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When Catheter Ablation Should Be First Line Therapy
Neil K. Sanghvi, M.D.
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Unfortunately, this depicts the current state of affairs in the US.
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Common Symptoms Palpitations (often sudden on & off) Anxiety
Light-headedness Chest pain Neck Pounding Dyspnea Polyuria in prolonged cases secondary to ANP release Neck pounding is typically from canon A waves or pulsing carotids
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Types of Supraventricular Tachycardias
AVNRT (AV nodal reentrant tachycardia) AVRT (AV reciprocating tachycardia) Atrial tachycardia Multifocal atrial tachycardia Atrial flutter Atrial fibrillation Junctional tachycardia Sinus tachycardia Paroxysmal junctional reciprocating tachycardia (PJRT) Sinus node reentry
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Cardiac Electrical System
SA Node AV Node His Bundle Left Bundle Right Bundle
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Frequency of various types of SVT
60% due to AVNRT (AV-nodal reentrant tachycardia) 30% due to AVRT (AV reciprocating tachycardia) <10% due to atrial tachycardia It is estimated that 10% of the general population may suffer from AVNRT 15% of the general population may exhibit dual AV-nodal physiology 60% of the general population may exhibit retrograde VA conduction via the AV node
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Reentrant tachycardias
Usually precipitated by a PVC or PAC May also occur secondary to: Excessive caffeine intake Alcohol intake Recreational drug use Hyperthyroidism Exercise
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Initial Workup History, history, history… 12 lead EKG Echocardiogram
Holter monitoring Thyroid function CBC (looking for anemia, infection)
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Observations From An EKG
Observe zones of transition for clues towards the mechanism: onset termination slowing, AV nodal block bundle branch block (what happens to the cycle length of the tachycardia)
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Understanding Reentry
Panel A: Most impulses conduct down both pathways. Panel B: Unidirectional block, due to longer refractoriness in one pathway. Panel C: Potential to have reentry back up the previously refractory pathway Panel D: Reentry then can persist. α = slow pathway, β = fast pathway Panel B: block occurs usually due to a premature beat Reentry-most common mechanism: Represents a “short circuit” that forms between two “pathways” that are either anatomically or functionally distinct. Path 1: Slow conduction, short refractory period. Path 2: Rapid conduction, long refractory period
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Orthodromic AVRT A. Sinus impulses travel down both the accessory pathway and AV node. B. Premature beat finds the accessory pathway refractory but is able to travel down the AV node. C. Impulses are able to traverse the myocardium and find the accessory pathway excitable thereby sustaining the tachycardia.
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Short RP>PR tachycardias
AVNRT AVRT Junctional tachycardia Atrial tachycardia with 1o AVB Permanent junctional re-entrant tachycardia (PJRT) is a rare arrhythmia due to a concealed accessory pathway with decremental retrograde conduction properties
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Long RP>PR tachycardias
Atrial tachycardia Atypical AVNRT Sinus Tachycardia
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QRS morphology based on the mechanism of the tachycardia
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33yo with sudden onset of palpitations and SOB after driving from NY to FL.
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Sinus Tachycardia Note the classic S1Q3T3 seen with pulmonary emboli
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40yo with sudden onset of palpitations while mowing the lawn.
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AVNRT Look for “pseudo S-wave” in inferior leads and “pseudo-R prime” in V1 which actually indicate retrograde P-waves Terminates with vagal maneuvers in 1/3 cases Responsive to AV nodal blocking agents such as beta blockers, CA channel blockers, adenosine. Recurrences are the norm on medical therapy Catheter ablation 95% successful with 1-2% major complication rate (including heart block)
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AVNRT Ablation – Catheter Position
HRA His Here is a schematic representation of catheter positioning for a typical slow-fast AVNRT AV node modification. Abl
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Triangle of Koch HB Tendon of Todaro CS Septal TV
The triangle of koch is the area of interest in AVNRT ablation. The area is defined by the 1. Tendon of Todaro, 2. the CS, and 3. the septal leaflet of the TV. The apex of the triangle is marked by the HB. The AV nodal “slow” pathway typically lies inferior to the HB and anterior to the CS os.
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31yo man presenting with palpitations after a night on the town.
Note certain R-R intervals that are ~ 300 BPM. Mixture of “narrow” and “wide” complexes.
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How would you treat this man?
Verapamil/Diltiazem Beta Blocker Adenosine Digoxin Procainamide/Amiodarone
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Atrial fibrillation with Wolf-Parkinson-White
Never use nodal agents when evidence of pre-excitation exists and the accessory pathway is capable of rapid conduction >95% cure rate for ablation of accessory pathway
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Baseline EKG for Previous Patient
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EKG requirements to diagnose Pre-excitation (WPW)
P-R < 120ms Delta wave QRS > 100ms Normal P-wave axis Patients with WPW should be evaluated for their risk of sudden death Typically, asymptomatic patients may be placed on a treadmill to determine whether they lose their preexcitation with higher HR (low risk) Risk of SCD is high if accessory pathway is able to conduct faster than (250ms = 240bpm) EP study only indicated if patient’s are symptomatic, h/o SCD, or in a high-risk profession
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72yo woman with history of HTN p/w palpitations and SOB.
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Atrial Flutter with variable block
“Typical” since flutter waves are negative in inferiorly and upright in V1 which implies a right atrial isthmus-related tachycardia
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66yo woman with rapid heart rate and anxiety.
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Atrial flutter with 2:1 conduction
>95% cure rate with catheter ablation with a major complication rate of < 1% Will be able to stop anticoagulation within 1 month
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Activation on Halo Catheter During Typical Atrial Flutter
II aVF V1 CS Os TA 1,2 TA 3,4 TA 5,6 TA 7,8 TA 9,10 TA 11,12 TA 13,14 TA 17,18 TA 19,20 TA 19,20 CS Os TA 9,10 TA 1,2 Opening of the anterior RA. SVC upper left, IVC lower left, TV on right, fossa in the middle Modified LAO view Cavotricuspid isthmus is defined by the tricuspid valve annulus and IVC Typical = CCW
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Activation on Halo Catheter
II aVF V1 CS Os TA 1,2 TA 3,4 TA 5,6 TA 7,8 TA 9,10 TA 11,12 TA 13,14 TA 17,18 19,20 TA 19,20 TA 9,10 CS Os TA 1,2 Atypical = Clockwise
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3D Propagation Map of Atrial Flutter
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Atrial Flutter CTI Ablation - LAO
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Atrial Flutter CTI Ablation - RAO
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68yo woman with severe COPD exacerbation.
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Atrial tachycardia with variable block
Atrial rates typically bpm Often treated with AAD for rhythm control, nodal agents for rate control Catheter ablation has success rates of > 80%
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Atrial Tachycardia Carto map revealing a focal atrial tachycardia originating from the SVC
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25yo man with fever of 102.
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Sinus tachycardia
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65yo man presenting with palpitations.
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Atrial fibrillation with rapid ventricular response
Typically managed with AAD or nodal agents for rate control Ablation with success rates in the 70—75% range if no other risk factors
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2014 Guidelines
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AF Success w/ Ablation Device insertion Pre- ablation Post- ablation
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Conclusion Most SVTs should be referred for ablation even with a first occurrence since there is a high recurrence rate (anywhere from 25-80%) Ablation may be considered first line therapy for certain AF patients – young, few to no comorbidities, not interested in AAD Frequent PVCs may be ablated with > 90% cure VT should be referred for ablation if failing AAD
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