Abstract
Background: ICE has demonstrated its utility in imaging right atrial structures but its utility in slow pathway (SP) ablation has not been documented in a randomized trial.
Methods: The feasibility of using ICE as a imaging modality to identify the effective site of SP ablation was done in part one of the study comprising 10 patients of typical AVNRT. Subsequently, a prospective randomized study was done comparing the conventional (group A) and ICE guided (group B) ablation of the SP. Each group had 20 patients of typical AVNRT. Ablation in the conventional arm was guided by intracardiac electrograms and fluoroscopy. Group B patients underwent SP ablation guided primarily by ICE imaging; fluoroscopy was used mainly for initial placement of catheters.
Results: Reliable & stable ICE images were obtained in all patients. Part I of the study showed that RF pulses given when the ablation catheter was seen to cross the atrioventricular muscular septum (AVMS), always resulted in junctional rhythm. In Group B, RF pulse was delivered only when the ablation catheter was at the AVMS making an obtuse angle with the image of the His-bundle catheter. Consistent junctional rhythm and abolition of SP resulted at this site. Compared to group A, patients in group B required fewer pulses (mean 1.4±0.6 vs. 4.4±3.0; p < 0.05, median 1 vs. 5; p < 0.01), achieved a higher temperature (56±4 °C vs. 50±6 °C) and had more frequent junctional rhythm (100% vs. 70%) during RF pulse.
Conclusions: A critical portion of SP exists adjacent to Tricuspid valve overlying the AVMS. ICE imaging consistently and reliably localizes this site and RF applications here result in interruption of antegrade SP conduction.
Similar content being viewed by others
References
Jackman WM, Beckman KJ, McClelland JH, Wang X, et al. Treatment of supraventricular tachycardia due to atrioventricular nodal reentrant tachycardia by radiofrequency ablation of slow pathway conduction. N Engl J Med 1992; 327: 313–318.
Kay GN, Epstien AE, Dailey SM, Plumb VJ. Selective radiofrequency ablation of the slow pathway for the treatment of atrioventricular nodal reentrant tachycardia: evidence for involvement of perinodal myocardium within the circuit. Circulation 1992; 85: 1675–1688.
Jazayeri MR, Hempe SL, Sra JS, et al. Selective transcathter ablation of the fast and slow pathway using radiofrequency energy in patients with atrioventricular reentrant nodal tachycardia. Circulation 1992; 85: 1318–1328.
Hassigguerr M, Gaita F, Fischer B, Commenges D, Montserrat P, d'Iversois C, Lemetayer P, Warin JF. Elimination of atrioventricular nodal reentrant tachycardia using discrete slow potential to guide application of radiofrequency energy. Circulation 1995; 85: 2162–2175.
Epstein LM, Lesh MD, Grillin JC, Lee RJ, Scheinman MM. A direct midseptal approach to slow atrioventricular nodal pathway ablation. Pacing Clin Electrophysiol 1995; 18: 57–64.
Kalbtleisch SJ, Strickberger SA, Williamson B, Vorperian VR, Man C, Hummel JD, Langberg JJ, Morady F. Randomized comparison of anatomic and electrogram mapping approaches to ablation of slow pathway of atrioventricular node reentrant tachycardia. J Am Coll Cardiol 1994; 23: 716–723.
Langberg JJ, Leon A, Borganelli M, Kalbtleisch SJ, El-Attasi R, Calkins H, Morady F. A randomized, prospective comparison of anterior and posterior approaches to radiofrequency cathter ablation of atrioventricular reentrant tachycardia. Circulation 1993; 87: 1551–1556.
Lindsday BD, Chung MK, Gamache MC, Luke RA, Schechtman KB, Osborn JL, Cain ME. Therapeutic end points for the treatment of atrioventricular nodal reentrant tachycardia by cathter-guided radiofrequency current. J Am Coll Cardiol 1993; 22: 733–740.
Wathen M, Natale A, Wolfe K, Yee R, Newman D, Klein G. An anatomically guided approach to atrioventricular node slow pathway ablation. Am J Cardiol 1992; 70: 886–889.
Niebauer MJ, Daoud E, Williamson B, Man KC, Strickberger A, Hummel J, Morady F. Atrial electrogram characteristics in patients with and without atrioventricular nodal reentrant tachycardia. Circulation 1995; 92: 77–81.
Ineou S, Becker AK. Koch's triangle sized up: anatomical landmarks in perspective of cathter ablation procedures. Pacing Clin Electrophysiol 1998; 21: 1553–1558.
Ueng KC, Chen SA, Chiang CE, et al. Dimensions and related anatomical distance of Kochs triangle in patients of atrioventricular nodal reentrant tachycardia. J Cardiovasc Electrophysiol 1996; 7: 1017–1023.
Chu E, Kalman JM, Kwasman MA, Jue JCY, Epstein LM, Schiller NB, Yock PG, Lesh MD. Intracardiac echocardiography during radiofrequency ablation of arrhythmias in humans. J Am Coll Card 1994; 24: 1351–1357.
Chu E, Fitzpatrick A, Chin M, Sudhir K, Yock P, Lesh M. Radiofrequency cathter ablation guided by intracardiac echocardiography. Circulation 1994; 89: 1301–1305.
Olgin JE, Kalman JM, Fitzpatrik AP, Lesh MD. Role of right atrial endocardial structures as barriers to conduction during human Type I atrial flutter: activation and entrainment mapping guided by intracardiac echocardiography. Circulation 1995; 92: 1839–1848.
Fisher WG, Pelini MA, Bacon ME. Adjunctive intracardiac echocardiography to guide slow pathway ablation in human atrioventricular nodal reentrant tachycardia:anatomic insights. Circulation 1997; 96: 3021–3029.
Kalbfleisch SJ, Strickberger SA, Williamson B, et al. Randomised comparison of anatomic and electrogram mapping approaches to ablation of the slow pathway of atrioventricular node reentrant tachycardia. J Am Coll Card 1994; 23: 716–723.
Zhu DWX, Maloney JD. Radiofrequency cathter ablative therapy for atrioventricular nodal reentrant tachycardia. In: Singer I, ed. Interventional Electrophysiology, Ist edition, Baltimore, MD: Williammsand Wilikins, 1997: 275–231.
Moulton K, Miller B, Scott J, et al. Radiofrequency cathter ablation for AV nodal reentry: a technique for rapid transection of the slow AV nodal pathway. PACE 1993; 16: 760–768.
Yamane Y, Iesaka Y, Goya M, Takashi A, Fujiwara H, Hiraoka M. Optimal target site for slow AV nodal pathway ablation: possibility of predetermined focal mapping approach using anatomic reference in the Kochs triangle. J Cardiovasc Electrophysiol 1999; 10: 529–537.
Hintringer F, Hartikainent J, Davies DW, Heald SC, Gill JS, Ward DE, Rowland E. Prediction of atrioventricular block during radiofrequency ablation of the slow pathway of the atrioventricular node. Circulation 1996; 92: 3490–3496.
Tebbenjohanns J, Pfeiffer D, Schumacher B, Manz M, Ludritz B. Impact of the local atrial electrogram in AV nodal reentrant tachycardia: ablation versus modification of the slow pathway. J Cardiovasc Electrophysiol 1995; 6: 245–251.
Li HG, Klein GJ, Stites HW, Zardini M, Morillo CA, Thakur RK, Yee R. Elimination of slow pathway conduction: an accurate indicator of clinical success after radiofrequency atrioventricular nodal modification. J Am Coll Cardiol 1993; 22: 1849–1853.
Barker JH, Plumb VJ, Epstein AE, Kay GN. Predictors of recurrent atrioventricular reentry after selective slow pathway ablation.AmJ Cardiol 1994; 73: 765–769.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Batra, R., Nair, M., Kumar, M. et al. Intracardiac Echocardiography Guided Radiofrequency Catheter Ablation of the Slow Pathway in Atrioventricular Nodal Reentrant Tachycardia. J Interv Card Electrophysiol 6, 43–49 (2002). https://doi.org/10.1023/A:1014124206594
Issue Date:
DOI: https://doi.org/10.1023/A:1014124206594