Nonpharmacological Therapy of Supraventricular Arrhythmias: Surgery and Catheter Ablation Techniques

Treatment of supraventricular tachyarrhythmias has undergone substantial change and development over the past decade. Pharmacological approaches to management of supraventricular arrhythmias have been supplanted by nonpharmacological techniques. These nonpharmacological techniques are the subject of the present review. The first part of this review will concentrate on the nonpharmacological techniques available for the treatment of supraventricular tachycardia, excluding Wolff-Parkinson-White syndrome, whereas Part 2 will concentrate on the surgical and the ablative procedures for management of tachycardias associated with Wolff-Parkinson-White syndrome. Pacing techniques for termination of supraventricular tachycardias are beyond the scope of this article and will not be included in the discussion.     

Catheter Cryoablation of Supraventricular Arrhythmias:

LOWE, M.D., et al .: Catheter Cryoablation of Supraventricular Arrhythmias: A Painless Alternative to Radiofrequency Energy. Cryothermy has potential advantages over RF energy for catheter ablation, including reversibility of lesion formation, catheter stability, and less procedural discomfort. Cryoablation procedures were performed in 14 patients with atrioventricular reentrant tachycardias (AVNRTs), 13 patients with accessory pathway (AP)-mediated tachycardias, and 5 patients with atrial fibrillation. The numbers of energy applications, pain scores, procedural times, and outcomes were recorded and compared with age- and sex-matched patients undergoing similar RF procedures. Cryoablation was successful in 26 of 32 patients (11/14 AVNRT, 10/13 AP, 5/5 AF) compared with 30 of 32 undergoing RF procedures, with similar numbers of energy applications and procedural times. Cryothermy was painless in all patients, and the overall procedural discomfort was significantly less than in patients treated with RF   (1.3 ± 2.2 vs 6.1 ± 3.5)   . In patients with anteroseptal pathways, cryomapping successfully identified safe sites to target the delivery of energy. Cryothermy is a painless and safe alternative to RF. It may be particularly useful for catheter ablation of patients with pathways close to the atrioventricular node. (PACE 2003; 26[Pt. II]:500–503)     

室上性心动过速的射频消融治疗

应用射频导管消融术治疗室上性心动过速204例。其中房室折返性心动过速175例;房室结折返性心动过速28例;房性心动过速1例。成功 189例,成功率为92.7％。有5例出现并发症,占2.45％。随访 1～36个月,有8例复发,5例再次消融成功。我们认为射频消融术是一种安全和有效的根治室上性心动过速主要方法。     

Role of Catheter Ablation in Postoperative Arrhythmias

Background: Patients who have undergone repair of congenital heart disease are at risk for atrial and ventricular tachyarrhythmias and sudden death, both because of altered substrate for arrhythmias and an altered hemodynamic response. Despite an armamentarium of arrhythmia management tools, including drug therapy, antibradycardia, pacing, antitachycardia pacing, surgical ablation and catheter ablation, management of these arrhythmias remains a challenge. Conclusions: This report provides an overview of the successes and failures of catheter ablation for treating and preventing these postoperative arrhythmias, and discusses ongoing developments, which may improve early and late outcome.     

Catheter Ablation for Patients with Cardiac Arrhythmias

Catheter ablative techniques have recently been introduced as therapy for patients with drug-resistant cardiac arrhythmias. These techniques include delivery of high-energy direct-current shocks in order to electrocoagulate the atrioventricular junction for those with supraventricular arrhythmias. This technique, if successful, results in arrhythmia control but induces chronic pacemaker dependency. The evidence, to date, suggests that 90% of these patients are improved after attempted atrioventricular junctional ablation. Catheter ablative procedures have been used for attempted ablation of accessory pathways and has been shown to be especially effective for those with posteroseptal accessory pathways. More recently, techniques for ablation of ventricular tachycardia foci have been introduced but experience with this procedure is too limited to allow for definitive recommendations.     

儿童阵发性室上性心动过速的射频消融治疗

目的观察射频消融治疗儿童阵发性室上性心动过速(SVT)的有效性和安全性.方法38例患儿,男22例,女16例;年龄8～14岁,平均(12.5±2.2)岁,有反复阵发性心悸1～144个月,平均(36.4±32.0)个月.全部患儿均接受心内电生理检查及射频消融治疗.左旁道经主动脉逆行法或经房间隔法,右旁道和双径路经股静脉法.结果左旁路22例、右旁路9例、双径路7例.双径路成功率100%、左旁路100%、右旁路88.9%.术中有Ⅰ°AVB1例,一过性Ⅱ°AVB1例,未发现其它严重并发症.操作时间(91±27)min,X线透视时间(30±12)min.随访10～87个月,1例双径路2周后再发,再次消融获得成功,1例右旁路不成功.结论射频消融治疗儿童SVT是一种有效而安全的方法,但应根据儿童特点严格掌握适应症.     

Control of Refractory Supraventricular Arrhythmias After Unsuccessful Closed-Chest His Bundle Ablation

Six patients underwent attempted catheter ablation of the His bundle for control of refractory supraventricular tachyarrhythmias. Permanent complete heart block was achieved in only three patients. All six patients have remained asymptomatic without antiarrhythmic medications over a follow-up period of six to 17 months (mean 10 months). There were no complications of the procedure apart from mild elevation of creatine kinase levels in three patients. In this series, resumption of atrioventricular (AV) conduction following attempted His bundle ablation was not associated with recurrence of symptomatic arrhythmias. Preservation of AV conduction may also obviate the need for permanent ventricular pacing.     

Atrial Tachycardias Encountered in the Context of Catheter Ablation for Atrial Fibrillation Part II: Mapping and Ablation

Over the past decade, there has been an exponential increase in the number of catheter ablation procedures performed for atrial fibrillation (AF). While for paroxysmal AF, proximal pulmonary vein isolation is sufficient in the majority of cases, ablation of persistent and longstanding AF requires an extensive surgical-like procedure. This approach is correlated with a high rate of AF termination; however, this is achieved at the cost of at least one atrial tachycardia (AT) during the index procedure or during the patient's follow-up in the vast majority of cases. As these ATs are often multiple, complex, and frequently more symptomatic than AF, they constitute the last and frequently the most difficult step in ablation for patients with persistent AF. This review concentrates on the practical approaches to the treatment of AT in the context of AF ablation and provides an algorithm that aims at facilitating mapping and ablation strategies using conventional electrophysiological tools .     

经导管射频消融治疗室上性心动过速复发原因分析

目的:分析总结经导管射频消融(RFCA)治疗阵发性室上性心动过速(PSVT)术后复发的原因,以进一步指导临床工作.方法:对1992年2月-2008年6月我院实施RFCA治疗的1256例PSVT术后随访资料进行回顾分析.每3个月随访1次,随访期3个月-16年,统计复发例数,分析复发原因.结果:1256例首次行RFCA成功1227例,一次成功率97.7%;术后复发29例,复发率2.3%.743例房室折返性心动过速(AVRT)中复发18例,复发率2.4%,其中左侧旁道复发10例(1.7%),右侧旁道复发8例(4.9%);513例房室结折返性心动过速(AVNRT)中复发11例,复发率2.1%.结论:RFCA治疗快速性心律失常安全、有效、成功率高.精确的靶点标测、熟练的操作技巧以及正确运用消融方式是降低RFCA术后复发率的关键.     

Migraine Following Trans-Septal Access for Catheter Ablation of Cardiac Arrhythmias

There is increasing recognition that migraine with aura may be associated with intra-cardiac shunting because of a patent foramen ovale. Radio-frequency ablation to treat cardiac arrhythmias is an increasingly popular means of treating cardiac arrhythmias. Trans-septal puncture is routinely performed to gain access to the left atrium in order to ablate arrhythmias originating in the left heart. We report several cases of migraine triggered acutely by trans-septal puncture at our center.     

Skin Burns Associated with Radiofrequency Catheter Ablation of Cardiac Arrhythmias

Skin burns are a rare complication associated with radiofrequency catheter ablation of cardiac arrhythmias. Burns related to the indifferent electrode patch may be severe and result in significant comorbidity. We describe our experience of skin burns and discuss potential predisposing and possible causative factors.