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: Purpose To demonstrate the feasibility of comprehensive assessment of cardiac arrhythmias by combining body surface electrocardiographic (ECG) mapping (BSM) and imaging. Materials and Methods This study was approved by the institutional review board, and all patients gave written informed consent. Twenty-seven patients referred for electrophysiologic procedures in the context of ventricular tachycardia (VT) (n = 9), Wolff-Parkinson-White (WPW) syndrome (n = 2), atrial fibrillation (AF) (n = 13), or scar-related ventricular fibrillation (VF) (n = 3) were examined. Patients underwent BSM and imaging with multidetector computed tomography (CT) (n = 12) and/or delayed enhanced magnetic resonance (MR) imaging (n = 23). BSM was performed by using a 252-electrode vest that enabled the computation of epicardial electrograms from body surface potentials. The epicardial geometry used for BSM was registered to the epicardial geometry segmented from imaging data by using an automatic algorithm. The output was a three-dimensional (3D) cardiac model that integrated cardiac anatomy, myocardial substrate, and epicardial activation. Results Acquisition, segmentation, and registration were feasible in all patients. In VT, this enabled a noninvasive assessment of the arrhythmia mechanism and its location with respect to the myocardial substrate, coronary vessels, and phrenic nerve. In WPW syndrome, this enabled understanding of complex accessory pathways resistant to previous ablation. In AF and VF, this enabled the noninvasive assessment of arrhythmia mechanisms and the analysis of rotor trajectories with respect to the myocardial substrate. In all patients, 3D models were successfully integrated in navigation systems and used to guide mapping and ablation. Conclusion By combining information on anatomy, substrate, and electrical activation, the fusion of BSM and imaging enables comprehensive noninvasive assessment of cardiac arrhythmias, with potential applications for diagnosis, prognosis, and ablation targeting. © RSNA, 2013 Online supplemental material is available for this article.Radiology 12/2013; · 6.21 Impact Factor
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ABSTRACT: The coronary cusps have been well described as a successful site for ablation in patients with symptomatic outflow tract ventricular tachycardia. The earliest site of activation is rarely found at the ostia or into the main coronary arteries. The exact anatomic substrate, diagnostic characteristics, and therapeutic approaches for such instances are poorly understood. We retrospectively reviewed outflow tract ventricular arrhythmia (OTVA) ablations done at Mayo Clinic Rochester from 2003 to 2011 (total VT: 414; outflow tract VT: 106). Three cases were identified where the earliest site of activation was not within the cusp but rather at or within the coronary ostia (3/414 for all VT: 0.7%; 3/106 for all OTVT: 2.8%). In 1 patient, the left main coronary artery (LMCA) was found to have electrograms (EGMs) recorded with bipolar mapping that preceded activation in the cusps or the left ventricular outflow tract. In 2 cases, the right coronary ostium and proximal right coronary artery recorded the earliest signals. Intracardiac echocardiographic guidance was used to successfully ablate these arrhythmias targeting the aortic route (1 patient) or the right coronary cusp (2 patients), and essentially isolated the focus of origin from the ventricular outflow tracts. Detailed mapping of surrounding structures, including the atrial appendages, the contralateral outflow tract, and the coronary venous system excluded far-field mapping in the artery as a cause for early activation at the ostial location. Local EGM characteristics suggested an unusually lengthy supravalvar myocardial extension as the likely arrhythmogenic substrate. Ablation was successful without coronary arterial or valvular injury and without valvular or root stenosis. Endocardial ablation isolating foci of origin in the vicinity of the coronary ostia is a challenging procedure but can be performed safely with appropriate visualization and is effective in the treatment of OTVA.Journal of Cardiovascular Electrophysiology 08/2013; · 3.48 Impact Factor
- Archivos de cardiología de México 08/2014;