Zero-fluoroscopy catheter ablation of symptomatic pre-excitation from non-coronary cusp during pregnancy

Abstract

Current recommendations avoid the use of antiarrhythmic drugs in pregnancy and support catheter ablation (CA) due to symptomatic arrhythmias prior to pregnancy. Zero-fluoroscopy (ZF) mapping and navigation with three-dimensional electroanatomical mapping systems (3D-EAMS) allowed routine and safe non-fluoroscopic guidance of the procedure without X-ray exposure. We present the first case of a pregnant patient who underwent successful ZF CA of symptomatic pre-excitation from non-coronary cusp (NCC). A 24-year-old Caucasian pregnant without structural heart disease at the 24 th week of pregnancy was referred for CA due to three recurrences of syncope and drug-refractory palpitations associated with Wolf-Parkinson-White (WPW) syndrome. Twelve months prior to pregnancy the woman had failed radiofrequency (RF) ablation procedure in another centre for para-Hisian right-sided pathway. A 12-lead electrocardiogram (ECG) showed pre-excitation with a positive delta wave in leads I, II, aVF, V4, and V5 and a negative delta wave in lead V1, suggesting a para-Hisian accessory pathway ( Fig. 1). She was referred to our hospital for rescue CA with ZF. Our centre had at least five years of experience with the minimally invasive non-fluoroscopic imaging and navigation approach using the Ensite NavX system (St. Jude Medical, St. Paul, MN) for CA of regular supraventricular arrhythmias and idiopathic ventricular arrhythmias. A multidisciplinary consultation reached the consensus that only pre-excitation is a substrate for syncope recurrences and poses a potential risk to the foetus and mother. The right femoral vein was cannulated with a 7 F or 8 F sheath and one ablation 4 mm Gold tip catheter and one diagnostic decapolar catheter (Biotronik, Berlin, Germany) were introduced. Atrial pacing protocols demonstrated a septal accessory pathway, but no isoproterenol was given to induce tachycardia. The refractory period of the accessory pathway was 300 ms. After six failed right-sided applications right sided mapping was stopped due to frequent junctional beats and proximity of His potential recordings. Then, the right femoral artery was cannulated with an 8 F introducer, and the ablation catheter was removed using a right to left retrograde approach (Fig. 2). Finally, six RF applications (240 s) were delivered approximately in the NCC and the accessory pathway was successfully ablated (Fig. 1). The procedure time was 71 min and no fluoroscopy was used. Several ECGs and Holter monitoring confirmed no pre-excitation and arrhythmias within 14 months. The patient delivered a healthy male child at 35 weeks of gestation by Caesarean section. Both mother and child had an uneventful postoperative course. The case documents that routinely using ZF for CA may support this approach even for unfavourable locations (e.g. NCC) and not only as the last resort for several arrhythmias including WPW-syndrome in pregnant patients.

Feasibility and performance of catheter ablation with zero-fluoroscopy approach for regular supraventricular tachycardia in patients with structural and/or congenital heart disease

“…However, even with a combination of 3D-EAM and ICE, complete ZF approach was followed only in a minority of patients. [27–30] In contrast, our study showed ZF approach feasibility wherein even in the SHD group, procedural time could be reduced significantly, probably because of lesser time spent on detailed contour mapping and multichamber 3D mapping.…”

Pregnancy and congenital complete atrioventricular block: management during pregnancy and periparturient period (RCD code: VII-V)

“…Any dosage of X-ray is potentially harmful, as there is no threshold dose. A lower dosage of X-ray means a lower risk of potential harm for the embryo and various precautions are undertaken to minimize radiation exposure during invasive procedures in pregnancy [10]. In our patient, the late period of pregnancy (near its end) was an extenuating factor.…”

Zero-fluoroscopy approach for catheter ablation of left-sided slow-fast AVNRT.

“…Routinely using ZF for CA may support this approach even for unfavorable locations and especially in pregnant patients. [11] Even rare and difficult anatomy could be effectively treated. Therefore the ZF approach could be used in experienced hands as a standard approach.…”