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Supraventricular arrhythmias: ablation and medical therapy

Latest update 2013 December

Arrhythmias


Differential diagnosis of  supraventricular tachycardias


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 Society.

Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF, Antman EM, Smith SC, Jr., Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO, Jr., Priori SG, Blanc JJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MA, Klein WW, Lekakis J, Lindahl B, Mazzotta G, Morais JC, Oto A, Smiseth O, Trappe HJ.
J Am Coll Cardiol 2003;42:1493-1531.

Guidelines from a joint committee of the ESC/AHA/ACC mechanisms, clinical presentation, evaluation and management of patients with supraventricular arrhythmias in general and a detailed discussion on specific entities in particular. Also special circumstances like pregnancy and congenital heart disease are reviewed. Atrial fibrillation is not part of these guidelines, since it forms the subject of a separate document.

Catheter ablation of supraventricular arrhythmias: state of the art.
Morady F.
J Cardiovasc Electrophysiol 2004;15:124-139.

Extensive review summarizing more than 20 years of ablation of supraventricular arrhythmia

Ablation above the semilunar valves: when, why, and how? Part II.
Suleiman M, Asirvatham SJ.
Heart Rhythm. 2008 Nov;5(11):1625-30.

Excellent overview of special anatomical circumstances referring to the invasive treatment of “conventional” arrhythmia targets

Principles of entrainment: diagnostic utility for supraventricular tachycardia.
Veenhuyzen GD, Quinn FR. Indian Pacing Electrophysiol J. 2008 Feb 1;8(1):51-65.

A very nice overview of the differential diagnosis of SVT in the EP lab.

 

Ablation of AV-nodal and AV-reentrant tachycardias


Predictors of acute and long-term success of slow pathway ablation for atrioventricular nodal reentrant tachycardia: a single center series of 1,419 consecutive patients.
Feldman A, Voskoboinik A, Kumar S, Spence S, Morton JB, Kistler PM, Sparks PB, Vohra JK, Kalman JM. Pacing Clin Electrophysiol. 2011 Aug;34(8):927-33.

Analysis of a large series of 1448 patients, showing a very low risk of persistent AV block (0.07%), no association between residual slow pathway conduction, single echo beats and recurrence, but a positive correlation between postablation echo-window and AVNRT recurrence.

How to ablate typical 'slow/fast' AV nodal reentry tachycardia.
Heidbuchel H.
Europace 2000;2:15-19.

A practical guide to ablation of AV nodal reentrant tachycardia, based on a combination of electrogram and anatomical criteria.

Comparison of the retrograde and transseptal methods for ablation of left free wall accessory pathways.
Lesh MD, Van Hare GF, Scheinman MM, Ports TA, Epstein LA.
J Am Coll Cardiol 1993;22:542-549.

Radiofrequency catheter ablation of left-sided accessory pathways can be performed either by a retrograde (transaortic) approach or by means of a transseptal puncture. This study compared both approaches and concluded that they are comparable in outcome, that the transseptal approach may be best suited to be the primary approach, and that they are complementary (i.e. if one method fails, the other should be attempted), yielding an overall success rate close to 100%.

Ablation of posteroseptal and left posterior accessory pathways guided by left atrium-coronary sinus musculature activation sequence.
Pap R, Traykov VB, Makai A, Bencsik G, Forster T, Sághy L.
J Cardiovasc Electrophysiol. 2008 Jul;19(7):653-8.


Reentrant and focal atrial tachycardias


Radiofrequency catheter ablation of type 1 atrial flutter. Prediction of late success by electrophysiological criteria.
Poty H, Saoudi N, Abdel Aziz A, Nair M, Letac B.
Circulation 1995;92:1389-1392.

An electrical endpoint for ablation of atrial flutter (i.e. the creation of bi-directional conduction block) is an important procedural factor to ensure good long-term outcome. This article was the first to highlight the importance of isthmus block evaluation.

Effect of right atrial isthmus ablation on the occurrence of atrial fibrillation: observations in four patient groups having type I atrial flutter with or without associated atrial fibrillation.
Nabar A, Rodriguez LM, Timmermans C, van den Dool A, Smeets JL, Wellens HJ.
Circulation 1999;99:1441-1445.

In some patients with atrial fibrillation, class-1 drugs result in its conversion into atrial flutter that can subsequently be ablated. This led to concepts such as “class-1c flutter” and “hybrid therapy”. Nabar et al. describe the outcome of such combined drugs+ablation strategy in different patient groups with atrial flutter and fibrillation.

Mapping and ablation of left atrial flutters.
Jaïs P, Shah DC, Haïssaguerre M, Hocini M, Peng JT, Takahashi A, Garrigue S, Le Métayer P, Clémenty J:
 Circulation 2000; 101(25): 2928-2934.

This is the first publication describing the delineation of left atrial flutter (left atrial macroreentry) circuits and their ablation based on the analysis of the mapping data.

Dual loop intra-atrial reentry in man.
Shah DC, Jaïs P, Takahashi A, Hocini M, Peng JT, Clémenty J, Haïssaguerre M:
Circulation 2000; 101(6): 631-639.

This study provides the first description of multi-loop reentrant tachycardias in man.
 
Characterization of reentrant circuit in macroreentrant right atrial tachycardia after surgical repair of congenital heart disease: isolated channels between scars allow "focal" ablation.
Nakagawa H, Shah N, Matsudaira K, Overholt E, Chandrasekaran K, Beckman KJ, Spector P, Calame JD, Rao A, Hasdemir C, Otomo K, Wang Z, Lazzara R, Jackman WM.  
Circulation. 2001 Feb 6;103(5):699-709

This paper describes the mapping and ablation of multiple reentrant right atrial tachycardias in patients with a previous surgical repair of congenital heart disease. This study highlights the substrate of these tachycardias and describes the recognition of critical isthmuses during tachycardia as well as during sinus rhythm based essentially upon 3D activation mapping.

Characterization of reentrant circuits in left atrial macroreentrant tachycardia: critical isthmus block can prevent atrial tachycardia recurrence.
Ouyang F, Ernst S, Vogtmann T, Goya M, Volkmer M, Schaumann A, Bänsch D, Antz M, Kuck KH.
Circulation. 2002 Apr 23;105(16):1934-42.

This study describes the correlation of the achievement of critical isthmus conduction block with the prevention of recurrence of mainly left atrial reentrant tachycardias.

Muscular architecture of the mitral isthmus: anatomical determinants for catheter ablation.
Cabrera JA, Pizarro G, Sánchez-Quintana D.
Europace. 2012 Aug;14(8):1069-71.

A better understanding of the anatomo-functional substrate is essential for developing a proper LA isthmus ablation strategy that can contribute to successful outcome.

Narrow slow-conducting isthmus dependent left atrial reentry developing after ablation for atrial fibrillation: ECG characterisation and elimination by focal RF ablation.
Shah D, Sunthorn H, Burri H, Gentil-Baron P, Pruvot E, Schlaepfer J, Fromer M Cardiovasc Electrophysiol 2006: 17: 508-515.

This study describes a specific type of left atrial reentry occurring after catheter ablation of atrial fibrillation dependent upon a small dimension, slowly conducting critical isthmus which can therefore be ablated usually with a single ablation lesion without requiring a composite linear lesion.

Ablation of post-surgical intra-atrial reentrant tachycardia. Predilection target sites and mapping approach.
Anne W, van Rensburg H, Adams J, Ector H, Van de Werf F, Heidbuchel H.
Eur Heart J 2002;23:1609-1616.

Post-surgical atrial macroreentrant tachycardias may be challenging to ablate. Recognition of patterns in these arrhythmogenic substrates has facilitated their ablation.

Surgical technique and the mechanism of atrial tachycardia late after open heart surgery.
Pap R, Kohári M, Makai A, Bencsik G, Traykov VB, Gallardo R, Klausz G, Zsuzsanna K, Forster T, Sághy L.
 J Interv Card Electrophysiol. 2012 Nov;35(2):127-35.

This article describes the association between surgical atriotomy and the mechanism of late postoperative atrial tachycardias.

Atrial Tachycardia: Mechanisms, Diagnosis, and Management.
Kurt C. Roberts-Thomson, MBBS, FRACP, Peter M. Kistler, MBBS, PhD, FRACP, and Jonathan M. Kalman, MBBS, PhD, FACC
Curr Probl Cardiol 2005;30: 529-573

Very extensive review, discussing the clinical features, diagnosis, and treatment of focal atrial tachycardia. There is particular focus on the mechanisms, anatomic locations, and P wave mor- phology, as well as the techniques of mapping and radiofrequency ablation.

Ablation of atrial tachycardia originating from the vicinity of the atrioventricular node: significance of mapping both sides of the interatrial septum.
Frey B, Kreiner G, Gwechenberger M, Gössinger HD.
J Am Coll Cardiol. 2001 Aug;38(2):394-400.

Interesting report on 16 patients undergoing radiofrequency catheter ablation of perinodal atrial tachycardia, showing that mapping of only the right side of the septum cannot exclude a left-sided origin. Therefore, mapping of both sides of the interatrial septum is required prior to ablation of focal atrial tachycardia originating from the vicinity of the atrioventricular node.

Atrial tachycardia arising adjacent to noncoronary aortic sinus: distinctive atrial activation patterns and anatomic insights.
Liu X, Dong J, Ho SY, Shah A, Long D, Yu R, Tang R, Hocini M, Haissaguerre M, Ma C. J Am Coll Cardiol. 2010 Aug 31;56(10):796-804.

One of the biggest series of focal atrial tachycardia ablated from the non-coronary aortic sinus and analysis of the biatrial activation pattern during these tachycardias.