Abstract
The case of a 71-year-old female patient with recurrent supraventricular tachycardia is reported. During the initial electrophysiological study, an orthodromic atrioventricular reentrant tachycardia utilizing a concealed left-sided accessory pathway (AP) was induced. Radiofrequency (RF) ablation via a retrograde aortic approach was unsuccessful. A second ablation attempt 6 weeks later via a transseptal approach using the EnSite Precision three-dimensional (3-D) cardiac mapping system and an irrigated-tip RF ablation catheter also failed to ablate the AP. Therefore, mapping in the coronary sinus (CS) was performed. During right ventricular pacing, the earliest retrograde atrial activation was found in the mid-CS. Irrigated-tip RF ablation for 1.8 s at this region successfully ablated the AP permanently. In complicated cases after failed conventional ablation attempts via a transfemoral or transseptal approach, CS ablation is an effective alternative to percutaneous or surgical ablation of epicardial APs. In such cases, electroanatomical mapping systems may be useful in determining the location of the AP and reducing fluoroscopy time. Furthermore, ablation with irrigated-tip RF catheters can improve the treatment success rate due to larger and deeper lesion formation.
Zusammenfassung
Wir berichten über den Fall einer 71-jährigen Frau mit rezidivierenden supraventrikulären Tachykardien. In der elektrophysiologischen Untersuchung konnte eine orthodrome atrioventrikuläre Reentry-Tachykardie bei verborgener linksseitig gelegener akzessorischer Leitungsbahn induziert werden. Die Radiofrequenz(RF)-Ablation über einen retrograden transaortalen Zugangsweg war nicht erfolgreich. Da bei einem zweiten Ablationsversuch nach sechs Wochen über einen transseptalen Zugangsweg unter Nutzung des EnSite-Precision-3-D-Mapping-Systems mit einem gekühlten RF-Ablations-Katheter ebenfalls keine Blockade der Bahn erreicht werden konnte, erfolgte ein Mapping im Koronarsinus (CS). Unter rechtsventrikulärer Stimulation fanden wir die früheste retrograde atriale Erregung im mittleren CS. Die gekühlte RF-Ablation an dieser Stelle führte zu einer permanenten Blockade der Leitungsbahn nach 1,8 s RF-Energieabgabe. In komplizierten Fällen ist die Ablation im Koronarsinus nach erfolglosen konventionellen Ablationsversuchen über einen transfemoralen oder transseptalen Zugangsweg eine effektive Alternative zu einer perkutanen oder chirurgischen Ablation bei epikardialer Lage der akzessorischen Leitungsbahn. Die Nutzung von elektroanatomischen Mappingverfahren kann in solchen Fällen nützlich sein, um die akzessorische Leitungsbahn zu lokalisieren und die Durchleuchtungszeit zu verkürzen. Die Nutzung eines gekühlten Ablationskatheters kann dabei die Erfolgsrate durch eine größere Eindringtiefe und Induktion größerer Läsionen erhöhen.
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D. Prochnau, H. Fischer, D. Mühlhammer and R. Eggers declare that they have no competing interests.
For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case. Additional written informed consent was obtained from all individual participants or their legal representatives for whom identifying information is included in this article.
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Prochnau, D., Fischer, H., Mühlhammer, D. et al. Radiofrequency ablation of a concealed left-sided accessory pathway in the mid-coronary sinus after failed conventional ablation attempts. Herzschr Elektrophys 30, 316–321 (2019). https://doi.org/10.1007/s00399-019-00642-1
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DOI: https://doi.org/10.1007/s00399-019-00642-1
Keywords
- Concealed accessory pathway
- Catheter ablation
- Coronary sinus
- Left-sided accessory pathway
- Radiofrequency ablation, irrigated-tip