Europace Advance Access published online on May 6, 2008
Europace, doi:10.1093/europace/eun120
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
CASE REPORT
Radiofrequency catheter ablation of atrioventricular nodal reciprocating tachycardia using intracardiac echocardiography in pregnancy
Maria Grazia Bongiorni,
Andrea Di Cori*,
Ezio Soldati,
Giulio Zucchelli,
Luca Segreti,
Gianluca Solarino,
Raffaele De Lucia and
Mario Marzilli
Cardiac and Thoracic Department, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
Manuscript submitted 25 March 2008. Accepted after revision 14 April 2008.
* Corresponding author. Tel: +39 050 995333; fax: +39 050 995327. E-mail address: a.dicori{at}virgilio.it
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Abstract
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We describe a case report of a 32-year-old woman during the
10th week of pregnancy with symptomatic and recurrent atrioventricular
nodal reciprocating tachycardia successfully treated by conventional
radiofrequency ablation, under intracardiac echocardiography
surveillance.
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Introduction
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Conventional radiofrequency (RF) treatment for drug refractory
paroxysmal supraventricular tachycardia occurring during pregnancy
arises concerns about the foetus exposure to radiation and should
be avoided if possible, especially during the first trimester.
1
We describe the case of a pregnant woman with a drug-refractory, poorly tolerated atrioventricular nodal reciprocating tachycardia (AVNRT) successfully treated by RF ablation with intracardiac echocardiography (ICE) guiding and without radiation exposure.
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Case report
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A 32-year-old woman presented at the 10th week of pregnancy
with poorly tolerated, recurrent palpitations and multiple admissions
at the emergency department, where the electrocardiogram documented
episodes of narrow QRS complex tachycardia (heart rate 170 bpm.)
with regular RR interval and no P-waves evidence. Owing to the
patient refusal of pharmacological therapy, a decision was made
to attempt RF catheter ablation of the tachycardia under ICE
surveillance, in order to avoid fluoroscopy and X-ray exposure.
The procedure was performed in the EP laboratory. Intracardiac echocardiography was performed using a commercially available 9F–9 MHz Ultra ICE catheter-based ultrasound transducer (EP Technologies, Boston Scientific Corp., San Jose, CA, USA). The Ultra ICE catheter was introduced percutaneously into the left femoral vein through a 55° precurved polyethylene long venous sheath (Convoy, EP Technologies, Boston Scientific Corp., San Jose, CA, USA) to guide the advancement of a quadripolar catheter (Spike ultra 4R/6 J 125, Fiab, Florence, Italy) and a 4-mm-tip ablation catheter (Cerablate Easy, Osypka Medical, Berlin, Germany) along the venous system (Figure 1) and in the heart chambers (Figure 2). Using two atrial extra-stimuli, a dual pathway conduction was demonstrated with the initiation of AVNRT (Figure 3). Three RF applications were delivered at the posterior portion of the Koch's triangle, where a slow potential was recorded. At the end of the procedure and 30 min later, AVNRT was no longer inducible both without and with isoproterenol infusion. Total procedural time was 80 min. Neither complications were associated with the procedure or overt effect was noted on the foetus.
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Figure 1 Intracardiac echocardiography imaging during the catheters advancement in the venous system. Intracardiac echocardiography guided the catheters advancement from the right femoral venous entry site, through the IVC (A and B), into the RA (C).
AO, aorta; CS, coronary sinus; FO, fossa ovalis; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; and TV, tricuspide valve.
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Figure 2 Intracardiac echocardiography imaging during electrophysiological study and radiofrequency ablation. (A) Upper right atrium level with the atrial catheter positioned at the level of interatrial septum. (B) Tricuspide valve level with the catheter position in the right ventricle. (C) Tricuspide valve level with the catheter pullback from the right ventricle to the region of His bundle. (D) Tricuspide valve level with catheter position in the posterior region of Koch's triangle.
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Discussion
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There are only a few reported cases of RF ablation in pregnant
women, mostly performed with fluoroscopy guiding; more recently,
a strict radioactive dosimeter surveillance and a three-dimensional
mapping system approach have been successfully used.
2,3 In patients
with AVNRT, ICE may facilitate slow pathway ablation, because
it can clearly visualize the structures in and around Koch's
triangle, and may be useful in locating the ablation tip and
the endocardial contact, obviating the need for fluoroscopy.
4,5 To the best of our knowledge, this is the first report describing
a RF ablation of a AVNRT with ICE guiding and without fluoroscopic
exposure during the first trimester of pregnancy. In conclusion,
ICE-guided RF catheter ablation could be an alternative approach
in highly symptomatic patients with AVNRT whenever patient conditions
suggest to avoid X-ray exposure.
Conflict of interest: none declared.
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References
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[1] Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, et al. European Society of Cardiology Committee, NASPE-Heart Rhythm Society. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary. A report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol (2003) 42:1493–531.
[Free Full Text][2] Berruezo A, Díez GR, Berne P, Esteban M, Mont L, Brugada J. Low exposure radiation with conventional guided radiofrequency catheter ablation in pregnant women. Pacing Clin Electrophysiol (2007) 30:1299–302.[CrossRef][Medline]
[3] Kozluk E, Piatkowski R, Lodzinski P, Tokarczyk M, Kurowski A, Kochanowski J, et al. Radiofrequency ablation without fluoroscopy in pregnant with permanent junctional re-entrant tachycardia. Europace (2005) 7:28.[Abstract/Free Full Text]
[4] Fisher WG, Pelini MA, Bacon ME. Adjunctive intracardiac echocardiography to guide slow pathway ablation in human atrioventricular nodal reentrant tachycardia: anatomic insights. Circulation (1997) 96:3021–9.[Abstract/Free Full Text]
[5] Batra R, Nair M, Kumar M, Mohan J, Shah P, Kaul U, et al. Intracardiac echocardiography guided radiofrequency catheter ablation of the slow pathway in atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol (2002) 6:43–9.[CrossRef][Web of Science][Medline]
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Abstract
Introduction