 vs. 8.6±1.3 respectively). There were no incidence of mortality and arrhythmia recurrence at follow up. Conclusions Zero-fluoroscopy ablation is feasible and can be safety performed during gestation with good outcomes.

Not too old to be treated: electrophysiological study and catheter ablation in eldery patients

Abstract Background The number of elderly patients referred for electrophysiological study (EPS) and catheter ablation (CA) is increasing. These patients are thought to have more complications due to age and comorbidity. Purpose The aim of our study was to evaluate the safety (EPS and CA) and acute success (CA) in a group of elderly patients (age ≥75 years old). Methods Between August 2020 and September 2023, consecutive elderly patients (32.7% older than 80 years) underwent EPS alone or EPS and CA at our center. Left atrial thrombus was ruled out performing transesophageal echocardiography when indicated. Anticoagulation (ACO) was not interrupted. Femoral veins, arteries and transeptal punctures were performed under ultrasound guidance. A navigation system was used for all CA procedures, except for pulmonary vein isolation, which was performed with a cryoballoon. We analysed procedural complications related to EPS and CA and the acute success of CA procedures. Results A total of 104 patients undergoing EPS±CA (79.9±4.6 years, 41.3% female, 75% HTA, 67.3% diabetes type 2, 19.4% COPD, 20.2% chronic renal disease, 25% structural heart disease, CHA2DS2VasC score 3.6±0.8, IMC 27.3±4.5 kg/m2, weight 72.3±13.6 kg, LVEF 52.7±10.8%, 31% history of atrial fibrillation (AF), 47.1% on ACO, 38.5% bundle-branch block, 34.6% first-degree atrioventricular block, 4.8% implanted pacemaker or ICD) were included. Indications for referral (Figure 1) were typical atrial flutter (TAF, 34.6%), atrioventricular nodal reentrant tachycardia (AVNRT, 26.9%), study of syncope (11.5%) atypical atrial flutter or atrial tachycardia (AAF/AT, 10.6%), AF (8.6%, 6 patients for AV node ablation, 3 for pulmonary vein isolation), ventricular tachycardia or ectopy (VT or VE, 5.7%), orthodromic reentrant tachycardia (ORT, 1.9%). 2 patients had TAF and AVNRT, treated in the same procedure. Acute success was achieved in 100% of AF, 94.6% of TAF, 89.6% of AVNRT, 66% of VT/VE, 50% of ORT, 45% of AAF/AT. There were 4 complications (2.9%) in 3 patients, all during the CA procedure: an AV block during an AVNRT ablation, another AV block during an ischaemic septal VT ablation, a femoral artery pseudoaneurism in the same patient (femoral artery approach), and a dislocation of the electrodes from a previous pacemaker during an AT ablation. None of the patients undergoing EPS alone had complications. Weight was the only variable associated with the development of complications (mean difference= -19.8, 95% CI(-38.9-0.7); p=0.04), being higher in those with than in those without complications (91.5±2.2 vs 71.6±13 Kg),(Table 1). Conclusions EPS and CA procedures in elderly patients with multiple comorbidities are safe and effective. Acute success and complication rates of CA procedures are substrate-dependent and similar to those reported in the literature for younger patients. We conclude that age is not a barrier to the study and treatment of arrhythmias.