Wolff-Parkinson-White ablation after a prior failure: a 7-year multicentre experience.
ABSTRACT Catheter ablation for Wolff-Parkinson-White syndrome (WPW) can be challenging and is associated with failure in approximately 1-5% of cases. We analysed the reasons for failure.
All patients (89 patients, 28 +/- 16 years old) referred for WPW ablation after a prior failure were studied. Reasons for the prior failure as well as for the acute success were analysed. The repeat procedure was successful in 81 (91%) patients. Multiple (2.7 +/- 0.9) or large accessory pathways (APs) were seen in 13 patients. For left lateral APs, inaccurate mapping and lack of transseptal access during the index procedure accounted for failure (n = 15). An irrigated-tip catheter was required for epicardial APs (n = 7). In addition, seven posteroseptal APs required bi-atrial and coronary sinus (CS) applications in order to succeed. For parahisian and midseptal APs, radiofrequency was cautiously titrated from 5 to 30 W, eliminating the AP in three patients. Cryoablation was used in seven patients (acute success in six but delayed recurrences in three of these). For patients with CS AP, irrigated ablation in the CS was crucial to deliver adequate power. For anteroseptal and right lateral APs, a successful outcome was achieved with long sheaths (n = 5) or a left subclavian approach (anteroseptal, n = 4).
Failure in WPW ablation may be due to a variety of reasons but catheter manipulation and inaccurate mapping remain the two major causes. Knowledge of the reasons for failure depending on the location of the WPW may facilitate a successful outcome.
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ABSTRACT: Coronary Vein Accessory Pathways. Introduction: Some posteroseptal accessory pathways (APs) can be successfully ablated by radiofrequency current only from inside the coronary sinus (CS) or its branches, because of an absolute or relatively epicardial location. The aim of this study was to identify ECG features of manifest posteroseptal APs requiring ablation in the CS or the middle cardiac veins (MCVs).Methods and Results: One hundred seventeen consecutive patients with manifest posteroseptal APs successfully ablated: (1) ≥ 1 cm deep inside the MCV (group MCV: n = 13); (2) inside the CS, including the area adjacent to the MCV ostium (group CS: n = 10); (3) at the right (group R: n = 60); or (4) the left posteroseptal endocardial region (group L: n = 34) were included. We reviewed delta wave polarity (initial 40 msec) and QRS morphology during sinus rhythm and atrial pacing as well as electrogram characteristics in these patients. The local target site electrogram in groups MCV and CS was characterized by a longer atrial to ventricular electrogram interval, suggesting a longer course of the pathway and more frequent recording of a presumptive AP potential compared to the group ablated at the right or left endocardium. The most sensitive ECG feature for group CS or group MCV was a negative delta wave in lead II in sinus rhythm (87%), but specificity (79%) and positive predictive value (50%) were relatively low. A steep positive delta wave in aVR during maximal preexcitation possessed the highest specificity and positive predictive value (98% and 88%, sensitivity 61%) which increased to 99% and 91%, respectively, when combined with a deep S wave in V6 (R wave ≤ S wave).Conclusion: These data suggest that posteroseptal APs ablated inside the coronary venous system have highly specific features, including the combination of a steep positive delta wave in lead aVR and a deep S wave in lead V6 (R wave ≤ S wave) during maximal preexcitation. The highest sensitivity is provided by a negative delta wave in lead II. These findings may be helpful for anticipating and planning an epicardial ablation strategy.Journal of Cardiovascular Electrophysiology 09/1998; 9(10):1015 - 1025. · 3.48 Impact Factor
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ABSTRACT: Patients with accessory pathway-mediated supraventricular tachycardia have typically been treated with drugs or surgery. Although catheter ablation using high voltage direct current shocks has been used to treat patients with drug-refractory supraventricular tachycardia, there are associated disadvantages, including damage due to barotrauma as well as the need for general anesthesia. Recently, transcatheter radiofrequency energy has evolved as an alternative to direct current shock or surgery to ablate accessory pathways. Percutaneous catheter ablation of 109 accessory pathways with use of radiofrequency energy was attempted in 100 consecutive patients. Patient age ranged from 3 to 67 years. The patients had been treated for recurrent tachycardia with a mean of 2.7 +/- 0.2 antiarrhythmic agents that either proved ineffective or caused unacceptable side effects. In seven patients previous attempts at accessory pathway ablation with use of direct current shock had been unsuccessful. Forty-five (41%) of the pathways were left free wall, 43 (40%) were septal and 21 (19%) were right free wall. Eighty-nine (89%) of the 100 patients had successful radiofrequency ablation at the time of hospital discharge. In all but 12 patients the ablation was accomplished in a single session. Complications attributable to the procedure, but not to the ablation itself, occurred in four patients (4%). No patient developed atrioventricular block or other cardiac arrhythmias. Over a mean follow-up period of 10 months, nine patients had some return of accessory pathway conduction; a repeat ablation procedure was successful in all five patients in whom it was attempted. It is concluded that a catheter ablation procedure using radiofrequency energy can be performed on accessory pathways in all locations. The procedure is effective and safer, less costly and more convenient than cardiac surgery and can be considered as an alternative to lifelong medical therapy in any patient with symptomatic accessory pathway-mediated tachycardia.Journal of the American College of Cardiology 06/1992; 19(6):1303-9. · 14.09 Impact Factor
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ABSTRACT: The aim of this study was to evaluate our results of radiofrequency catheter ablation (RFCA) of concealed accessory atrioventricular pathways (CP). We treated with RFCA 19 patients, with 21 CP, 10 men and 9 women, mean age 37 +/- 16 years, with supraventricular tachycardia (SVT) and absence of ventricular pre-excitation in the electrocardiogram (ECG). These patients comprised 50% of the patients who underwent RFCA for SVT and had no ventricular pre-excitation in the ECG. The diagnosis of CP was made by electrophysiologic study, based on the demonstration of a pathway capable of retrograde conduction only. The RFCA was performed without antiarrhythmic drugs in the same session of the electrophysiologic diagnosis. The location of the CP site was obtained by catheter mapping, looking for the earliest atrial retrograde activation during tachycardia or ventricular pacing. The CP had a right-sided location in only 2 patients who had an incessant form of SVT, the CP in these patients exhibit decremental conduction--permanent junctional reciprocating tachycardia. In the other patients the CP was left-sided, lateral in 11 patients, posterior in 3, postero-septal in 3 and medial septal in one patient. In 9 patients there was a simultaneous ventricular activation in the his bundle electrogram and in the electrogram of the ablation site, suggesting partial anterograde penetration of the stimuli on the accessory pathway. Success criteria were achieved in 18 patients (95%) corresponding to 20 CP. The prevalence of CP in the presence of SVT without ventricular pre-excitation is high, almost all left-sided. The CP displays eccentric atrial activation during SVT. It is possible that CP are capable of partial anterograde conduction as well. The success rate of RFCA is high.Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 03/1996; 15(2):111-7, 99. · 0.59 Impact Factor