Background Atrioventricular (AV) node ablation with biventricular (BiV) pacemaker implantation is a feasible rate control strategy for symptomatic permanent atrial fibrillation (AF) with rapid ventricular response and tachycardia-induced heart failure (HF). However, certain controversy exists since BiV pacing delivers non-physiological ventricular resynchronization and does not return left ventricular (LV) activation times to those seen in individuals with intrinsically narrow QRS. Permanent His bundle pacing (HBP) is a physiological alternative to conventional and BiV pacing. By capturing the native conduction system, depolarization of the ventricles through the His-Purkinje system induces normal synchronous ventricular activation. Purpose The aim of the study was to compare short-term outcomes between BiV pacing and HBP after AV node ablation in HF patients with symptomatic permanent AF and narrow QRS. Methods A total of 25 consecutive HF patients with permanent AF and narrow QRS (≤110 ms) who underwent AV node ablation in conjunction with BiV pacing or HBP in our centre were enrolled. Post-implant QRS duration, echocardiographic data, and New York Heart Association (NYHA) functional class were assessed in short-term follow-up. Results Among 25 HF patients (aged 68 ± 7 years, 52% female, QRS 96 ± 9 ms, LVEF 37 ± 7%, NYHA II-IV), 13 received BiV pacing and 12 HBP. Implant and ablation procedures were acutely successful in both groups. In BiV group 1 patient had a LV lead dislodgement and 1 patient in the HBP group had an acute HB lead threshold increase after AV node ablation. In HBP group post-implant QRS duration was shorter compared to BiV (103 ± 15 ms vs. 177 ± 13 ms, p < 0.001). At a median follow-up of 6 months, patients treated with HBP had greater increase in LV ejection fraction compared to BiV (44 ± 10 vs. 37 ± 6, p = 0.045). A trend toward greater reduction of LV volumes (EDV 119 ± 54 ml vs. 153 ± 33 ml, p = 0.07; ESV 75 ± 34 ml vs. 97 ± 26 ml, p = 0.09) and improvement of NYHA class (2.1 ± 0.7 vs. 2.7 ± 0.8, p = 0.08) was also observed in HBP group compared to BiV group. Conclusion In rate control refractory HF patients with permanent AF and narrow QRS atrioventricular node ablation in conjunction with HBP demonstrated superior electrical resynchronization and greater increase in LV ejection fraction compared to BiV pacing. Larger prospective studies are warranted to address clinical outcomes between both pace and ablate strategies.
Funding Acknowledgements Type of funding sources: None. Introduction Intracardiac echocardiography (ICE) is gaining increasingly wider adoption in interventional electrophysiology (EP) and represents an all-round tool for ablation of atrial fibrillation (AF). The key upgrade to the usefulness of ICE is its integration into three-dimensional (3D) electroanatomic mapping (EAM) system (ICE/EAM automatic integration system). Purpose The aim of this single-centre retrospective study was to evaluate feasibility, safety and acute efficacy of ICE/EAM automatic integration system guided fluoroless ablation of AF. Methods Patients with symptomatic paroxysmal or persistent AF referred for first pulmonary vein isolation (PVI) radiofrequency catheter ablation (RFCA) from September 2017 to August 2020 were included in the study. Those who underwent additional ablations for concomitant arrhythmias were excluded from statistical analysis. All procedures were performed without the use of fluoroscopy. A detailed 3D virtual anatomy of the left atrium (LA) and structures relevant to AF ablation was constructed from ultrasound contours obtained with ICE probe inside the LA. Pulmonary veins (PVs) and antral regions were additionally mapped with fast anatomical mapping. PVI was performed with contact force (CF) sensing catheter. Procedural endpoint was successful PVI. Results A total of 56 patients underwent RFCA (35.7% females, median age 62.7 years, 53.6% paroxysmal AF). Acute PVI was achieved in all patients (100%). Adverse events were detected in two patients (3.6%). The median procedure duration was 110.5 min (IQR 100.0-133.8). First-pass isolation was achieved in 50/56 LPVs (89.3%) and in 44/56 RPVs (78.6%). In patients where first-pass isolation was no achieved, intravenous carina had to be ablated in 3/6 (50%) of LPVs and 9/12 (75%) of RPVs. Conclusions Flouroless PVI using ICE/EAM automatic integration system is feasible, safe and acutely effective. We achieved high rate of first-pass isolation.
Funding Acknowledgements Type of funding sources: None. Introduction Catheter ablation (CA) of supraventricular tachycardias (SVTs) in pediatric patients is conventionally performed with the aid of X-ray fluoroscopy. Usage of the three-dimensional (3D) electro-anatomical mapping (EAM) system and the intracardiac echocardiography (ICE) enables zero-fluorscopy ablation, eliminating the harmful effects of the radiation (1-3). Purpose We retrospectively analyzed the feasibility, effectiveness and safety of zero-fluoroscopy radiofrequency and cryoablation of various types of SVTs in pediatric patients. Methods In this retrospective study, we analyzed consecutive pediatric patients who underwent CA procedure due to SVT in our institution from April 2014 to October 2021. All procedures were performed completely without the use of fluoroscopy. A 3D EAM system and ICE were used as the principal modes of catheter visualisation. Left-sided procedures were done with ICE guided transseptal approach. Radiofrequency was the principal energy source, while cryoablation was used for arrhythmia substrates in the proximity of the conduction system. Results The study included 174 consecutive patients (69/174 (66%) female; 12.5 ± 3.9 years; 19.2 ± 3.6 kg/m2). Altogether 176 SVTs were diagnosed and treated. Atrio-ventricular nodal reentry tachycardia (AVNRT) was diagnosed in 45% of cases (80/176), atrio-ventricular reentry tachycardia (AVRT) in 47% (82/176), focal atrial tachycardia (AT) in 7% (13/176), typical atrial flutter (AFL) was treated in only one patient, while 2 patients had multiple arrhythmias (AVNRT and AVRT). In total, 202 procedures were performed. Radiofrequency ablation was performed in 76% (154/202), cryoablation in 20% (40/202) and both in 4% (8/202) of procedures. The acute procedural success rate was 96% (195/202). Procedural success rate was 99% (79/80) for AVNRT, 94% (77/82) for AVRT, 92% (12/13) for AT, and 100% (1/1) for AFL, respectively. There were no major complications in our study group. Follow-up was complete in 99% (172/174) of patients. During the follow-up period of a median of 316 days (181 - 747), 98% of patients were arrhythmia free. On average, 1.16 procedures per patient were performed with the long-term success rate of 99% (79/80), 98% (80/82), 100% (13/13) and 100% (1) for AVNRT, AVRT, AT, and AFL, respectively. Conclusion Zero-fluoroscopy CA of various types of SVTs in pediatric population is a feasible, effective, and safe treatment option.
Funding Acknowledgements Type of funding sources: None. Introduction Traditionally, X-ray fluoroscopy is used during catheter ablation procedures. The utilisation of ionising radiation carries non-negligible stochastic and deterministic risks to the health of both the patient and the professional staff. These effects are cumulative and behave in a linear no-threshold manner and, as such, are especially important in paediatric populations (1). The importance of reducing ionising radiation exposure has been recognised by the American College of Cardiology, which recommends the ALARA (as low as reasonably achievable) principle in all interventional laboratories (2). In recent years, advances in three-dimensional electroanatomical mapping systems and their utilisation have enabled the near-zero and zero-fluoroscopy approaches to be studied (3). Purpose The aim of this study was to evaluate the safety and efficacy of zero-fluoroscopy catheter ablation for supraventricular tachycardias (SVT). Methods 584 consecutive patients referred to our institution for catheter ablation of SVT were analysed. Patients were categorised into two groups; zero-fluoroscopy (ZF) group and conventional fluoroscopy (CF) group. Patient characteristics, procedural information, and follow-up data were compared. Results The ZF group had a higher proportion of paediatric patients (42.2% vs 0.0 %; p < 0.001), resulting in a younger age (30.9 ± 20.3 years vs 52.7 ± 16.5 years; p < 0.001) and lower BMI (22.8 ± 5.7 kg/m2 vs 27.0 ± 5.4 kg/m2; p < 0.001). Procedure time was shorter in the ZF group (94.2 ± 50.4 min vs 104.0 ± 54.0 min; p = 0.002). There were no major complications and the rate of minor complications did not differ between groups (0.0% vs 0.4%; p = 0.304). Acute procedural success as well as the long-term success rate when only the index procedure was considered did not differ between groups (92.5% vs 95.4%; p = 0.155; 87.1% vs 89.2%; p = 0.422). When repeated procedures were included, the long-term success rate was higher in the ZF group (98.3% vs 93.5%; p = 0.004). The difference can be partially explained by the operators’ preferences. Conclusion The safety and efficacy of ZF procedures in adult and paediatric populations are comparable to that of CF procedures.
Background Transseptal puncture (TSP) for catheter ablation (CA) of left-sided tachycardias is traditionally performed with the aid of fluoroscopy. Compared to fluoroscopy, intracardiac echocardiography (ICE) can provide better orientation and imaging of soft tissue structures that are relevant to TSP. Objective Our aim was to evaluate feasibility and safety of ICE-guided TSP in CA treatment of left-sided tachyarrhythmias. Methods Consecutive fluoroless CA procedures with combined use of three-dimensional electroanatomic mapping system and ICE requiring TSP were evaluated in 357 patients (269 male, mean age 54 ± 18 years) referred to our hospital from July 2014 to November 2018. Among CA treated left-sided tachyarrhythmias 55 patients had accessory pathway, 16 had focal atrial tachycardia, 276 had atrial fibrillation or atypical atrial flutter and 10 had ventricular tachycardia. Success of transseptal access and complications related to TSP were analyzed. Adverse event requiring additional intervention was defined as major complication. Results Double TSPs were performed in 253 patients and single in 104 patients. Additional ablation procedures were needed in 26 patients and the rest had a single CA procedure. Altogether, 661 TSPs (274 double and 111 single) were attempted and 659 were successful (99.7%). Both TSPs failed due to severely thickened interatrial septum after previous cardiac surgery. In 14 patients (21 TSPs, 3.2%) a cardiac implantable electronic device (CEID) was present. ICE provided excellent lead visualisation and no lead dislodgements were recorded. Additional radiofrequency energy application to the transseptal needle was used for 3 challenging TSPs. Minor complications (pericardial effusions managed conservatively) occurred after 7 double TSP procedures (12/661, 1.8%). Major complication with pericardial tamponade (requiring pericardiocentesis) occurred during one double TSP (2/661, 0.3%). No TSP-related embolic complications were observed. Conclusion ICE-guided TSP in CA of left-sided tachyarrhythmias is safe with excellent success rates. In addition, ICE could provide additional reassurance in difficult cases and in patients with CEIDs.
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