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How to ablate difficult arrhythmias


This session was chaired by myself and Luc Joardens from Rotterdam and we had a very prominent group of speakers . The scientific quality of the session was very high with lively interaction with the audience. Particularly the format of the talks as “case based discussion” was very useful and right to the point.

The first talk was given by Hans Kottkamp of Zurich and his talk was mainly focused on the ablation of the paraseptal accessory pathways. He explained that a lot of epicardial accessory pathways took place at the paraseptal region and sometimes gave enormous difficulty for the operator. He presented four cases of paraseptal accessory pathways with overt or concealed pre-excitation, decremental conductivity pattern, coronary sinus related or with a diverticulum of the coronary sinus or ligament of Marshall related, which were successfully ablated with careful study by observing the accessory pathway potential or in some cases in combination with electroanatomic mapping .

Gerhard Hindricks from Leipzig first gave some general information about scar related tachycardias. They are developed sometimes years after surgery, most frequently after ASD closure. Usually regular atrial tachycardias 1:1 to 5:1 , most frequently 2:1 conduction and tend to recur after cardioversion and do not usually respond to antiarrhythmic drugs. Substrate is created by the surgeon. The re-entrant activation usually occurs around the incision or rarely around the patch. He recommend suspecting incisional atrial tachycardia in a patient with stable supraventricular tachycardia after surgery. Surface ECG is not specific but usually shows the feature of isthmus dependent atrial flutter. He suggests using activation mapping, entrainment and 3-D PPI mapping for the success of the procedure. Double potential identifies the surgical scar and the line of block should include the anatomical obstacles (SVC, IVC, TA). Recurrence after ablation is rare.

Post infarct ventricular angina was discussed by Mathias Antz again with the presentation of informative cases. He first gave the main indications of VT ablation post MI as the failure of the antiarrhythmic drugs and frequent ICD shocks. He suggests using mid-diastolic potentials, activation mapping and entrainment to detect the exit site. In case of non-inducible VT during the EPS voltage, mapping by EAM and pacing from the scar area to detect the exit site would be helpful. Sometimes endocardial ablation is not successful and an epicardial approach may be needed.

Andrea Natale focused on the epicardial ablation of difficult ventricular tachycardias. He mentioned the potential limitations of the endocardial ablation. The series presented were usually small numbers of patients. He gave examples of ventricular tachycardia of arrhythmogenic right ventricular cardiomyopathy and some idiopathic VT like left ventricular aortic cusp tachycardia. ECG clues to suggest the epicardial substrate were slurring in the initial portion of the QRS and delayed activation and Q waves where they do not belong. Limitations of the epicardial approach were phrenic nerve injury, epicardial fat, damage to the coronary arteries and mid myocardial foci and having always good contact with the epicardial surface.




How to ablate difficult arrhythmias

Notes to editor

This congress report accompanies a presentation given at the ESC Congress 2009. Written by the author himself/herself, this report does not necessarily reflect the opinion of the European Society of Cardiology.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.