Catheter Technique for Closed-Chest Ablation of the Atrioventricular Conduction System

Gallagher, John J.; Svenson, Robert H.; Kasell, J; German, Lawrence D.; Bardy, Gust H.; Broughton, Archer; Critelli, G

doi:10.1056/nejm198201283060402

Cited by 701 publications

(110 citation statements)

References 23 publications

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“…During these periods, the atrium could be dissociated from the tachycardia by pacing the high right atrium. 8 She subsequently underwent insertion of a DDD pacemaker and is symptom free.…”

Section: Methodsmentioning

confidence: 99%

Clinical and electrophysiologic characterization of automatic junctional tachycardia in adults.

Ruder¹,

Davis²,

Eldar³

et al. 1986

Circulation

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Junctional ectopic tachycardia has been described in infants but not in adults. Five adults with rapid symptomatic paroxysmal junctional tachycardia, distinct from the more common slower nonparoxysmal junctional tachycardia, were recently evaluated. The tachycardia was irregular (rate 120 to 250) and accompanied by periods of atrioventricular dissociation and narrow QRS complexes. A junctional origin was documented during electrophysiologic study in four of the five patients. Analysis of Holter recordings; the response to exercise, isoproterenol, and propranolol; and the effects of atrial and ventricular stimulation appeared to implicate abnormal automaticity of a high junctional focus that was catecholamine sensitive or dependent as the tachycardia mechanism. All patients responded somewhat to /3-blockers, although a combination of procainamide and propranolol proved to be the most effective therapy in one patient and another chose electrode catheter ablation of the atrioventricular junction rather than continued drug therapy. Thus, junctional ectopic tachycardia may occur in adults and its mechanism appears to be related to abnormal automaticity that is catecholamine sensitive or dependent. Initial therapy should include fl-blockers but selected patients may require more aggressive management.Circulation 73, No. 5, 930-937, 1986.

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“…During these periods, the atrium could be dissociated from the tachycardia by pacing the high right atrium. 8 She subsequently underwent insertion of a DDD pacemaker and is symptom free.…”

Section: Methodsmentioning

confidence: 99%

Clinical and electrophysiologic characterization of automatic junctional tachycardia in adults.

Ruder¹,

Davis²,

Eldar³

et al. 1986

Circulation

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“…3,4 Creation of complete atrioventricular (AV) block should be carried out at the most proximal penetrating part of the His bundle to preserve the underlying automaticity and to avoid pacemaker dependency. 5,6 At that site, the bundle is a single, thin strand and is vulnerable to interruption of AV conduction by a relatively small radiofrequency (RF) lesion. This technique for AVJ ablation is generally guided by bipolar recordings from near the His bundle region, and the ideal site usually has a barely visible His deflection and ample atrial electrogram, with an atrial to ventricular electrogram ratio ≥1.0.…”

mentioning

confidence: 99%

Randomized Comparison of Bipolar vs Unipolar Plus Bipolar Recordings During Atrioventricular Junction Ablation Importance and Efficacy of Unipolar Recording

Ito

Tada

Naito

et al. 2007

Circ J

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Background No prior studies have clarified the utility and efficacy of unipolar recording for identifying successful sites for atrioventricular junction (AVJ) ablation. Methods and Results Thirty-six patients underwent radiofrequency (RF) AVJ ablation for drug-resistant atrial fibrillation (AF) or AF/flutter. AVJ ablation was performed with either bipolar (Bi-group; n=18) or unipolar plus bipolar recording (Uni-group; n=18). In the Uni-group, the primary parameter used to select ablation sites was a QS or rS morphology of the His bundle unipolar recording. There was no significant difference between the 2 groups for the bipolar electrogram characteristics at the successful ablation site. However, in the Uni-group, the procedure time and fluoroscopy duration were shorter (both p<0.05), and the total number of RF energy applications less (p<0.05) than in the Bi-group. In the Uni-group, unipolar His bundle recordings could be assessed in 26 (76%) of 34 RF energy applications: Complete atrioventricular block was obtained at 15 (83%) of 18 sites with QS morphology and in 3 (37%) of 8 sites with rS morphology on the unipolar His bundle recording. Conclusions AVJ ablation can be achieved more efficiently and with fewer RF energy applications when guided by unipolar recordings than by bipolar recordings alone. (Circ J 2007; 71: 874 -879)

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“…IA Recently, closed-chest ablation in the His bundle was successfully performed in patients with medically refractory supraventricular tachyarrhythmias by delivery of a direct current (DC) shock through a standard electrode catheter.5 6 Reasoning that high-energy discharge would also interrupt reentrant pathways responsible for ventricular tachycardia (VT), Hartzler7 has also used this procedure in the ventricle for ablation of VT in human beings. However, the hemodynamic and electrophysiologic consequences of DC shock on endocardium are unknown.…”

mentioning

confidence: 99%

Myocardial injury and induction of arrhythmia by direct current shock delivered via endocardial catheters in dogs.

Lerman

Weiss²,

Bulkley

et al. 1984

Circulation

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Although electrical ablation of ventricular tachycardia via percutaneous catheters has been recently accomplished in human beings, little is known of its pathologic or arrhythmogenic effects. We studied 21 open-chest anesthetized dogs in which an endocardial electrode catheter was percutaneously introduced into the left ventricle. Direct current (DC) shock was delivered by a standard defibrillator through the distal electrode to a back paddle. Cross-sectional two-dimensional echocardiographic studies were performed in the plane of the catheter (confirmed by epicardial metal beads), and blood flow was determined by the microsphere technique before DC shock and when the animals were killed 2 to 8 days later. Of 1 1 dogs receiving a total of 100 to 400 J, only three survived 48 hr compared with nine of 10 receiving 50 J and all three control dogs. Holter monitoring demonstrated sustained ventricular tachycardia (VT) (-30 sec) in all 1 1 dogs monitored (six received 100 J), beginning within 5 hr of the DC shock; three control dogs had no VT. Two dogs that died suddenly while being monitored showed ventricular fibrillation. Histologic examination revealed hemorrhagic contraction band necrosis in the shock zone, a type of injury similar to that observed in reperfusion necrosis. Necrosis of the left ventricle was 0.5% to 5%. There was no significant difference in necrosis between dogs receiving 100 J or more and those receiving 50 J (2.5 vs 1.7 g; p > 10). Percent systolic thickening determined in eight equally divided regions around the left ventricle showed no difference between the shock zone, perishock zone, or remote normal zone in dogs receiving 50 J. Blood flow was diminished in the shock zone by 21 + 6% (p < .005) but was unchanged elsewhere. Thus DC shock with as little as 50 J through an endocardial catheter results in localized nontransmural hemorrhagic necrosis. Despite its involvement of a relatively small portion of the left ventricle, this lesion is markedly arrhythmogenic, resulting in sustained VT/sudden death during the first week after DC shock.

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Catheter Technique for Closed-Chest Ablation of the Atrioventricular Conduction System

Cited by 701 publications

References 23 publications

Clinical and electrophysiologic characterization of automatic junctional tachycardia in adults.

Clinical and electrophysiologic characterization of automatic junctional tachycardia in adults.

Randomized Comparison of Bipolar vs Unipolar Plus Bipolar Recordings During Atrioventricular Junction Ablation Importance and Efficacy of Unipolar Recording

Myocardial injury and induction of arrhythmia by direct current shock delivered via endocardial catheters in dogs.

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