CASE REPORT
Mechanically induced complete atrioventricular block during retrograde catheter ablation of a left-sided incessant tachycardia A.E. van den Bosch, L.J. Jordaens
Concern for potentially letial complications related to ternsseptal catheterisation, such as perforation ofthe aorta, has made this approach less attactive over the last decades. Neverthdess, this method is now increasingly being used for ablation of leftsided arrhythumias. We report a transient complication of a retrograde procedure in a patient with a left-sided 'Coumel-type' incessant tachycardia. We had to proceed to transsweptal catheterisation, as the complication recurred during the second attempt even when using a less rigid transaortic radiofrequency catheter. The transseptal approach using a less stiff cryoenergy catheter was perforned without complications. (Neth HeartJ
2003;11:469-72.)
Key words: left-sided atrioventricular accessory pathways, transseptal catheterisation A ccessory (AV) may I'Dbe located anywhere along the left or right wall of atrioventricular
connections
the heart or within the septum. Since the introduction of radiofrequency catheter ablation, it has become possible for cardiologists to effectively ablate accessory pathways. It even became the therapy ofchoice. The predominance of left-sided accessory pathways has renewed interest in transseptal catheterisation over the last decade. Earlier comparisons of the transseptal and retrograde transaortic approaches for radiofrequency catheter ablation ofleft-sided accessory pathways was shown to be both safe and successful in the vast majority of the patients.' The aim of this case report is to demonstrate a potential advantage of transseptal A.E. van den Bosch. U. Jordm. Erasmus Medical Centre, Thoraxcentre, Department of Clinical Electrophysiology, PO Box 2060, 3000 CB Rotterdam.
Address for correspondence: A.E. van den Bosch. E-mail: [email protected]
Netherands Heart Journal, Volunie 11, Number 11, November 2003
catheterisation compared with the retrograde transaortic approach for catheter ablation of left-sided arrhythmias. Case prsentatin A 52-year-old woman presented with incessant tachycardia based on an orthodromic conducting accessory atrioventricular pathway. Although the patient claimed to have no symptoms, she could not fully compete with her age peers. The patient had a history of this arrhythnia since the age of 16 years and had completely adapted to her high heart rate. With a low heart rate she felt uncomfortable and triggered the tachycardia with a Valsalva manoeuvre. On admission she was not on any regular medication, although she had taken multiple antiarrhythmic drugs for several years without suppression of the arrhythmia. On physical exanination we found a blood pressure of 150/95 mmHg, a regular heart rate of 130 beats/ min and normal venous pressure. Auscultation of the heart revealed a fixed second heart sound with no additional clinical abnormalities. The electrocardiogram (ECG) showed a tachycardia of 130 beats/min with narrow QRS complexes, normal QRS axis and a negative P wave in II, III and aVF (figure LA). The P wave was biphasic or isoelectric in I, and V4 to V6. There were minimal voltage criteria for left ventricular hypertrophy. On the chest X-ray the heart was not enlarged, the C/T ratio waslO.5/23. Echocardiography showed a mildly depressed left ventricular function with normal dimensions of the heart (LVEDD 56 mm, LVESD 40 mm) and a slightly elevated right ventricular pressure of 35 mmHg. A reciprocating tachycardia with long retrograde conduction time was suspected, also because of the incessant character.2
Electrophyskogy procedure All surface ECG and intracardiac signals were recorded on a digital acquisition system (Prucka Engineering, Inc). Three multi-electrode catheters were inserted through a right femoral venous access. A quadripolar 469
Mechanically induced complete atrioventricular block during retrograde catheter ablation of a left-sided incessant tachycardia
Conductr, Medtronc Inc.) and showed later activation ofthe tachycardia at the bundle of His, the mid-septal segment and under the ostium of the coronary sinus. After retrograde transaortic insertion the earliest retrograde activity was rather near CS 5-6 (figure 2). While introducing the catheter through the aortic valve to the left ventride, a total atrioventricular block was created through mechanical manipulation ofthe normal conduction system (figure 3). At the same time the circus movement tachycardia stopped and intraventricular conduction delay became present with a superior left axis of -90°. The tachycardia could not be reinitiated by pacing or by 0.5 mg atropine intravenously. The procedure was ended. Within two hours, however, the circus movement tachycardia recurred with a left bundle branch block morphology. A second session was performed two days later. A diagnostic decapolar catheter was placed in the coronary sinus and earliest activation ofthe accessory pathway was again found at CS 5-6. After swift introduction ofa 7 Fr ablation catheter (Webster Cordis B-curve) through the aortic valve, the atrioventricular block again returned. The escape rhythm was wide with disappearance of the circus movement tachycardia. Given the experience ofthe first session, we continued the procedure and the retrograde catheter was removed. A transseptal puncture was performed under intracardiac echocardiographic guidance - (ICE 9900 catheter, Boston Scientific Inc.).3 With !.-2 the cryothermal ablation catheter 'ice mapping' (freezing to -30°, presumed reversible) was carried out from the atrial side at a spot preceding the earliest CS activation by 7 ms (figures 4 and 5). After 44 seconds the tachycardia terminated (figure 6). When the ablation was stopped, the tachycardia recurred immediately. Focal ablation was done with a temperature of-750C. After 10 seconds the tachycardia terminated. A double Figure IB. The ECG after the sece Figure IA. The ECG on adfreeze thaw at the same spot was performed. EP session, showing normal sii nus The electrocardiogram at discharge showed mission shows atrioventricular tachycardia with negative P rhytm witha k.ft bundle branchbihck continuous sinus rhythm with normal atriowaves in kads II, III and aVF. moiphology. ventricular conduction but a persisting left bundle branch block (figure 1B). Two months after the ablation, she visited the outpatient clinic with a persistelectrode catheter (Vlking Courmand, Bard Electroing LBBB, and no complaints: she revealed that she had physiology Billarica) was introduced to record a stable had to adapt to the new rhythm, but overall felt better. His potential. A bipolar pacing catheter (Medtronic Inc.) was positioned in the right ventricular apex. A 6 Dscussion Fr decapolar electrode catheter (Supreme CS, Daig Reciprocating atrioventricular tachycardia with a long Corp, St Jude Medical Inc.) was advanced through retrograde conduction time has been described in the left subclavian vein and positioned in the coronary sinus. A LocaLisa system (Medtronic Inc.) was used for patients who often develop incessant or permanent the 3D localisation ofthe mapping/ablation catheter. tachycardia, because ofthis long retrograde conduction time.4'5 The atrial exit is very often located posteroseptalThe earliest retrograde activity of circus movement ly at the left side (inferior paraseptal in the new tachycardia was found at CS 7-8, near the ostium of nomenclature).4-6 This case was uncommon, because the coronary sinus. Mapping of the target sites was of its relative lateral (or true posterior) position. done with the 8 Fr ablation catheter (Medtronic 470
Netherlands Heart Journal, Volume 11, Number 11, Novanber 2003
Mechanically induced complete atrioventricular block during retrograde catheter ablation of a left-sided incessant tachycardia
Figure 2. Fluowpic image during tranaortic approach, showing the positions of the catheters by which a totalAVblock was induced. (CS=coronarysinus catheter, AbL=ablation catheter, RVcath=brght ventricular pacing catheter.)
Retrograde transaortic catheterisation is the most frequently used approach for ablation of atrioventricular bypass tracts. It requires arterial puncture and placement ofthe ablation catheter in the left ventricle. Therefore, the ablation catheter has to be bent and positioned over the atrioventricular groove to detect the endocardiac insertion of the accessory pathway. This technique is not always easy to perform, and
Figure 4. Fluoroscopic image of the transseptal approach, showing the positions of the catheters at ablation site. (CS=ncoronary sinus
catheter, Abl=ablation catheter.)
preshaped or steerable catheters can facilitate the procedure. Especially the paraseptal location can be very difficult. Thereby, this approach has a few other shortcomings, including the possibility that the aorta and its valvular structures are damaged. Late endocarditis has been described. Further, damage to the normal conduction system as observed in this case report is a possibility.
1.
Figure 3. ECG when total AVblock occurred.
Netherlands Heart Joumal, Volume
II,
Number 11, November 2003
Figure 5. ECG obtained before the ablation, showing two beats in surface ECG leads I and V1 and the endocardial recording from the coronary sinus catheter. The earliest activation is seen at CS 56. The ablation signal precedes this by 7 ms.
471
Mechanically induced complete atrioventricular block during retrograde catheter ablation of a left-sided incessant tachycardia
References 1 2
21CS 940 LO
B -3
2CS 758 2
LI L L
L
4
I LlLI 11_ I_LsLL _LL
K2.ii4
24-C
'CS:2l
34
5
504. 6
Figure 6. ECG and endocardial recording obtained after successful ablation of the atrioventricular accessory pathway. 7
Transseptal catheterisation, already described in 1957,7 is a demanding procedure and the operator's experience seems to play a major role in minimising the occurrence of complications. Concern for the potentially lethal complications related to transseptal catheterisation, such as perforation of the aorta, led to an underuse of this procedure. In the last decade comparisons of the transseptal with the retrograde transaortic approach for radiofrequency catheter ablation renewed the interest in this approach.8 During transseptal ablation, the catheter has direct access to the mitral ring and left atrial walls. This facilitates both manipulation during mapping and catheter stability during radiofrequency energy delivery. In the second session we used the novel technique of cryothermal ablation.9 A cryocatheter should also be positioned in firm contact with the desired spot to guarantee good cooling and to avoid dissipation ofthe cold in the blood stream. This becomes easier with transseptal puncture. On top of this, the shaft of the cryo-catheter is less stiff than the generally used radiofrequency catheter. While this is a disadvantage for a retrograde approach to difficult areas, it becomes an advantage when vulnerable structures as the conduction system are mechanically blocked. Further, cryoablation may have additional advantages when lesions are required adjacent to sensitive structures and may result in less tissue destruction at ineffective sites. Conclusion The elective use of transseptal catheterisation can be preferred over the transaortic approach in patients with left-sided accessory pathways, certainly when the location is paraseptal. Mechanical heart block is a wellknown complication of retrograde catheterisation. The combination of transseptal techniques with more focused energy as cryoablation may help to avoid collateral damage. a
472
Calkins H. Radiofrequency catheter ablation of supraventricular arrhythmias. Heart2001;85:594-600. Brugada P, Farre J, Green M, Heddle B, Roy D, Wellens HJ. Observations in patients with supraventricular tachycardia having a P-Rinterval shorter than the R-P interval: differentiation between atrial tachycardia and reciprocating atrioventricular tachycardia using an accessory pathwaywith long conduction times. Am Heart J 1984;107:556-70. Szili-Torok T, Kimman G, Theuns D, Res J, Roelandt JR, Jordaens LJ. Transseptal left heart catheterisation guided by intracardiac echocardiography. Heart 2001;86:E1 1. Farre J, Ross D, Wiener I, Bar FW, Vanagt EJ, Wellens HJ. Reciprocal tachycardias using accessory pathways with long conduction times. AmjCardiol 1979;44:1099-109. Stein ML, Stone FM, Benditt DG. Incessant atrial tachycardia in childhood: association with rate-dependent conduction in an accessory atrioventricular pathway. AmJ Cardiol 1979;44:498-
8 9
Cosio FG, Anderson RH, Becker A, Borggrefe M, Campbell RW, Gaita F, et al. Living anatomy of the atrioventricular junctions. A guide to electrophysiological mapping. A Consensus Statement from the Cardiac Nomenclature Study Group, Working Group of Arrhythmias, European Society ofCardiology, and the Task Force on Cardiac Nomenclature from NASPE. North American Society of Pacing and Electrophysiology. Eur HeartJ 1999;20:1068-75. Manfredi D. Un nuovo catetere per lo studio fisiopatologico del cuore sinistro. Arch Ital Chir 1957;81:409-16. De Ponti R, Zardini M, Storti C, Longobardi M, Salemo-Uriarte JA. Trans-septal catheterization for radiofrequency catheter ablation of cardiac arrhythmias. Eur Heartj 1998;19:943-50. Skanes AC, Dubuc M, Klein GJ, Thibault B, Krahn AD, Yee R, et al. Cryothermal Ablation ofthe Slow Pathway for the Elimination of Atrioventricular Nodal Reentrant Tachycardia. Circulation
2000;102:2856-60.
U.'
-
..
0
TAMBOCORTh Verkorte productinformatie Sarnensteillng De tableten bevatten 50 of 100 mg flecainide-aceoaat en als hulpstoffen croscarmellose natrium, magnesiumstearaat, gepreelatiniseerd mans zetmeel, gehydrogeneerde plantaardige olie en microkrisalliine cellulose. (E460) De capsules beatten 100, 150 of 200 mg flecinide-acetaat en als hulpstoffen o.m.microkristllijne cellulose, methacrylzuur-methyl methacrylaat (1:2) copolymeer, macrogol 400, tlk, gelatine, titnium dioxide, zovarte ijzeroxide en erythrosine. Tambocor- ampullen bevatten 15 ml injectievioeistof met 10 mg/ml flecainide-acetoat, bestemd voor intraveneuze toediening. Indicatles Behandeling van re-entry tachycardle, uitgaande van de AV-knoop. Aritmieen geassocieerd met Wboff-Parkinson-White syndroom en gelijksoortige condities met bijbehorende geleiding. Symptomatisch sustained ventriculaire tachycardieen. Premature ventriculaire contr-acties en/of non-sustained ventriculaire tachycardie melke invaliderende symptomen veroorzaken indien deze resistent zijn Lov. andere therapieen of wanneer andere therapieen niet goed worden verdragen. Onderhouden van een normaal hartritme na conversie via andere middelen. Behoud van sinusrinme na conversie van acuut paroxismaal boezemfibrilleren, indien er sprake is van een duidelijke noodzaak tot behandelen als gevoig van ernstige klinische symptomen. Sructureel hartlijden en/of een slechte linkeroamerfunctie dient daarbij uitgesloten te ziin, vanwege de toegenomen kons op pro-aritmisch risico. Dosering on wioze van toodioning- Suprevntkucolire arismiteni: De aanbevolen begindosering is 100 mg per dag. Een dosisverhoging zou pas na een periode van 4 tot 5 dagen overwogen moeten worden. De optimale dosis is 200 mg per dag. Indien nodig bon de dosering worden verhoogd tot een maximum van 300 mg per dag. Ventricuitre arotrneen: De aanbevolen begindosering is 200 mg per dag. De maximale dosering bedraagt 400 mg per dag en deze dosering wordt gewoonlijk toegepast bij patdenten met een groot postuur of indien snelle coupering van de aritmie vereist is.Aanbevolen wordt de dosering na 3-5 dagen stapsgewijs te verdgen tot de laagst mogelijke dosering waarmee de ritmestoomnis nog te couperen is. Zo nodig bon ti/dens langdurige behandeling de dosering verlaagd worden. Contra-Indicaties: Bekende overgevoeligheid voor flecoinide of voor een van de overige bestanddelen non de capsule, hartfalen en myocardinfarct (in de anamnese), met asymptomatische venuticulire ectopia of asymptomatische ventriculire tachycardieen. Patinten met reeds langer bestaande boezemfibrillatie bij wie er geen poging is ondernomen om het sinusritme te veranderen en patienten met hemodynamisch significante hartklepziekten. Waarschuwlngen en voorzorgen: Behandeling met flecainide dient klinisch te worden ingesteld en doseringsaanpassingen dienen klinisch doorgevoerd on worden onder contcole van ECG en plasmaspiegel. Intercties: Gelijktijdig gebruik met andere naoriumkanaal blokkers wordt tint aanbevooen. Behandeling met fbecanide is verenigbaar met het gebruik van orale anticoagulantia. Zwangerschy>: Over het gebruik van fleciinide in de zwangerschap bij de mens bestaan onvoldoende gegevens om de mogelijke schadelijkheid te beoordelen. Lactatie: Flc/inide wordt in de moedermelk uitgescheiden.Vanwege de lage totale dosis die neonaat met de moedermelk krijgt toegediend, is de bons op nadelige effecten erg klein. BIjw.rldngen: Pro-aritmische affecten zijn waargenomen bij sommige paointen met structureel hardijden en/of een slechte linkerkomerfunctie. Er zijn geisoleerde gevallen van fotosensidoviteit gemeld.Allergische huidreactes, waaronder zeldzame gevallen van emstdge urticaria. Vooral duizeligheid, draaierigheid en licht gevoel in het hoofd komen voor. Fanecuotloche voorzorgen: Bemaren bij een temperatuur onder de 25 'C. De ampullen in het donker bewaren. Afleversnttus: UR. Tambocorn mordt vergoed.Voor prijzen zie KNMP taxe.Voor nadere informatie overTambocor verwsijzen wij naar de geregistreerde deel B tekst. 3M Pharma Nederland B.., Leiden, d.d. 6 juni 2002 en 10 juni 2002.
3M Pharma 3M Pharma Nederland BY Postbus 193, 2300 AD Leiden. Tel.: (071 ) 54 50 492
fTAMBOCORCR
Netherlands Heart Joumal, Volume 11, Number 11, November 2003
Mechanically induced complete atrioventricular block during retrograde catheter ablation of a left-sided incessant tachycardia A.E. van den Bosch, L.J. Jordaens
Concern for potentially letial complications related to ternsseptal catheterisation, such as perforation ofthe aorta, has made this approach less attactive over the last decades. Neverthdess, this method is now increasingly being used for ablation of leftsided arrhythumias. We report a transient complication of a retrograde procedure in a patient with a left-sided 'Coumel-type' incessant tachycardia. We had to proceed to transsweptal catheterisation, as the complication recurred during the second attempt even when using a less rigid transaortic radiofrequency catheter. The transseptal approach using a less stiff cryoenergy catheter was perforned without complications. (Neth HeartJ
2003;11:469-72.)
Key words: left-sided atrioventricular accessory pathways, transseptal catheterisation A ccessory (AV) may I'Dbe located anywhere along the left or right wall of atrioventricular
connections
the heart or within the septum. Since the introduction of radiofrequency catheter ablation, it has become possible for cardiologists to effectively ablate accessory pathways. It even became the therapy ofchoice. The predominance of left-sided accessory pathways has renewed interest in transseptal catheterisation over the last decade. Earlier comparisons of the transseptal and retrograde transaortic approaches for radiofrequency catheter ablation ofleft-sided accessory pathways was shown to be both safe and successful in the vast majority of the patients.' The aim of this case report is to demonstrate a potential advantage of transseptal A.E. van den Bosch. U. Jordm. Erasmus Medical Centre, Thoraxcentre, Department of Clinical Electrophysiology, PO Box 2060, 3000 CB Rotterdam.
Address for correspondence: A.E. van den Bosch. E-mail: [email protected]
Netherands Heart Journal, Volunie 11, Number 11, November 2003
catheterisation compared with the retrograde transaortic approach for catheter ablation of left-sided arrhythmias. Case prsentatin A 52-year-old woman presented with incessant tachycardia based on an orthodromic conducting accessory atrioventricular pathway. Although the patient claimed to have no symptoms, she could not fully compete with her age peers. The patient had a history of this arrhythnia since the age of 16 years and had completely adapted to her high heart rate. With a low heart rate she felt uncomfortable and triggered the tachycardia with a Valsalva manoeuvre. On admission she was not on any regular medication, although she had taken multiple antiarrhythmic drugs for several years without suppression of the arrhythmia. On physical exanination we found a blood pressure of 150/95 mmHg, a regular heart rate of 130 beats/ min and normal venous pressure. Auscultation of the heart revealed a fixed second heart sound with no additional clinical abnormalities. The electrocardiogram (ECG) showed a tachycardia of 130 beats/min with narrow QRS complexes, normal QRS axis and a negative P wave in II, III and aVF (figure LA). The P wave was biphasic or isoelectric in I, and V4 to V6. There were minimal voltage criteria for left ventricular hypertrophy. On the chest X-ray the heart was not enlarged, the C/T ratio waslO.5/23. Echocardiography showed a mildly depressed left ventricular function with normal dimensions of the heart (LVEDD 56 mm, LVESD 40 mm) and a slightly elevated right ventricular pressure of 35 mmHg. A reciprocating tachycardia with long retrograde conduction time was suspected, also because of the incessant character.2
Electrophyskogy procedure All surface ECG and intracardiac signals were recorded on a digital acquisition system (Prucka Engineering, Inc). Three multi-electrode catheters were inserted through a right femoral venous access. A quadripolar 469
Mechanically induced complete atrioventricular block during retrograde catheter ablation of a left-sided incessant tachycardia
Conductr, Medtronc Inc.) and showed later activation ofthe tachycardia at the bundle of His, the mid-septal segment and under the ostium of the coronary sinus. After retrograde transaortic insertion the earliest retrograde activity was rather near CS 5-6 (figure 2). While introducing the catheter through the aortic valve to the left ventride, a total atrioventricular block was created through mechanical manipulation ofthe normal conduction system (figure 3). At the same time the circus movement tachycardia stopped and intraventricular conduction delay became present with a superior left axis of -90°. The tachycardia could not be reinitiated by pacing or by 0.5 mg atropine intravenously. The procedure was ended. Within two hours, however, the circus movement tachycardia recurred with a left bundle branch block morphology. A second session was performed two days later. A diagnostic decapolar catheter was placed in the coronary sinus and earliest activation ofthe accessory pathway was again found at CS 5-6. After swift introduction ofa 7 Fr ablation catheter (Webster Cordis B-curve) through the aortic valve, the atrioventricular block again returned. The escape rhythm was wide with disappearance of the circus movement tachycardia. Given the experience ofthe first session, we continued the procedure and the retrograde catheter was removed. A transseptal puncture was performed under intracardiac echocardiographic guidance - (ICE 9900 catheter, Boston Scientific Inc.).3 With !.-2 the cryothermal ablation catheter 'ice mapping' (freezing to -30°, presumed reversible) was carried out from the atrial side at a spot preceding the earliest CS activation by 7 ms (figures 4 and 5). After 44 seconds the tachycardia terminated (figure 6). When the ablation was stopped, the tachycardia recurred immediately. Focal ablation was done with a temperature of-750C. After 10 seconds the tachycardia terminated. A double Figure IB. The ECG after the sece Figure IA. The ECG on adfreeze thaw at the same spot was performed. EP session, showing normal sii nus The electrocardiogram at discharge showed mission shows atrioventricular tachycardia with negative P rhytm witha k.ft bundle branchbihck continuous sinus rhythm with normal atriowaves in kads II, III and aVF. moiphology. ventricular conduction but a persisting left bundle branch block (figure 1B). Two months after the ablation, she visited the outpatient clinic with a persistelectrode catheter (Vlking Courmand, Bard Electroing LBBB, and no complaints: she revealed that she had physiology Billarica) was introduced to record a stable had to adapt to the new rhythm, but overall felt better. His potential. A bipolar pacing catheter (Medtronic Inc.) was positioned in the right ventricular apex. A 6 Dscussion Fr decapolar electrode catheter (Supreme CS, Daig Reciprocating atrioventricular tachycardia with a long Corp, St Jude Medical Inc.) was advanced through retrograde conduction time has been described in the left subclavian vein and positioned in the coronary sinus. A LocaLisa system (Medtronic Inc.) was used for patients who often develop incessant or permanent the 3D localisation ofthe mapping/ablation catheter. tachycardia, because ofthis long retrograde conduction time.4'5 The atrial exit is very often located posteroseptalThe earliest retrograde activity of circus movement ly at the left side (inferior paraseptal in the new tachycardia was found at CS 7-8, near the ostium of nomenclature).4-6 This case was uncommon, because the coronary sinus. Mapping of the target sites was of its relative lateral (or true posterior) position. done with the 8 Fr ablation catheter (Medtronic 470
Netherlands Heart Journal, Volume 11, Number 11, Novanber 2003
Mechanically induced complete atrioventricular block during retrograde catheter ablation of a left-sided incessant tachycardia
Figure 2. Fluowpic image during tranaortic approach, showing the positions of the catheters by which a totalAVblock was induced. (CS=coronarysinus catheter, AbL=ablation catheter, RVcath=brght ventricular pacing catheter.)
Retrograde transaortic catheterisation is the most frequently used approach for ablation of atrioventricular bypass tracts. It requires arterial puncture and placement ofthe ablation catheter in the left ventricle. Therefore, the ablation catheter has to be bent and positioned over the atrioventricular groove to detect the endocardiac insertion of the accessory pathway. This technique is not always easy to perform, and
Figure 4. Fluoroscopic image of the transseptal approach, showing the positions of the catheters at ablation site. (CS=ncoronary sinus
catheter, Abl=ablation catheter.)
preshaped or steerable catheters can facilitate the procedure. Especially the paraseptal location can be very difficult. Thereby, this approach has a few other shortcomings, including the possibility that the aorta and its valvular structures are damaged. Late endocarditis has been described. Further, damage to the normal conduction system as observed in this case report is a possibility.
1.
Figure 3. ECG when total AVblock occurred.
Netherlands Heart Joumal, Volume
II,
Number 11, November 2003
Figure 5. ECG obtained before the ablation, showing two beats in surface ECG leads I and V1 and the endocardial recording from the coronary sinus catheter. The earliest activation is seen at CS 56. The ablation signal precedes this by 7 ms.
471
Mechanically induced complete atrioventricular block during retrograde catheter ablation of a left-sided incessant tachycardia
References 1 2
21CS 940 LO
B -3
2CS 758 2
LI L L
L
4
I LlLI 11_ I_LsLL _LL
K2.ii4
24-C
'CS:2l
34
5
504. 6
Figure 6. ECG and endocardial recording obtained after successful ablation of the atrioventricular accessory pathway. 7
Transseptal catheterisation, already described in 1957,7 is a demanding procedure and the operator's experience seems to play a major role in minimising the occurrence of complications. Concern for the potentially lethal complications related to transseptal catheterisation, such as perforation of the aorta, led to an underuse of this procedure. In the last decade comparisons of the transseptal with the retrograde transaortic approach for radiofrequency catheter ablation renewed the interest in this approach.8 During transseptal ablation, the catheter has direct access to the mitral ring and left atrial walls. This facilitates both manipulation during mapping and catheter stability during radiofrequency energy delivery. In the second session we used the novel technique of cryothermal ablation.9 A cryocatheter should also be positioned in firm contact with the desired spot to guarantee good cooling and to avoid dissipation ofthe cold in the blood stream. This becomes easier with transseptal puncture. On top of this, the shaft of the cryo-catheter is less stiff than the generally used radiofrequency catheter. While this is a disadvantage for a retrograde approach to difficult areas, it becomes an advantage when vulnerable structures as the conduction system are mechanically blocked. Further, cryoablation may have additional advantages when lesions are required adjacent to sensitive structures and may result in less tissue destruction at ineffective sites. Conclusion The elective use of transseptal catheterisation can be preferred over the transaortic approach in patients with left-sided accessory pathways, certainly when the location is paraseptal. Mechanical heart block is a wellknown complication of retrograde catheterisation. The combination of transseptal techniques with more focused energy as cryoablation may help to avoid collateral damage. a
472
Calkins H. Radiofrequency catheter ablation of supraventricular arrhythmias. Heart2001;85:594-600. Brugada P, Farre J, Green M, Heddle B, Roy D, Wellens HJ. Observations in patients with supraventricular tachycardia having a P-Rinterval shorter than the R-P interval: differentiation between atrial tachycardia and reciprocating atrioventricular tachycardia using an accessory pathwaywith long conduction times. Am Heart J 1984;107:556-70. Szili-Torok T, Kimman G, Theuns D, Res J, Roelandt JR, Jordaens LJ. Transseptal left heart catheterisation guided by intracardiac echocardiography. Heart 2001;86:E1 1. Farre J, Ross D, Wiener I, Bar FW, Vanagt EJ, Wellens HJ. Reciprocal tachycardias using accessory pathways with long conduction times. AmjCardiol 1979;44:1099-109. Stein ML, Stone FM, Benditt DG. Incessant atrial tachycardia in childhood: association with rate-dependent conduction in an accessory atrioventricular pathway. AmJ Cardiol 1979;44:498-
8 9
Cosio FG, Anderson RH, Becker A, Borggrefe M, Campbell RW, Gaita F, et al. Living anatomy of the atrioventricular junctions. A guide to electrophysiological mapping. A Consensus Statement from the Cardiac Nomenclature Study Group, Working Group of Arrhythmias, European Society ofCardiology, and the Task Force on Cardiac Nomenclature from NASPE. North American Society of Pacing and Electrophysiology. Eur HeartJ 1999;20:1068-75. Manfredi D. Un nuovo catetere per lo studio fisiopatologico del cuore sinistro. Arch Ital Chir 1957;81:409-16. De Ponti R, Zardini M, Storti C, Longobardi M, Salemo-Uriarte JA. Trans-septal catheterization for radiofrequency catheter ablation of cardiac arrhythmias. Eur Heartj 1998;19:943-50. Skanes AC, Dubuc M, Klein GJ, Thibault B, Krahn AD, Yee R, et al. Cryothermal Ablation ofthe Slow Pathway for the Elimination of Atrioventricular Nodal Reentrant Tachycardia. Circulation
2000;102:2856-60.
U.'
-
..
0
TAMBOCORTh Verkorte productinformatie Sarnensteillng De tableten bevatten 50 of 100 mg flecainide-aceoaat en als hulpstoffen croscarmellose natrium, magnesiumstearaat, gepreelatiniseerd mans zetmeel, gehydrogeneerde plantaardige olie en microkrisalliine cellulose. (E460) De capsules beatten 100, 150 of 200 mg flecinide-acetaat en als hulpstoffen o.m.microkristllijne cellulose, methacrylzuur-methyl methacrylaat (1:2) copolymeer, macrogol 400, tlk, gelatine, titnium dioxide, zovarte ijzeroxide en erythrosine. Tambocor- ampullen bevatten 15 ml injectievioeistof met 10 mg/ml flecainide-acetoat, bestemd voor intraveneuze toediening. Indicatles Behandeling van re-entry tachycardle, uitgaande van de AV-knoop. Aritmieen geassocieerd met Wboff-Parkinson-White syndroom en gelijksoortige condities met bijbehorende geleiding. Symptomatisch sustained ventriculaire tachycardieen. Premature ventriculaire contr-acties en/of non-sustained ventriculaire tachycardie melke invaliderende symptomen veroorzaken indien deze resistent zijn Lov. andere therapieen of wanneer andere therapieen niet goed worden verdragen. Onderhouden van een normaal hartritme na conversie via andere middelen. Behoud van sinusrinme na conversie van acuut paroxismaal boezemfibrilleren, indien er sprake is van een duidelijke noodzaak tot behandelen als gevoig van ernstige klinische symptomen. Sructureel hartlijden en/of een slechte linkeroamerfunctie dient daarbij uitgesloten te ziin, vanwege de toegenomen kons op pro-aritmisch risico. Dosering on wioze van toodioning- Suprevntkucolire arismiteni: De aanbevolen begindosering is 100 mg per dag. Een dosisverhoging zou pas na een periode van 4 tot 5 dagen overwogen moeten worden. De optimale dosis is 200 mg per dag. Indien nodig bon de dosering worden verhoogd tot een maximum van 300 mg per dag. Ventricuitre arotrneen: De aanbevolen begindosering is 200 mg per dag. De maximale dosering bedraagt 400 mg per dag en deze dosering wordt gewoonlijk toegepast bij patdenten met een groot postuur of indien snelle coupering van de aritmie vereist is.Aanbevolen wordt de dosering na 3-5 dagen stapsgewijs te verdgen tot de laagst mogelijke dosering waarmee de ritmestoomnis nog te couperen is. Zo nodig bon ti/dens langdurige behandeling de dosering verlaagd worden. Contra-Indicaties: Bekende overgevoeligheid voor flecoinide of voor een van de overige bestanddelen non de capsule, hartfalen en myocardinfarct (in de anamnese), met asymptomatische venuticulire ectopia of asymptomatische ventriculire tachycardieen. Patinten met reeds langer bestaande boezemfibrillatie bij wie er geen poging is ondernomen om het sinusritme te veranderen en patienten met hemodynamisch significante hartklepziekten. Waarschuwlngen en voorzorgen: Behandeling met flecainide dient klinisch te worden ingesteld en doseringsaanpassingen dienen klinisch doorgevoerd on worden onder contcole van ECG en plasmaspiegel. Intercties: Gelijktijdig gebruik met andere naoriumkanaal blokkers wordt tint aanbevooen. Behandeling met fbecanide is verenigbaar met het gebruik van orale anticoagulantia. Zwangerschy>: Over het gebruik van fleciinide in de zwangerschap bij de mens bestaan onvoldoende gegevens om de mogelijke schadelijkheid te beoordelen. Lactatie: Flc/inide wordt in de moedermelk uitgescheiden.Vanwege de lage totale dosis die neonaat met de moedermelk krijgt toegediend, is de bons op nadelige effecten erg klein. BIjw.rldngen: Pro-aritmische affecten zijn waargenomen bij sommige paointen met structureel hardijden en/of een slechte linkerkomerfunctie. Er zijn geisoleerde gevallen van fotosensidoviteit gemeld.Allergische huidreactes, waaronder zeldzame gevallen van emstdge urticaria. Vooral duizeligheid, draaierigheid en licht gevoel in het hoofd komen voor. Fanecuotloche voorzorgen: Bemaren bij een temperatuur onder de 25 'C. De ampullen in het donker bewaren. Afleversnttus: UR. Tambocorn mordt vergoed.Voor prijzen zie KNMP taxe.Voor nadere informatie overTambocor verwsijzen wij naar de geregistreerde deel B tekst. 3M Pharma Nederland B.., Leiden, d.d. 6 juni 2002 en 10 juni 2002.
3M Pharma 3M Pharma Nederland BY Postbus 193, 2300 AD Leiden. Tel.: (071 ) 54 50 492
fTAMBOCORCR
Netherlands Heart Joumal, Volume 11, Number 11, November 2003
