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When Catheter Ablation Should Be First Line Therapy Neil K. Sanghvi, M.D. Common Symptoms Palpitations (often sudden on & off) Anxiety Light-headedness Chest pain Neck Pounding Dyspnea Polyuria in prolonged cases secondary to ANP release 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 Cardiac Electrical System SA Node AV Node His Bundle Left Bundle Right Bundle 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 Reentrant tachycardias Usually precipitated by a PVC or PAC May also occur secondary to: Excessive caffeine intake Alcohol intake Recreational drug use Hyperthyroidism Exercise Initial Workup History, history, history… 12 lead EKG Echocardiogram Holter monitoring Thyroid function CBC (looking for anemia, infection) 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) 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. 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. Short RP>PR tachycardias AVNRT AVRT Junctional tachycardia Atrial tachycardia with 1o AVB Long RP>PR tachycardias Atrial tachycardia Atypical AVNRT Sinus Tachycardia QRS morphology based on the mechanism of the tachycardia 33yo with sudden onset of palpitations and SOB after driving from NY to FL. Sinus Tachycardia Note the classic S1Q3T3 seen with pulmonary emboli 40yo with sudden onset of palpitations while mowing the lawn. 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) AVNRT Ablation – Catheter Position HRA His Abl HB CS Triangle of Koch 31yo man presenting with palpitations after a night on the town. How would you treat this man? A. B. C. D. E. Verapamil/Diltiazem Beta Blocker Adenosine Digoxin Procainamide/Amiodarone Atrial fibrillation with Wolf-ParkinsonWhite 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 Baseline EKG for Previous Patient EKG requirements to diagnose Preexcitation (WPW) P-R < 120ms Delta wave QRS > 100ms Normal P-wave axis 72yo woman with history of HTN p/w palpitations and SOB. 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 66yo woman with rapid heart rate and anxiety. 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 Activation on Halo Catheter During Typical Atrial Flutter V1 II aVF TA 1,2 TA 19,20 TA 9,10 CS Os TA 1,2 TA 3,4 TA 5,6 TA 7,8 TA 9,10 TA 11,12 TA 13,14 Typical = CCW TA 17,18 TA 19,20 CS Os Activation on Halo Catheter V1 II aVF TA 1,2 TA 9,10 TA 19,20 CS Os TA 1,2 TA 3,4 TA 5,6 TA 7,8 TA 9,10 TA 11,12 TA 13,14 Atypical = Clockwise TA 17,18 19,20 CS Os 3D Propagation Map of Atrial Flutter Atrial Flutter CTI Ablation LAO Atrial Flutter CTI Ablation RAO 68yo woman with severe COPD exacerbation. Atrial tachycardia with variable block Atrial rates typically 150 -250bpm Often treated with AAD for rhythm control, nodal agents for rate control Catheter ablation has success rates of > 80% Atrial Tachycardia Carto map revealing a focal atrial tachycardia originating from the SVC 25yo man with fever of 102. Sinus tachycardia 65yo man presenting with palpitations. 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 2014 Guidelines AF Success w/ Ablation Pre- ablation Post- ablation 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