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Transcript
Spatial relation of the right coronary artery to the cavotricuspid isthmus and the impact on radiofrequency catheter ablation of common-type atrial flutter HANNO U KLEMM Heart Center Dortmund TIM F WEBER University Medical Center Heidelberg CHRISTIN JOHNSEN University Heart Center Hamburg PHILIPP G C BEGEMANN University Medical Center Hamburg THOMAS MEINERTZ University Heart Center Hamburg RODOLFO VENTURA Electrophysiology Bremen, Bremen, Germany Rationale for the study Why should the right coronary artery (RCA) influence cavotricuspid isthmus (CTI) ablation? 1. The RCA is in close proximity to the CTI. Anatomic studies report a distance of approximately 5mm whereas RFlesions penetrate up to 8mm. 2. Isthmus anatomy is highly variable. 3. There are cases of CTI that are resistant to block. 4. At out center higher incidence of failure to block with cryoablation (unreported data). 5. There are few case reports of RCA injury due to ablation. Cavotricuspid Isthmus Anatomy Cabrera et al. J Cardiovasc Electrophysiol 2005 Study design 60 patients scheduled for ablation of paroxysmal or persistant AF underwent cardiac CT for image integration. The CT protocoll was modified to visualize the right atrium in addition to the left atrium and coronary arteries. In 6 patients CT quality was poor due to atrial fibrillation at the time of the CT study. Irrigated tip (3.5mm tip, Thermocool, Biosense) CTI ablation was performed using a step-up protocoll starting at 30W with increments of 5W. The course of the RCA was tagged at the Ensite Verismo Workstation and segmentation data were exported for further analysis. Anatomical variations of the CTI were evaluated using multiplanar reconstructions of the CT-scans (Merge eFilm). Invasive follow-up was available for 34 patients who required ablation for recurrence of atrial fibrillation. Gaps were detected and reablation performed if necessary Variations of RCA Anatomy Ensite Verismo® segmentation of CT model Possible confounders What about pouch-like recesses and prominent Eustachian valves? Both, pouch-like recesses and prominent Eustachian valves, have been found to complicate CTI ablation. (Heidbüchel et al. Circulation 2001; Da Costa et al. Circulation 2004) Acute CTI-block, however, was achieved in almost all patients. There are few data on invasive follow-up and late conduction recurrence. Variations of CTI Anatomy straight pouch concave Eust. v. Threedimensional CTI Model CTI spatial relation with RCA septal inferior anterior p* 26 ±8 28 ±8 33 ±9 <0.01 Mean RCA distance from CTI (mm) 7.3 ±3.3 5.3 ±2.5 5.7 ±2.3 <0.01 Mean RCA distance from TV (mm) 5.2 ±4.4 5.4 ±4.5 5.8 ±4.6 0.78 Mean Isthmus length (mm) Ablation Results I Ablation Results II Ablation Results III Ablation Results IV 7 6 5 4 3 2 1 0 ventricular central Gap RCA at Gap caval Conclusion The proximity of the right coronary artery to the cavotricuspid isthmus results in a protective (cooling) effect with the requirement of higher ablation power for closer distances. Anatomical variations with the RCA leaving the AV-groove towards the atrial aspect might be responsible for myocardial strands surviving RF ablation giving rise to late conduction recurrence.