Circulation, Vol 89, 1074-1089, Copyright © 1994 by American Heart Association
MD Lesh, GF Van Hare, LM Epstein, AP Fitzpatrick, MM Scheinman, RJ Lee, MA Kwasman, HR Grogin and JC Griffin
BACKGROUND: Radio frequency catheter ablation is accepted therapy for
patients with paroxysmal supraventricular tachycardia and has a low rate of
complications. For patients with atrial arrhythmias, catheter ablation of
the His bundle has been an option when drugs fail or produce untoward side
effects. Although preventing rapid ventricular response, this procedure
requires a permanent pacemaker and does not restore the atrium to normal
rhythm. Therefore, we evaluated the safety and efficacy of radiofrequency
ablation directed at the atrial substrate. METHODS AND RESULTS:
Thirty-seven patients with 42 atrial arrhythmias (mean +/- SD age, 41 +/-
24 years) who had failed a median of three drugs were enrolled. Diagnoses
were automatic atrial tachycardia in 12, atypical atrial flutter in 1,
typical atrial flutter in 18, reentrant atrial tachycardia in 8, and sinus
node reentry in 3 patients. Sites for atrial flutter ablation were based on
anatomic barriers in the floor of the right atrium. For automatic atrial
tachycardia, the site of earliest activation before the P wave was sought.
All with reentrant atrial tachycardia had previous surgery for congenital
heart disease and reentry around a surgical scar, anatomic defect, or
atriotomy incision and our goal was to identify a site of early activation
in a zone of slow conduction. At target sites, 20 to 50 W of radiofrequency
energy was delivered during tachycardia between the 4- or 5-mm catheter tip
and a skin patch, except in 4 patients with atrial flutter, in whom a
catheter with a 10-mm thermistor-embedded tip was used. Procedure end point
was inability to reinduce tachycardia. Acute success was achieved in 11 of
12 (92%) with automatic atrial tachycardia, 17 of 18 (94%) with typical
atrial flutter, 7 of 8 (88%) with reentrant atrial tachycardia, and 3 of 3
(100%) with sinus node reentry but not in the patient with atypical atrial
flutter. For tachycardia involving reentry (reentrant atrial tachycardia
and atrial flutter), successful ablation required severing an isthmus of
slow conduction. For those with atrial flutter, this was between the
tricuspid annulus and the coronary sinus os (10) or posterior (4) or
posterolateral (3) between the inferior vena cava (2) or an atriotomy scar
(1) and the tricuspid annulus. Deep venous thrombosis occurred in 1
patient. At mean follow-up of 290 +/- 40 days, the ablated arrhythmia
recurred in 1 (9%) with automatic atrial tachycardia, 5 (29%) with atrial
flutter, and 1 (14%) with reentrant atrial tachycardia, all of whom had
successful repeat ablation. Previously undetected arrhythmias occurred in 2
patients who are either asymptomatic or controlled with medication.
CONCLUSIONS: Ablation of automatic and reentrant atrial tachycardia and
atrial flutter had a high success rate and caused no complications from
energy application. Repeat procedures may be required for long-term
success, especially in patients with atrial flutter. The mechanism by which
ablation is successful is similar for atrial flutter and other forms of
atrial reentry and involves severing a critical isthmus of slow conduction
bounded by anatomic or structural obstacles. Automatic arrhythmias are
abolished by directing lesions at the focus of abnormal impulse formation.
ARTICLES
Radiofrequency catheter ablation of atrial arrhythmias. Results and mechanisms
Department of Medicine, University of California, San Francisco 94143- 1354.
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