Approaches to empiric ablation of slow pathway: Results from the Canadian EP web survey

Arrhythmia Services, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite D-377, Toronto, ON, M4N 3M5, Canada.
Journal of Interventional Cardiac Electrophysiology (Impact Factor: 1.58). 07/2012; 35(2):183-7. DOI: 10.1007/s10840-012-9696-z
Source: PubMed


Dual atrioventricular nodal physiology (DAVNP) is a frequent finding in patients with suspected or documented supraventricular tachycardia (SVT). Empiric slow pathway ablation (ESPA) is sometimes performed in patients with DAVNP without inducible SVT at the time of electrophysiological study. Evidence to guide this practice in the adult population is limited. This study was aimed to assess the practice of ESPA by adult electrophysiologists in Canada.
All Canadian interventional electrophysiologists (n = 81) were invited to complete a web-based questionnaire assessing their practice of ESPA in patients with suspected and documented SVT. Operator experience, reimbursement models, diagnostic, and treatment decisions regarding ESPA were assessed with case scenarios.
Forty-one responses (50 %) were obtained. Ninety-five percent of the responders stated that the evidence for ESPA is lacking or limited. Responders were more likely to perform ESPA in the setting of non-inducible SVT when there was documentation of the clinical arrhythmia (64 vs. 31 % (p = 0.017)). The threshold to perform ESPA was highly variable. Longer time in practice (r = 0.38, p = 0.017) and less perceived complications with ESPA (r = 0.31, p = 0.05) were correlated with the practice of ESPA, whereas length of ablation waiting lists (r = -0.15, p = 0.38), number of procedures performed per day (r = 0.11, p = 0.51) and type of reimbursement (p = 0.24) were not associated with the practice of ESPA. The perceived complication rate with ESPA was <1 %.
Variability in the practice of ESPA in cases of non-inducible SVT exists. Documentation of the clinical arrhythmia, operator experience, and perceived low complication rates positively influence this practice.

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    ABSTRACT: Interventional cardiac electrophysiology (EP) has experienced a significant growth in Canada. Our aim is to establish a periodic registry as a nationwide initiative. The registry is designed to collect information regarding EP laboratory infrastructure, human resources, and the spectrum and volumes of EP procedures. Respective administrative staff were contacted electronically. Out of 25 identified Canadian EP centers, 19 centers (76 %) have participated in the registry. Responding centers have access on average to 5.3 lab days per week to perform EP studies/ablations; average lab time per full- and part-time (prorated to 0.5) EP physician is 0.8 day per week. Diagnostic EP studies and radio-frequency ablations are performed in all (19) centers; cryoablation is available in 83 % of centers. Two centers have remote magnetic navigation systems. EnSite NavX is the most widely available 3D mapping system utilized in 15 (83 %) centers, followed by CARTO and intracardiac echo which are each available in 14 (78 %) centers; LocaLisa is actively used in one center. The number of full-time physicians ranges between 0 and 7, with a mean of 3.5 full-time physicians per center. The ratio of staff to trainees is 1.6:1. A total of 8,041 EP procedures are performed in the 19 centers per annum. On an annual average, 104 procedures per one operator and 159 procedures per trainee are performed. This registry provides contemporary information on invasive EP lab resources and procedures in Canada. It also demonstrates that Canadian EP procedural intensities of practice and training are comparable to international standards.
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    ABSTRACT: Background: The data supporting the practice of empiric slow pathway ablation (ESPA) in patients with documented supraventricular tachycardia (SVT) who are non-inducible at electrophysiology study (EPS) is limited. The aim of this study is to assess the efficacy of ESPA in adults. Methods: A multi-center cohort study of patients who had ESPA between January 2008 and October 2013 was performed. Patients were identified by screening sequential SVT ablation procedures. Results: Forty-three (5%) out of 859 SVT ablation procedures were identified as ESPA. The median age was 53 (IQR: 24) years; 63% were female. All patients had pre-EPS documentation of SVT (either strip or ECG). In 23 (53.5%) cases, pre-EPS ECG showed short RP tachycardia. Thirty-two (74.4%) patients had dual atrioventricular nodal physiology (DAVNP) plus echo beats. Junctional rhythm (JR) as procedural endpoint was noted in 39 (90.7%) patients. In 18 (41.9%) patients, the abolishment of DAVNP was achieved. No complications were encountered. A median follow-up of 17 months (range: 6 to 31 months) revealed 83.7% (36 of 43) success rate, defined as the absence of pre-procedural symptoms and any documented sustained arrhythmia. As compared to patients with recurrence (n=7), patients with no recurrence (n=36) had significantly higher prevalence of clinical short RP tachycardia (61.1% vs. 14.3%, p=0.038), and EPS finding of DAVNP plus echo beats (80.6% vs. 42.9%, p=0.034). Conclusions: ESPA is a reasonable approach in patients with documented SVT, in particular in short RP tachycardia, who are not inducible at EPS. Larger studies are required to assess this practice.
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