Cateheter ablation treatment of atrioventricular nodal re-entrant tachycardia

Öz

Objectives: In this study, we aimed to evaluate our clinical experience about the catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT) including complications and long-term outcomes. Materials and Methods: The study population consisted of 166 patients with AVNRT, 52 of whom from hospital-1 and 114 of who from hospital-2. Radio-frequency (RF) ablation therapy was applied after the basic electrophysiology study. Complications in RF ablation and long-term recurrences were noted. Results: More than 90% of the patients had symptoms persisting for more than one year and again more than 90% of those were suffering at least 2 episodes per month. The success rate of RF ablation was 98.2% for the entire study population. The recurrence rate was observed to be 3% (n=5) throughout the follow-up period. In the multivariate Cox regression analysis; young age, operator`s experience (Hospital 1 vs. 2), and presence of atypical AVNRT were the independent predictors of long-term recurrence. Major complications related to AVNRT ablation are not encountered frequently. Death, myocardial infarction and stroke were not seen in any of the patients, however, two patients developed deep vein thrombosis. Minor complications in RF ablation included asymptomatic minimal/mild pericardial effusion (n=5), femoral hematoma requiring no transfusion (n=5) and transient AV block (n=5). Atrio-ventricular block requiring permanent pacemaker implantation was found only in one patient (0.6%). Conclusion: Radio-frequency catheter ablation in patients with AVNRT appears to be a safe and effective method. The presence of atypical AVNRT, young age and operator`s experience were observed to be the independent predictors of long-term recurrence.

Anahtar Kelimeler

• Atrioventricular nodal reentrant tachycardia, radio-frequency ablation, recurrence, complication.

Cateheter ablation treatment of atrioventricular nodal re-entrant tachycardia

Öz

Amaç: Atriyoventriküler nodal re-entrant taşikardilerin (AVNRT) radyo-frekans (RF) ablasyon tedavisi ile ilgili olarak klinik deneyimimizi, gözlenen komplikasyonları ve uzun dönem sonuçları kapsamlı bir şekilde değerlendirmeyi amaçladık. Gereç ve yöntem: Çalışmaya Hastane-1 (n=52) ve Hastane-2`de (n=114) olmak üzere toplam 166 AVNRT hastası alınmıştır. Bu hastalara temel elektrofizyolojiden sonra RF ablasyon tedavisi uygulanmıştır. işlem esnasında gözlenen komplikasyonlar ve uzun dönem takipte gelişen tekrarlamalar kaydedilmiştir. Bulgular: Çalışmaya alınan hastaların >%90 da semptomlar bir yıldan fazla devam etmekteydi ve en az 2 atak yaşamaktaydı. Tüm grup için RF ablasyon başarı oranı %98,2 idi. Tüm popülasyon için rekürrens oranı % 3 (5 hasta) idi. AVNRT ablasyonu sonrası uzun dönem takipte rekürrens prediktorleri olarak yaş, operatör deneyimi (hastane 1 ve 2) ve atipik AVNRT varlığı olarak bulundu. AVNRT ablasyonu ile ilişkili majör komplikasyon oranı oldukça düşük olup sadece 2 hastada derin ven trombozu izlenirken, hiç bir hastada ölüm, miyokard enfarktüsü, inme veya kardiyak tamponad izlenmedi. Minor komplikasyonlardan asemptomatik minimal-hafif perikardiyal efüzyon 5 hastada, kasık yerinde transfüzyon gerektirmeyen hematom (5 hasta) ve geçici AV blok (5 hasta) olarak tespit edildi. Sadece 1 hastada (% 0. 6) kalıcı pil implantasyonu gerektiren AV blok izlendi. Sonuç: AVNRT nin RF ablasyonu hem akut dönemde hemde uzun dönem takipte güvenli ve etkili bir yöntemdir. Atipik AVNRT varlığı, genç yaş ve operatör deneyimi uzun dönem rekürrens için esas belirleyicilerdir.

Anahtar Kelimeler

• Atriyoventriküler nodal re-entrant taşikardi, Radyofrekans ablasyon, rekürrens, komplikasyon

Kaynakça

1. Hindricks G. Incidence of complete atrioventricular block following attempted radiofrequency catheter modification of the atrioventricular node in 880 patients. Results of the Multicenter European Radiofrequency Survey (MERFS) The Working Group on Arrhythmias of the European Soci- ety of Cardiology. Eur Heart J 1996; 17(1): 82-8.
2. Scheinman MM, Huang S. The 1998 NASPE prospective catheter ablation registry. Pacing Clin Electrophysiol 2000; 23(6): 1020-8.
3. Jackman WM, Beckman KJ, McClelland JH, et al. Treat- ment of supraventricular tachycardia due to atrioventricular nodal reentry, by radiofrequency catheter ablation of slow- pathway conduction. N Engl J Med 1992; 327(5): 313-8.
4. Jackman WM, Wang XZ, Friday KJ, et al. Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson- White syndrome) by radiofrequency current. N Engl J Med 1991; 324(23): 1605-11.
5. Chen SA, Chiang CE, Tai CT, et al. Complications of diag- nostic electrophysiologic studies and radiofrequency cathe- ter ablation in patients with tachyarrhythmias: an eight-year survey of 3,966 consecutive procedures in a tertiary referral center. Am J Cardiol 1996; 77(1): 41-6.
6. Huang SK, Wood MA. Catheter ablation of cardiac arrhyth- mias, 2nd edn. Saunders: Philadelphia, PA, 2011.
7. Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm So- ciety. J Am Coll Cardiol 2003; 42(8): 1493-531.
8. Estner HL, Ndrepepa G, Dong J, et al. Acute and long-term results of slow pathway ablation in patients with atrioven- tricular nodal reentrant tachycardia--an analysis of the pre- dictive factors for arrhythmia recurrence. Pacing Clin Elec- trophysiol 2005; 28(2): 102-10.

9. Topilski I, Rogowski O, Glick A, Viskin S, Eldar M, Belhas- sen B. Radiofrequency ablation of atrioventricular nodal reentry tachycardia: a 14 year experience with 901 patients at the Tel Aviv Sourasky Medical Center. Isr Med Assoc J 2006; 8(7): 455-459.
10. Kihel J, Da Costa A, Kihel A, et al. Long-term efficacy and safety of radiofrequency ablation in elderly patients with atrioventricular nodal re-entrant tachycardia. Europace 2006; 8(6): 416-20.
11. Rostock T, Risius T, Ventura R, et al. Efficacy and safety of radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia in the elderly. J Cardiovasc Electro- physiol 2005; 16(6): 608-10.
12. Lipscomb KJ, Zaidi AM, Fitzpatrick AP, Lefroy D. Slow pathway modification for atrioventricular node re-entrant tachycardia: fast junctional tachycardia predicts adverse prognosis. Heart 2001; 85(1): 44-7.
13. Li YG, Gronefeld G, Bender B, Machura C, Hohnloser SH. Risk of development of delayed atrioventricular block after slow pathway modification in patients with atrioventricular nodal reentrant tachycardia and a pre-existing prolonged PR interval. Eur Heart J 2001; 22(1): 89-95.
14. Chen SA, Chiang CE, Tai CT, et al. Transient complete atrioventricular block during radiofrequency ablation of slow pathway for atrioventricular nodal reentrant tachycar- dia. Am J Cardiol 1996; 77(15): 1367-70.
15. 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(9): 886-9.
16. Fenelon G, d’Avila A, Malacky T, Brugada P. Prognostic significance of transient complete atrioventricular block during radiofrequency ablation of atrioventricular node re- entrant tachycardia. Am J Cardiol 1995; 75(10): 698-702.
17. Clague JR, Dagres N, Kottkamp H, Breithardt G, Borggrefe M. Targeting the slow pathway for atrioventricular nodal reentrant tachycardia: initial results and long-term follow- up in 379 consecutive patients. Eur Heart J 2001; 22(1): 82-8.
18. Hatzinikolaou H, Rodriguez LM, Smeets JL, Timmermans C, Vrouchos G, Grecas G, Wellens HJ. Isoprenaline and in- ducibility of atrioventricular nodal re-entrant tachycardia. Heart 1998; 79(2): 165-8.
19. Matsushita T, Chun S, Sung RJ. Influence of isoproterenol on the accelerated junctional rhythm observed during radio- frequency catheter ablation of atrioventricular nodal slow pathway conduction. Am Heart J 2001; 142(4): 664-8.
20. Stellbrink C, Diem B, Schauerte P, Brehmer K, Schuett H, Hanrath P. Differential effects of atropine and isoproterenol on inducibility of atrioventricular nodal reentrant tachycar- dia. J Interv Card Electrophysiol 2001; 5(4): 463-9.
21. Kose S, Amasyali B, Aytemir K, et al. Atrioventricular nodal reentrant tachycardia with multiple discontinuities in the atrioventricular node conduction curve: immediate suc- cess rates of radiofrequency ablation and long-term clinical follow-up results as compared to patients with single or no AH-jumps. J Interv Card Electrophysiol 2004; 10(3): 249- 54.
22. Manolis AS, Wang PJ, Estes NA. Radiofrequency ablation of slow pathway in patients with atrioventricular nodal re- entrant tachycardia. Do arrhythmia recurrences correlate with persistent slow pathway conduction or site of success- ful ablation? Circulation 1994; 90(6): 2815-9.
23. Haissaguerre M, Gaita F, Fischer B, et al. Elimination of atrioventricular nodal reentrant tachycardia using discrete slow potentials to guide application of radiofrequency en- ergy. Circulation 1992; 85(6): 2162-75.
24. Yildiz M, Aykan A.C., Kahveci G, Demir S, Ozkan M. Transvenous Radiofrequency Ablation Theraphy as an Ef- fective and Safe Method for The Treatment of The Slow Pathway Of Atrioventricular Nodal Re-Entrant Tachycardia Koşuyolu Kalp Dergisi 2011;14(2):51-5.
25. Feldman A, Voskoboinik A, Kumar S, Spence S, Morton JB, Kistler PM, Sparks PB, Vohra JK, Kalman JM. Predic- tors of Acute and Long-Term Success of Slow Pathway Ab- lation for Atrioventricular Nodal Reentrant Tachycardia: A Single Center Series of 1,419 Consecutive Patients. Pacing Clin Electrophysiol 2011; 34(8): 927-33.
26. D’Este D, Bertaglia E, Zanocco A, Reimers B, Pascotto P. Electrophysiological properties of the atrioventricular node and ageing: evidence of a lower incidence of dual nodal pathways in the elderly. Europace 2001; 3(3): 216-20.
27. Strickberger SA, Kalbfleisch SJ, Williamson B, et al. Ra- diofrequency catheter ablation of atypical atrioventricular nodal reentrant tachycardia. J Cardiovasc Electrophysiol 1993; 4(5): 526-32.
28. Pires LA, Huang SK, Wagshal AB, Mazzola F, Young PG, Moser S. Clinical utility of routine transthoracic echocar- diographic studies after uncomplicated radiofrequency catheter ablation: a prospective multicenter study. The Atakr Investigators Group. Pacing Clin Electrophysiol 1996; 19(10): 1502-7.
29. Calkins H, Yong P, Miller JM, et al. Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachy- cardia, and the atrioventricular junction: final results of a prospective, multicenter clinical trial. The Atakr Multi- center Investigators Group. Circulation 1999; 99(2): 262
30. Schaer BA, Maurer A, Sticherling C, Buser PT, Osswald S. Routine echocardiography after radiofrequency ablation: to flog a dead horse? Europace 2009; 11(2): 155-7