Variable Procedural Strategies Adapted to Anatomical Characteristics in Catheter Ablation of the Cavotricuspid Isthmus Using a Preoperative Multidetector Computed Tomography Analysis

Abstract

Variable Strategies for CTI AblationObjectivesThis study aimed to investigate the anatomical characteristics complicating cavotricuspid isthmus (CTI) ablation and the effectiveness of various procedural strategies.Methods and ResultsThis study included 446 consecutive patients (362 males; mean age 60.5 ± 10.4 years) in whom CTI ablation was performed. A total of 80 consecutive patients were evaluated in a preliminary study. The anatomy of the CTI was evaluated by multidetector row-computed tomography (MDCT) prior to the procedure. A multivariate logistic regression analysis revealed that the angle and mean wall thickness of the CTI, a concave CTI morphology, and a prominent Eustachian ridge, were associated with a difficult CTI ablation (P < 0.01). In the main study, 366 consecutive patients were divided into 2 groups: a modulation group (catheter inversion technique for a concave aspect, prominent Eustachian ridge, and steep angle of the CTI or increased output for a thicker CTI) and nonmodulation group (conventional strategy). The duration and total amount of radiofrequency energy delivered were significantly shorter and smaller in the modulation group than those in the nonmodulation group (162.2 ± 153.5 vs 222.7 ± 191.9 seconds, P < 0.01, and 16,962.4 ± 11,545.6 vs 24,908.5 ± 22,804.2 J, P < 0.01, respectively). The recurrence rate of type 1 atrial flutter after the CTI ablation in the nonmodulation group was significantly higher than that in the modulation group (6.3 vs 1.7%, P = 0.02).ConclusionChanging the procedural strategies by adaptating them to the anatomical characteristics improved the outcomes of the CTI ablation.

The deeper the pouch is, the longer the radiofrequency duration and higher the radiofrequency energy needed—Cavotricuspid isthmus ablation using intracardiac echocardiography

“…7 Recently, various imaging studies, including angiography, multiple-detector computed tomography, transthoracic echocardiography (TTE), transesophageal echocardiography, and intracardiac echocardiography (ICE), have been used to evaluate the isthmus. [4][5][6][7][8][9][10][11][12][13][14][15][16][17] In particular, using ICE provides a direct visualization and detailed assessment of the CTI anatomy and facilitates the ablation procedure. 7,[14][15][16][17] However, to the best of our knowledge, there have been no studies that have investigated the geometry of the CTI precisely with ICE and the occasional need for a knuckle-curve ablation during the CTI ablation.…”

Role of low kilovoltage electrocardiographic-gated multidetector CT in electrophysiological procedures in the paediatric age group

“…8 The cavo-tricuspid isthmusparaseptal isthmus, inferolateral, and central isthmuslength, angle, muscular thickness, and depth, all of which are important for proper selection of the technique for electrophysiological manipulation (Fig 3). 15 The anatomy of the sino-atrial node artery, evaluating its variable course and any pathology that may compromise the sino-atrial node blood supply. [16][17][18] The borders of Koch's triangle, particularly in the case of atrioventricular nodal re-entry tachycardia.…”

CT Imaging to Guide CTI Ablation: New Tricks for an Old Dog

“…With this background in mind, as reported in this issue of the Journal , Kajihara and colleagues performed a two‐phase study examining the role of computed tomography (CT) imaging of the CTI to identify and overcome anatomic challenges to successful catheter ablation . In the first phase, predictors of difficult CTI ablation, defined by longer procedure time necessary to achieve bidirectional block, were identified.…”