Europace Advance Access originally published online on November 10, 2006
Europace 2006 8(12):1041-1044; doi:10.1093/europace/eul122
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ELECTROPHYSIOLOGY
Catheter ablation of anteroseptal accessory pathway in the non-coronary aortic sinus
II. Medizinische Abteilung, Asklepios Klinik St. Georg, Lohmühlenstraße 5, 20099 Hamburg, Germany
Manuscript submitted 3 April 2006. Accepted after revision 5 July 2006.
* Corresponding author. Tel: +49 40 2890 2305; fax: +49 40 2890 4444. E-mail address: ouyangfeifan{at}aol.com
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Abstract |
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We report a patient with atrioventricular reentrant tachycardia (AVRT) with bidirectional conduction over an anteroseptal accessory pathway (AP) who underwent successful ablation in the non-coronary aortic sinus (AS). In three previous attempts, the intracardiac recordings showed an anteroseptal AP with antegrade and retrograde conduction that failed to be ablated in spite of radiofrequency (RF) applications from the right and left anteroseptal regions. During the study, the earliest atrial activation during tachycardia was recorded in the non-coronary AS preceding the atrial activation at the His bundle (HB) region by 24 ms, and the anteroseptal AP was successfully blocked by one single ablation in the non-coronary AS. These data strongly suggest that careful mapping of an anteroseptal AP in the non-coronary AS may provide an alternative ablation approach in patients with previously failed ablation.
Key Words: Atrioventricular reentrant tachycardia, Accessory pathway, Catheter ablation, Aorta, Sinus of Valsalva
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Introduction |
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Atrioventricular reentrant tachycardia (AVRT), via an anteroseptal accessory pathway (AP), can be cured by catheter ablation by a conventional approach in the right atrium (RA).1
–5 Since anteroseptal APs are relatively rare and very close to the His bundle (HB) region, this approach is associated with a potential risk of complete atrioventricular block (AVB) during ablation.3–5 In patients with failed ablation of this AP, an unusual location of the AP insertion must be considered.6 In this report, we describe an anteroseptal AP that was successfully ablated in the non-coronary aortic sinus (AS). |
Case report |
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A 29-year-old male patient presented with Wolff–Parkinson–White syndrome (WPW) syndrome to our institution. The 12-lead ECG showed discrete preexcitation with a positive delta wave in I, II, III and aVF leads, and a positive delta wave in V1 and V2, suggesting an anteroseptal AP in sinus rhythm (SR) (Figure 1A), and a clinical tachycardia with complete right bundle branch block. He had previously undergone three electrophysiological studies and ablation procedures in our institution. All intracardiac recordings had shown an anteroseptal AP with antegrade and retrograde conduction (Figure 1B), which could not be ablated in spite of a total of >100 applications from the right and left atrial anteroseptal regions. After the last ablation, the antegrade effective refractory period of the AP remained <250 ms. Oral amiodarone of 200 mg/day was administrated to prevent recurrence. Interestingly, oral amiodarone blocked the antegrade conduction over the AP, and the clinical arrhythmia became incessant with a heart rate of 110–160 bpm. Subsequently, he developed tachycardia-induced cardiomyopathy with a left ventricular ejection fraction (EF) of 25%.
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The patient gave written informed consent. The ablation procedure was performed on oral amiodarone for 2 years and under sedation with a continuous infusion of 1% propofol. Three catheters were advanced and placed at the RA, the right ventricular apex (RVA), and the HB region via the femoral veins. Also, a 7-F multipolar catheter was advanced within the coronary sinus (CS) via the left subclavian vein. Bipolar and unipolar electrograms were filtered at 30–400 and 0.05—400 Hz, respectively. During the study, the surface ECG during SR showed complete right bundle branch block without preexcitation. The cycle length in SR was 1120 ms with an AH interval of 108 ms, and an HV interval of 54 ms at baseline. No antegrade conduction over the AP was found during atrial pacing. The clinical arrhythmia with a CL of 620 ms was easily and reproducibly induced by atrial and ventricular stimulation. Atrial and ventricular activation with fractionated components was recorded at the HB region during atrial pacing most likely due to previous ablations at these sites (Figure 2). During tachycardia, the earliest atrial activation was found at the HB region. Preexcitated atrial activation with a premature ventricular complex during the refractory period of the HB was demonstrated, which confirmed that the clinical arrhythmia was due to retrograde conduction over the AP in the anteroseptal region.
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On the basis of the anatomical relationship between the anteroseptal region and the non-coronary AS,7
–8 mapping in the AS was performed with a 4 mm tip 7-F mapping catheter (Biosense-Webster Inc, Diamond Bar, USA) via the right femoral artery. During tachycardia, the earliest atrial activation preceded the atrial activation at the HB region in the RA by 24 ms (Figure 2), and was located in the aortic root posterior to the HB in the RA. Importantly, no His potentials were recorded at this site. Radiofrequency (RF) energy with a thermocouple 4 mm tip (Biosense-Webster) was delivered at the site with the earliest atrial activation. RF energy with a target temperature of 55°C was started at 20 W and increased up to 35 W in the aorta under continuous fluoroscopy to reach the target temperature. A single RF delivery at the site successfully resulted in tachycardia termination after 15 s (Figure 3), and ventriculo-atrial dissociation during ventricular pacing. Aortic root angiography via a 5-F pigtail catheter showed the successful ablation site in the non-coronary AS (Figure 4). No evidence of dual atrioventricular node physiology and induction of AV nodal reentry tachycardia were found after ablation.
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No procedure-related complications occurred in this patient immediately after ablation or during 1 month of follow-up after ablation. However, the clinical tachycardia recurred 40 days after this successful ablation procedure. The same AP with only retrograde conduction was demonstrated during a repeat procedure, which was performed 42 days after the successful ablation. A single RF application with irrigated energy (30 W and infusion rate of 17 ml/min) was delivered in the non-coronary AS. This terminated the tachycardia and blocked the AP.
No tachycardia recurred off antiarrhythmic drugs during 7 months of further follow-up, and the left ventricular EF increased to 75% at 6 months after the last ablation procedure.
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Disscusion |
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Anteroseptal APs, defined as the APs situated above the HB with ventricular activation cephalad and anterior to the membranous septum, are relatively rare.3
–5 Previous studies have demonstrated that catheter ablation is the treatment of choice using the right atrial approach in symptomatic and drug-refractory patients.3–5 In our patient, mapping during the previously failed procedures showed that the earliest atrial activation during orthodromic tachycardia was always near the HB region in the RA in spite of a total of >100 RF applications at that site. This strongly suggested that an unusual location of the AP must be considered.
It has been reported that catheter ablation with conventional RF energy in all three ASs can be safely performed in patients with ventricular tachycardia or with focal atrial tachycardia.7–9 Recently, Tada et al.6 reported that in a patient with a concealed anteroseptal AP, the earliest atrial activation was simultaneously recorded at the HB region and in the non-coronary AS during tachycardia, and the AP was successfully ablated in the non-coronary AS without RF delivery at the RA. Our patient resembles the patient described by Tada et al.,6 but several features separate them. In the present study, the patient presented with bidirectional conduction over the AP before oral administration of amiodarone; the earliest atrial activation in the non-coronary AS preceded that at the HB region by 24 ms; and the anteroseptal AP was permanently ablated only from the non-coronary AS.
The anteroseptal AP described in this study could not be ablated despite three ablation procedures in the right and left atria, and lately recurred after successful ablation in the non-coronary AS with conventional energy. This case strongly suggests that it is deeply located in the epicardial region of the non-coronary AS, which is consistent with recent studies showing that there is myocardium located epicardially in the non-coronary AS.7,8 Irrigated RF ablation in the non-coronary AS was needed for ablating this anteroseptal AP, which has not been reported in other studies on catheter ablation in the ASs. Importantly, no complications occurred during the procedure or in 7 months follow-up, and left ventricular function became normal. This report strongly suggests that ablation of anteroseptal APs with irrigated energy in the non-coronary AS may provide an alterative approach in patients with failed conventional ablation.
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References |
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[1] Jackman WM, Wang X, Friday KJ, et al. Catheter ablation of accessory atrioventricular pathways (Wolff–Parkinson–White syndrome) by radiofrequency current. N Engl J Med 1991; 324: 1605–11.[Abstract]
[2] Kuck KH, Schlüter M, Geiger M, Siebels J, Duckeck W. Radiofrequency current catheter ablation of accessory atrioventricular pathways. Lancet 1991; 337: 1557–61.[CrossRef][Web of Science][Medline]
[3] Schlüter M and Kuck KH. Catheter ablation from right atrium of anteroseptal accessory pathways using radiofrequency current. J Am Coll Cardiol 1992; 19: 663–70.[Abstract]
[4] Kuck KH, Ouyang F, Goya M, Boczor S. Ablation of anteroseptal and midseptal accessory pathways. In Zipes DP and Haïssaguerre M (Eds.). Catheter Ablation of Arrhythmias 2002; Armonk, NY Futura pp. 305–20.
[5] Gatzoulis K, Apostolopoulos T, Costeas X, et al. Paraseptal accessory connections in the proximity of the atrioventricular node and the His bundle. Additional observations in relation to the ablation technique in a high risk area. Europace 2004; 6: 1–9.
[6] Tada H, Naito S, Nogami A, Taniguchi K. Successful catheter ablation of an anteroseptal accessory pathway from the noncoronary sinus of Valsalva. J Cardiovasc Electrophysiol 2003; 14: 544–6.[CrossRef][Web of Science][Medline]
[7] Ouyang F, Fotuhi P, Ho SY, et al. Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp: electrocardiographic characterization for guiding catheter ablation. J Am Coll Cardiol 2002; 39: 500–8.
[8] Ouyang F, Ma J, Ho SY, et al. Focal atrial tachycardia originating from the non-coronary aortic sinus: electrophysiological characteristics and catheter ablation. J Am Coll Cardiol 2006; 48: 122–31.
[9] Kanagaratnam L, Tomassoni G, Schweikert R, et al. Ventricular tachycardia arising from the aortic sinus of Valsalva: An under-recognized variant of left outflow tract ventricular tachycardia. J Am Coll Cardiol 2001; 37: 1408–14.
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