Sinus node sparing novel hybrid approach for treatment of inappropriate sinus tachycardia/postural sinus tachycardia: multicenter experience

Abstract

Background The ideal treatment of inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) still needs to be defined. Medical treatments yield suboptimal results. Endocardial catheter ablation of the sinus node (SN) may risk phrenic nerve damage and open-heart surgery may be accompanied by unjustified invasive risks. Methods We describe our first multicenter experience of 255 consecutive patients (235 females, 25.94 ± 3.84 years) having undergone a novel SN sparing hybrid thoracoscopic ablation for drug-resistant IST (n = 204, 80%) or POTS (n = 51, 20%). As previously described, the SN was identified with 3D mapping. Surgery was performed through three 5-mm ports from the right side. A minimally invasive approach with a bipolar radiofrequency clamp was used to ablate targeted areas while sparing the SN region. The targeted areas included isolation of the superior and the inferior caval veins, and a crista terminalis line was made. All lines were interconnected. Results Normal sinus rhythm (SR) was restored in all patients at the end of the procedure. All patients discontinued medication during the follow-up. After a blanking period of 6 months, all patients presented stable SR. At a mean of 4.07 ± 1.8 years, normal SN reduction and chronotropic response to exercise were present. In the 51 patients initially diagnosed with POTS, no syncope occurred. During follow-up, pericarditis was the most common complication (121 patients: 47%), with complete resolution in all cases. Pneumothorax was observed in 5 patients (1.9%), only 3 (1.1%) required surgical drainage. Five patients (1.9%) required a dual-chamber pacemaker due to sinus arrest > 5 s. Conclusions Preliminary results of this multicenter experience with a novel SN sparing hybrid ablation of IST/POTS, using surgical thoracoscopic video-assisted epicardial ablation combined with simultaneous endocardial 3D mapping may prove to be an efficient and safe therapeutic option in patients with symptomatic drug-resistant IST and POTS. Importantly, in our study, all patients had a complete resolution of the symptoms and restored normal SN activity.

Hybrid epicardial and endocardial sinus node–sparing ablation therapy for inappropriate sinus tachycardia: Rationale and design of the multicenter HEAL-IST IDE trial

“…The HEAL-IST IDE trial will investigate the novel hybrid SAN-sparing ablation approach for IST; epicardial lesions are applied to electrically isolate the SAN from SVC and IVC, and an intercaval line is added. 12 , 13 , 14 The IVC line is performed to eliminate the potential of creating iatrogenic atrial flutter caused by the intercaval line. The SVC ablation eliminates any superior extensions of the sinus node extending into the SVC.…”

“… 12 More recently, a novel hybrid SAN-sparing ablation approach for IST has been described; epicardial lesions are applied to electrically isolate the SAN from the superior vena cava (SVC) and inferior vena cava (IVC), and an intercaval line is added. 12 , 13 , 14 In the multicenter SUSRUTA-IST (Sinus Node Sparing Hybrid Thoracoscopic Ablation Outcomes in Patients with Inappropriate Sinus Tachycardia) registry, 12 this hybrid ablation approach demonstrated a rate of pacemaker implantation as low as 4%, with a 100% acute success rate and 8% of recurrence.…”

Sinus Tachycardia: a Multidisciplinary Expert Focused Review

“…217 In a multicenter study of 255 consecutive patients (235 females, 25.9±3.8 years), a sinus node sparing hybrid thoracoscopic ablation procedure for drug-resistant IST or POTS using a minimally invasive bipolar radiofrequency ablation approach was performed targeting superior and inferior vena cavae and the crista terminalis. 218 Normal sinus rhythm was restored with symptom resolution so that medications were stopped. After 4.1±1.8 years, normal sinus function with chronotropic response to exercise remained present.…”

Targeted Treatment of Inappropriate Sinoatrial Node Tachycardia Based on Electrophysiological and Structural Mechanisms

“…Briefly, a right side thoracoscopic approach is used. Epicardial lesions set includes: (1) A line between SVC and right atrium to electrically isolate the SAN from SVC, (2) A line between IVC and right atrium, and (3) An intercaval line along the CT. 53,65,67 Therefore, endocardial mapping is performed to assess line block and an endocardial ablation is eventually performed if a gap is found (Figure 4). In a nonrandomized multicenter prospective registry, 50 patients with IST were treated with hybrid approach.…”

“…In the same registry, the standard SAN modification approach was used in 50 patients with pacemaker implantation in 50% and a redo procedure performed in all patients. 67 The efficiency of this strategy could be because of its potential targeting of increased automaticity (through local modulation of AG within the fat pad near the base of SVC and right pulmonary veins), SAN re-entry (through SVC, IVC and intercaval ablation lines targeting SACPs), and, eventually, caval latent pacemakers or micro-reentry (through electrical isolation of SVC and IVC). However, in a meta-analysis by Rodriguez-Manero, 9 the symptomatic benefits of ablation for IST wore off over time.…”