Catheter ablation of accessory atrioventricular pathways in young patients: use of long vascular sheaths, the transseptal approach and a retrograde left posterior parallel approach

Department of Cardiology, Children's Hospital, Boston, Massachusetts.

OBJECTIVES. This study retrospectively assesses the technical aspects of the catheter techniques used to ablate 83 accessory atrioventricular (AV) pathways during 88 procedures in 71 pediatric and adult patients (median age 14 years, range 1 month to 55 years). A number of catheter approaches and techniques evolved that may have improved success and shortened procedure times. BACKGROUND. Radiofrequency catheter ablation of accessory AV pathways can be highly successful. However, the technical difficulty of many of the procedures is masked by the success rate. METHODS. Left free wall, right free wall and septal accessory pathways were ablated with a variety of approaches. RESULTS. Left free wall pathways were ablated successfully by using a standard retrograde approach through the aortic valve in only 10 (24%) of 43 cases. The remaining 33 (76%) required an approach that was either retrograde through the mitral valve (2 of 33), transseptal (21 of 33) or retrograde where the catheter was advanced behind the posterior mitral leaflet at the point of mitral-aortic continuity, so that the catheter course was parallel rather than perpendicular to the mitral anulus (10 of 33). Nineteen of 20 septal pathways were ablated successfully by using either the parallel approach (2 of 29), a transseptal approach (2 of 19), ablation within the coronary sinus or one of its veins (8 of 19) or ablation on the atrial side of the tricuspid valve (7 of 19). Fifteen of 20 right free wall pathways were ablated successfully with a variety of approaches on both the atrial and the ventricular side of the tricuspid valve. Long vascular sheaths were judged to contribute directly to success in 33 (43%) of 77 pathways. The overall success rate has been 93% (77 of 83 pathways), with 100% success for left free wall (43 of 43), 75% for right free wall (15 of 20) and 95% for septal pathways (19 of 20). CONCLUSIONS. Thus, successful ablation of accessory AV pathways in a mixed group of pediatric and adult patients appears to benefit from a wide range of vascular and catheter approaches.

This article has been cited by other articles:

				R. De Ponti, R. Cappato, A. Curnis, P. Della Bella, L. Padeletti, A. Raviele, M. Santini, and J. A. Salerno-Uriarte Trans-Septal Catheterization in the Electrophysiology Laboratory: Data From a Multicenter Survey Spanning 12 Years J. Am. Coll. Cardiol., March 7, 2006; 47(5): 1037 - 1042. [Abstract] [Full Text] [PDF]

				A. D. Blaufox, G. L. Felix, and J. P. Saul Radiofrequency Catheter Ablation in Infants <=18 Months Old: When Is It Done and How Do They Fare?: Short-Term Data From the Pediatric Ablation Registry Circulation, December 4, 2001; 104(23): 2803 - 2808. [Abstract] [Full Text] [PDF]

				H. Bertram, R. Bokenkamp, M. Peuster, G. Hausdorf, and T. Paul Coronary Artery Stenosis After Radiofrequency Catheter Ablation of Accessory Atrioventricular Pathways in Children With Ebstein's Malformation Circulation, January 30, 2001; 103(4): 538 - 543. [Abstract] [Full Text] [PDF]

				J V De Giovanni, A Dindar, M J Griffith, R A Edgar, E D Silove, O Stumper, and J. C Wright Recovery pattern of left ventricular dysfunction following radiofrequency ablation of incessant supraventricular tachycardia in infants and children Heart, June 1, 1998; 79(6): 588 - 592. [Abstract] [Full Text]

				K. Hirao, K. Otomo, X. Wang, K. J. Beckman, J. H. McClelland, L. Widman, M. D. Gonzalez, M. Arruda, H. Nakagawa, R. Lazzara, et al. Para-Hisian Pacing: A New Method for Differentiating Retrograde Conduction Over an Accessory AV Pathway From Conduction Over the AV Node Circulation, September 1, 1996; 94(5): 1027 - 1035. [Abstract] [Full Text]

				A. E. Epstein, W. M. Miles, D. G. Benditt, A. J. Camm, E. J. Darling, P. L. Friedman, A. Garson, J. C. Harvey, G. A. Kidwell, G. J. Klein, et al. Personal and Public Safety Issues Related to Arrhythmias That May Affect Consciousness: Implications for Regulation and Physician Recommendations: A Medical/Scientific Statement From the American Heart Association and the North American Society of Pacing and Electrophysiology Circulation, September 1, 1996; 94(5): 1147 - 1166. [Full Text]

				J.-M. Cote, M. R. Epstein, J. K. Triedman, E. P. Walsh, and J. P. Saul Low-Temperature Mapping Predicts Site of Successful Ablation While Minimizing Myocardial Damage Circulation, August 1, 1996; 94(3): 253 - 257. [Abstract] [Full Text]

				J. D. Kugler, D. A. Danford, B. J. Deal, P. C. Gillette, J. C. Perry, M. J. Silka, G. F. Van Hare, E. P. Walsh, and The Pediatric Electrophysiology Society Radiofrequency Catheter Ablation for Tachyarrhythmias in Children and Adolescents N. Engl. J. Med., May 26, 1994; 330(21): 1481 - 1487. [Abstract] [Full Text]