Radial Intracardiac Echo Guided AVNRT Ablation in a Patient with Persistent Left Superior Vena Cava

Categories Electrophysiology Studies and Ablation, Intracardiac Echo (ICE)Leave a Comment on Radial Intracardiac Echo Guided AVNRT Ablation in a Patient with Persistent Left Superior Vena Cava

Atrioventricular nodal reentrant tachycardia (AVNRT) is one of the more common arrhythmias ablated in the U.S.  There is an estimated 2-6% major and minor complication rate during electrophysiology (EP) studies with ablation. [1-3]  The average age of AVNRT patients in a prior analysis of my cases [4] was 53+/-21 years.  These patients are often young with no major comorbidities and the risk of damaging the compact AV node and causing complete heart block is low but always present.

Radial intracardiac echo (UltraICE™, Boston Scientific, Natick, MA, USA) can be used to anatomically guide slow pathway modification and ensure stable endocardial-catheter contact.  The example below is a patient with AVNRT (and persistent left superior vena cava) that could not be ablated via the traditional fluoroscopy and electrogram (EGM) guided technique despite “good” EGM’s and multiple lesions.  The ICE video shown below depicts the initial catheter position encountered when ICE catheter first placed in right atrium using steerable sheath (St. Jude Medical, Agilis).  You can see the ablation catheter adjacent to the ICE catheter and overlying the tricuspid valve though not in contact with the anatomic location of the slow AV nodal pathway.

We then positioned the ablation catheter at the anatomic location of the the slow AV nodal pathway; near the anterior aspect of the coronary sinus (CS) os at the septal insertion of the tricuspid valve leaflet.  You can see the ablation catheter positioned right on this area and single RFA resulted in long run of junctional beats and successful ablation.

I use adjunctive ICE-guidance for most AVNRT ablations; though it adds some time and complexity, I feel it maximizes patient safety and successful outcomes.  There is a great summary article by Fisher et al [5] and I have shown one of their figures below to better show the anatomy of the AV node and coronary sinus.

References:

1     Chen S-A, Chiang C-E, Tai C-T, et al. ‘‘Complications of diagnostic electrophysiologic studies and radiofrequency catheter ablation in patients with tachyarrhythmias: An eight-year survey of 3,966 consecutive procedures in a tertiary referral center’’. Am J Cardiol 1996; 77:41–46. 12.

2     ZadoES,CallansDJ,GottliebCD,etal.Efficacyandsafetyof catheter ablation in octogenarians. JACC 2000; 35:458–462. 13.

3     O’Hara GE, Philippon F, Champagne J, et al. Catheter ablation for cardiac arrhythmias: A 14-year experience with 5330 consecutive patients at the Quebec Heart Institute, Laval Hospital. Can J Cardiol 2007; 23(Suppl B):67B–70B.

4     Williams JL, Valencia V, Lugg D, Gray R, Hollis D, Toth JW, Benson R, DeFrancesco-Loukas MA, Stevenson R, Teiken PJ, “High Frequency Jet Ventilation During Ablation of Supraventricular and Ventricular Arrhythmias: Efficacy, Patient Tolerance and Safety,” The Journal of Innovations in Cardiac Rhythm Management, 2 (2011), 1–7.

5    Fisher WG, Pelini MA, Bacon ME, “Adjunctive Intracardiac Echocardiography to Guide Slow Pathway Ablation in Human Atrioventricular Nodal Reentrant Tachycardia,” Circulation, V. 96 (1997), pp. 3021-3029.

Published by Heart Rhythm Center

Dr. Williams obtained his undergraduate degree with a double major in Biomedical and Electrical Engineering at Vanderbilt University. He was then awarded a Keck Fellowship for graduate school at the University of Pittsburgh where he obtained his Master’s degree in Bioengineering. Dr. Williams went on to obtain his medical degree at Drexel University in Philadelphia and completed 5 years of Fellowship training in both Cardiovascular Diseases and Clinical Cardiac Electrophysiology at the University of Pittsburgh Medical Center. His unique background and extensive knowledge of both engineering and cardiology have earned Dr. Williams many accolades in both clinical and academic settings. He’s published over 20 manuscripts and abstracts in the field of cardiology/electrophysiology and has received awards from both the American College of Cardiology Foundation and the National Institutes of Health. Dr. Williams started in the Invasive Electrophysiology Laboratory at The Good Samaritan Hospital in 2008 and the Heart Rhythm Center published outcomes on pacemaker and defibrillator implantations as well as the safety and efficacy of high frequency jet ventilation during EP studies with ablation under his direction. He is Chair of the Quality Committee at the Florida Chapter of the American College of Cardiology.

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