A Novel and Practical Method of Performing Atrioventricular Nodal Ablation via a Superior Approach in Patients with Refractory Atrial Fibrillation Undergoing Cardiac Resynchronization Device Implantation

Abstract

Atrioventricular node (AVN) ablation is a strategy to manage patients with drugrefractory atrial fibrillation (AF) and heart failure in whom cardiac resynchronization therapy (CRT) device implantation has been prescribed. This study describes a practical method to perform these two procedures using the same surgical site. Twenty-seven patients were indicated for AVN ablation and concurrent CRT device implantation while presenting with AF and rapid ventricular response (RVR) refractory to medical therapy. After placement of the right and left ventricular leads, a third puncture was made in the axillary vein to obtain access to perform the ablation. After hand-injecting contrast media through a RAMP™ (Abbott Laboratories, Chicago, IL, USA) sheath positioned in the right atrial cavity, the anatomical area corresponding to the AVN was identified using fluoroscopy cine runs obtained in the right anterior oblique and left anterior oblique projections. The adequate site for ablation was confirmed by the bipolar recording of a His-bundle deflection at the tip of the ablation catheter. Radiofrequency energy was delivered to achieve complete heart block. Subsequently, device implant was completed. The method was successfully applied in 27 consecutive cases, achieving permanent complete heart block in all patients. The mean radiofrequency time to achieve heart block was 110 seconds ± 43 seconds. The average procedural time including AVN ablation and device implant was 87 minutes ± 21 minutes. The images obtained with the hand-injected contrast media provided adequate information to readily identify the anatomical area corresponding to the AVN with 100% accuracy. This study suggests that ablation of the AVN can be safely and effectively accomplished via a superior approach in patients undergoing a CRT device implant.

Feasibility and Safety Study of Concomitant Left Bundle Branch Area Pacing and Atrioventricular Node Ablation with Same-Day Hospital Dismissal

“…Concerns about health-care-associated infections and financial cost secondary to extended hospital stays have led to more and more complex EP procedures being performed using a same-day dismissal protocol in the USA, especially since the onset of the COVID-19 pandemic. Multiple studies have confirmed the safety of same-day dismissals for device implantations as well as complex ablation procedures, such as atrial fibrillation ablation [16,17]. Nevertheless, because of the concerns about lead dislodgement and pacing dependency, traditional PPM implantations and AVN ablation procedures are still routinely performed at separate times and typically require two separate hospital admissions and at least one overnight stay in the hospital.…”

“…The third new procedure we adopted for this study was the approach of AVN ablation through left axillary vein access, which was later used as the access for the LBBAP lead. AVN ablation using the axillary vein has been recently studied and appears to have multiple inherent advantages compared to the conventional right femoral approach [16,17]. This approach is even more relevant in cases involving an LBBAP because the His bundle region is typically already mapped prior to the LBBAP lead implant, and the venous access for AVN ablation is also already established.…”

Successful fluoroless cardiac resynchronization therapy–pacemaker implantation with left bundle branch area pacing and atrioventricular node ablation via the left axillary vein access using an electroanatomic mapping system

“…Multiple studies have been conducted to investigate AVN ablation through the axillary vein, and these studies have established multiple inherent advantages of doing AVN ablation through the axillary vein compared to the conventional right femoral approach. 13 This approach is even more relevant in cases involving LBBAP because the His bundle region is typically already mapped prior to LBBA lead implant and the venous access for AVN ablation is also already established. The only additional step required is insertion of an ablation catheter (frequently over a long sheath to enhance stability) to ablate the AVN, guided by the His bundle position already recorded as part of the LBBAP procedure.…”