Volume Number
123 1
Catheter fulguration ectopic tachycardia
Brief Communications
ablation of left atrial in a child
Ming-Lon Young, MD, MPH, Zen-Kong Jeng-Sheng Chang, MD, and Ming-Ren Taipei, Taiwan, Republic of China
Dai, MD, Chen, MD.a
Because it is difficult to pharmacologically cure ectopic atrial tachycardia (EAT), the goal of medical treatment is to suppress the tachycardia to a hemodynamically tolerable heart rate.l As an alternative, a nonpharmacologic approach has been used to eradicate the focus.2-4 We report a patient with an EAT in whom the tachycardia focus was pinpointed to the left atrium by a catheter mapping technique. To our best knowledge, this is the first left atrial EAT in the literature that was successfully catheterablated in a child. A 5-year-old boy (weight 17 kg) had been complaining of abdominal pain off and on for 1 year. During one of these episodes, he was noted to have a tachycardia. His past history and physical examinations were otherwise unremarkable. The chest x-ray film showed no cardiomegaly. An echocardiographic study showed a structurally normal heart and a decreased left ventricular ejection fraction (40%). The diagnosis of EAT was established by: (1) the fact that the tachycardia had warm-up and cool-down phenomena and (2) the surface electrocardiogram had a P wave axis of +135 degrees, first-degree atrioventricular (AV) block, and sometimes Mobitz type I AV block.1,5 His heart rate could be maintained between 70 and 200 beats/ min with variable combinations of digoxin, verapamil, quinidine, and procainamide therapy. However, the EAT persisted, with an atria1 rate between 200 and 300 beats/min. When he was under this treatment, his abdominal pain disappeared. It reappeared when his heart rate was again 300 beatslmin 2 days prior to the cardiac catheterization, at which time all the medications were discontinued. After we had obtained written consent from his parents, he was sent to the catheterization laboratory. During the electrophysiologic study, marked cycle length variation (from 880 msec warm-up to 380 msec over a period of 20 seconds) of this tachycardia was again noted. When the tip of the No. 6F hexapolar catheter (Mansfield Webster 5209, interelectrode distance 2 mm, Boston Scientific Corp., Mansfield Division, Mansfield, Mass.) touched the anterolateral left atrium (Fig. l), the EAT was abruptly changed into sinus beats transiently (Fig. 2). His previous EAT then resumed spontaneously, with the first beat being identical to the subsequent beats of tachycardia. This phenomenon occured twice. The atria1 depolarization recorded by the distal pair of this hexapolar catheter (LA2 in Fig. 2) was the earliest atria1 depolarization of his EAT, which occurred 30 From the De’partment of Pediatrics, National Taiwan University Hospital, and BDepartment of Pediatrics, Mackay Memorial Hospital, Taipei. Reprint Pediatric 414133474
253
requests: Ming-Lon Young, MD, Department of Pediatrics Cardiology, P.O. Box 016960, Miami, FL 33101.
(R-76),
Fig. 1. Catheter position during mapping. Upper panel, Posteroanterior projection; lower panel, lateral projection. The hexapolar catheter that is positioned in the anterolatera1 left atrium is the ablation catheter (arrowhead).
msec before the beginning of the P wave of the EAT. Without further changing the position of this catheter, DC catheter ablation was carried out under diazepam anesthesia after blood and a cardiac surgeon on standby were available. A synchronized discharge of 100 joules was delivered via a standard DC defibrillator (Lifepak 6, Physio-Control Corp., Redmond, Wash.), with the most distal and the third poles of the catheter jointed to form the cathode and a cardioversion patch placed between the lower process of scapulae to serve as the anode. The EAT was instantly terminated, followed by a brief period of sinus arrest and then by normal sinus rhythm. An additional 100 joules shock was delivered 30 minutes later to ensure a permanent destruction of the tachycardia focus. After the procedure, the child complained of chest pain for 1 day. Blood chemistry showed an increased creatine kinase level
254
Brief Communications
American
January 1992 Heart Journal
"i
Fig. 2. The ectopic atria1 tachycardia (EAT) is abruptly converted into sinus beats by manipulating the ablation catheter. From the top: Calibration line (50 msec/division); surface leads I, AVF, VI, and intracardiac electrograms; HBE, His bundle electrogram; LRA, low right atria1 electrogram; HRA, high right atria1 electrogram. The hexapolar catheter was advanced into the heart from the superior vena cava. Its distal and proximal poles are used to record HRA and LRA, respectively (see Fig. 1). LAl, Left atria1 electrogram 1 (recorded from the distal pole of the quadripolar catheter that is placed in the posterolateral left atrium, indicated by arrow in Fig. 1). LA2, Left atria1 electrogram 2 (recorded from the distal pole of the left atria1 ablation catheter). Note that during EAT the earliest atria1 depolarization is recorded in LA2. Note also in lead I the P wave is negative during EAT and positive during sinus beats.
(807 U/L) but with a normal MB band fraction (4 % ). A follow-up echocardiogram showed an improved left ventricular ejection fraction (68%) and a small amount of pericardial effusion, which spontaneously resolved 2 weeks later. The follow-up electrocardiogram showed normal sinus rhythm. The patient was symptom-free and drug-free in the 11 months of follow-up. In this patient during manipulation of the mapping catheter the incessant EAT was suddenly converted into sinus beats when the catheter tip pressed the specific site of the left atrium. This is analogous to the sign of “disappearance of preexcitation related to the pressure of the catheter on the accessory pathway’@ in localizing the site of fulguration for treating the preexcitation syndrome. This site is also the earliest site of activation of the EAT. Fulguration of this site cured the patient’s EAT. It is likely that the ablation catheter was in the left atria1 appendage, as suggested by the chest radiographs. Because the right atria1 appendage is a favorable site for successful catheter ablation of right atria1 EAT,3 it stands to reason that catheter ablation may also be successful if the focus is inside the left atria1 appendage. For each individual shock, Gillette et a1.3 used 1 to 5 joules/kg of energy, with a cumulative energy of up to 15 joules/kg (one to three shocks) for each individual patient. DC ablation of the left atria1 EAT was not attempted for fear of embolization of gas or parts of the catheter. While our case of a left atria1 EAT was successfully ablated by a relatively large dose of energy (close to 6 joules/kg) without the development of any problems, a risk still exists. In light of a recent report of successful catheter ablation of left EAT by radiofrequency in an adult,7 DC ablation should not be used until radiofrequency ablation, if available, has first been attempted. REFERENCES
1. Mehta AV, Sanchez GR, Sacks EJ, Casta A, Dunn JM, ner RM. Ectopic atria1 tachycardia in children: clinical
Donchar-
2.
3.
4.
5.
6. 7.
acteristics, management and follow-up. J Am Co11 Cardiol 1988;11:379-85. Ott DA, Gillette PC, Garson A, Cooley DA, Reul GJ, McNamara DG. Surgical management of refractory supraventricular tachycardia in infants and children. J Am Co11 Cardiol 1985;5:124-9. Gillette PC, Wampler DG, Garson A, Zinner A, Ott D, Cooley D. Treatment of atria1 automatic tachycardia by ablation procedures. J Am Co11 Cardiol 1985;6:405-9. Davis J, Scheinman MM, Ruder MA, Griffin JC, Herre JM, Finkebeiner WE, Chin MC, Eldar M. Ablation of cardiac tissues by an electrode catheter technique for treatment of ectopic atrial supraventricular tachycardia in adults. Circulation 1986;74:1044-53. Gillette PC, Garson A Jr. Electrophysiologic and pharmacologic characteristics of automatic ectopic atria1 tachycardia. Circulation 1977;56:571-5. Warin JF, Haissaguerre M. Fulguration of accessory pathways in any location: report of seventy cases. PACE 1989;12:215-8. Margolis PD, Roman CA, Moulton KP, Calame J, Wang X, Lazzara R, Jackman WM. Radiofrequency catheter ablation of left and right ectopic atria1 tachycardia [Abstract]. Circulation 1990;82:111-718.
Oral sotalol in pediatric tachycardia Vincenzo Ventriglia,
atrial ectopic
Colloridi, MD, Cesare Perri, MD, and Giuseppe Critelli,
MD, Flavia MD. Rome, Italy
Sotalol has received increasing attention as an antiarrhythmic agent that combines class II beta-blocking properties From the Departments University of Rome Reprint 4/4/33473
requests:
“La
of Pediatric Sapienza.”
Giuseppe
Critelli,
Cardiology
and Cardiovascular
MD, Via Ceresio,
11.00199
Disease, Rome,
Italy.
123 1
Catheter fulguration ectopic tachycardia
Brief Communications
ablation of left atrial in a child
Ming-Lon Young, MD, MPH, Zen-Kong Jeng-Sheng Chang, MD, and Ming-Ren Taipei, Taiwan, Republic of China
Dai, MD, Chen, MD.a
Because it is difficult to pharmacologically cure ectopic atrial tachycardia (EAT), the goal of medical treatment is to suppress the tachycardia to a hemodynamically tolerable heart rate.l As an alternative, a nonpharmacologic approach has been used to eradicate the focus.2-4 We report a patient with an EAT in whom the tachycardia focus was pinpointed to the left atrium by a catheter mapping technique. To our best knowledge, this is the first left atrial EAT in the literature that was successfully catheterablated in a child. A 5-year-old boy (weight 17 kg) had been complaining of abdominal pain off and on for 1 year. During one of these episodes, he was noted to have a tachycardia. His past history and physical examinations were otherwise unremarkable. The chest x-ray film showed no cardiomegaly. An echocardiographic study showed a structurally normal heart and a decreased left ventricular ejection fraction (40%). The diagnosis of EAT was established by: (1) the fact that the tachycardia had warm-up and cool-down phenomena and (2) the surface electrocardiogram had a P wave axis of +135 degrees, first-degree atrioventricular (AV) block, and sometimes Mobitz type I AV block.1,5 His heart rate could be maintained between 70 and 200 beats/ min with variable combinations of digoxin, verapamil, quinidine, and procainamide therapy. However, the EAT persisted, with an atria1 rate between 200 and 300 beats/min. When he was under this treatment, his abdominal pain disappeared. It reappeared when his heart rate was again 300 beatslmin 2 days prior to the cardiac catheterization, at which time all the medications were discontinued. After we had obtained written consent from his parents, he was sent to the catheterization laboratory. During the electrophysiologic study, marked cycle length variation (from 880 msec warm-up to 380 msec over a period of 20 seconds) of this tachycardia was again noted. When the tip of the No. 6F hexapolar catheter (Mansfield Webster 5209, interelectrode distance 2 mm, Boston Scientific Corp., Mansfield Division, Mansfield, Mass.) touched the anterolateral left atrium (Fig. l), the EAT was abruptly changed into sinus beats transiently (Fig. 2). His previous EAT then resumed spontaneously, with the first beat being identical to the subsequent beats of tachycardia. This phenomenon occured twice. The atria1 depolarization recorded by the distal pair of this hexapolar catheter (LA2 in Fig. 2) was the earliest atria1 depolarization of his EAT, which occurred 30 From the De’partment of Pediatrics, National Taiwan University Hospital, and BDepartment of Pediatrics, Mackay Memorial Hospital, Taipei. Reprint Pediatric 414133474
253
requests: Ming-Lon Young, MD, Department of Pediatrics Cardiology, P.O. Box 016960, Miami, FL 33101.
(R-76),
Fig. 1. Catheter position during mapping. Upper panel, Posteroanterior projection; lower panel, lateral projection. The hexapolar catheter that is positioned in the anterolatera1 left atrium is the ablation catheter (arrowhead).
msec before the beginning of the P wave of the EAT. Without further changing the position of this catheter, DC catheter ablation was carried out under diazepam anesthesia after blood and a cardiac surgeon on standby were available. A synchronized discharge of 100 joules was delivered via a standard DC defibrillator (Lifepak 6, Physio-Control Corp., Redmond, Wash.), with the most distal and the third poles of the catheter jointed to form the cathode and a cardioversion patch placed between the lower process of scapulae to serve as the anode. The EAT was instantly terminated, followed by a brief period of sinus arrest and then by normal sinus rhythm. An additional 100 joules shock was delivered 30 minutes later to ensure a permanent destruction of the tachycardia focus. After the procedure, the child complained of chest pain for 1 day. Blood chemistry showed an increased creatine kinase level
254
Brief Communications
American
January 1992 Heart Journal
"i
Fig. 2. The ectopic atria1 tachycardia (EAT) is abruptly converted into sinus beats by manipulating the ablation catheter. From the top: Calibration line (50 msec/division); surface leads I, AVF, VI, and intracardiac electrograms; HBE, His bundle electrogram; LRA, low right atria1 electrogram; HRA, high right atria1 electrogram. The hexapolar catheter was advanced into the heart from the superior vena cava. Its distal and proximal poles are used to record HRA and LRA, respectively (see Fig. 1). LAl, Left atria1 electrogram 1 (recorded from the distal pole of the quadripolar catheter that is placed in the posterolateral left atrium, indicated by arrow in Fig. 1). LA2, Left atria1 electrogram 2 (recorded from the distal pole of the left atria1 ablation catheter). Note that during EAT the earliest atria1 depolarization is recorded in LA2. Note also in lead I the P wave is negative during EAT and positive during sinus beats.
(807 U/L) but with a normal MB band fraction (4 % ). A follow-up echocardiogram showed an improved left ventricular ejection fraction (68%) and a small amount of pericardial effusion, which spontaneously resolved 2 weeks later. The follow-up electrocardiogram showed normal sinus rhythm. The patient was symptom-free and drug-free in the 11 months of follow-up. In this patient during manipulation of the mapping catheter the incessant EAT was suddenly converted into sinus beats when the catheter tip pressed the specific site of the left atrium. This is analogous to the sign of “disappearance of preexcitation related to the pressure of the catheter on the accessory pathway’@ in localizing the site of fulguration for treating the preexcitation syndrome. This site is also the earliest site of activation of the EAT. Fulguration of this site cured the patient’s EAT. It is likely that the ablation catheter was in the left atria1 appendage, as suggested by the chest radiographs. Because the right atria1 appendage is a favorable site for successful catheter ablation of right atria1 EAT,3 it stands to reason that catheter ablation may also be successful if the focus is inside the left atria1 appendage. For each individual shock, Gillette et a1.3 used 1 to 5 joules/kg of energy, with a cumulative energy of up to 15 joules/kg (one to three shocks) for each individual patient. DC ablation of the left atria1 EAT was not attempted for fear of embolization of gas or parts of the catheter. While our case of a left atria1 EAT was successfully ablated by a relatively large dose of energy (close to 6 joules/kg) without the development of any problems, a risk still exists. In light of a recent report of successful catheter ablation of left EAT by radiofrequency in an adult,7 DC ablation should not be used until radiofrequency ablation, if available, has first been attempted. REFERENCES
1. Mehta AV, Sanchez GR, Sacks EJ, Casta A, Dunn JM, ner RM. Ectopic atria1 tachycardia in children: clinical
Donchar-
2.
3.
4.
5.
6. 7.
acteristics, management and follow-up. J Am Co11 Cardiol 1988;11:379-85. Ott DA, Gillette PC, Garson A, Cooley DA, Reul GJ, McNamara DG. Surgical management of refractory supraventricular tachycardia in infants and children. J Am Co11 Cardiol 1985;5:124-9. Gillette PC, Wampler DG, Garson A, Zinner A, Ott D, Cooley D. Treatment of atria1 automatic tachycardia by ablation procedures. J Am Co11 Cardiol 1985;6:405-9. Davis J, Scheinman MM, Ruder MA, Griffin JC, Herre JM, Finkebeiner WE, Chin MC, Eldar M. Ablation of cardiac tissues by an electrode catheter technique for treatment of ectopic atrial supraventricular tachycardia in adults. Circulation 1986;74:1044-53. Gillette PC, Garson A Jr. Electrophysiologic and pharmacologic characteristics of automatic ectopic atria1 tachycardia. Circulation 1977;56:571-5. Warin JF, Haissaguerre M. Fulguration of accessory pathways in any location: report of seventy cases. PACE 1989;12:215-8. Margolis PD, Roman CA, Moulton KP, Calame J, Wang X, Lazzara R, Jackman WM. Radiofrequency catheter ablation of left and right ectopic atria1 tachycardia [Abstract]. Circulation 1990;82:111-718.
Oral sotalol in pediatric tachycardia Vincenzo Ventriglia,
atrial ectopic
Colloridi, MD, Cesare Perri, MD, and Giuseppe Critelli,
MD, Flavia MD. Rome, Italy
Sotalol has received increasing attention as an antiarrhythmic agent that combines class II beta-blocking properties From the Departments University of Rome Reprint 4/4/33473
requests:
“La
of Pediatric Sapienza.”
Giuseppe
Critelli,
Cardiology
and Cardiovascular
MD, Via Ceresio,
11.00199
Disease, Rome,
Italy.
