Mapping and ablation of Junctional Mapping and ablation of Junctional Mapping and ablation of Junctional Mapping and ablation of Junctional Tachycardias Tachycardias Tachycardias Tachycardias Nitish Badhwar, MD, FACC, FHRS NO CONFLICT OF Associate Chief, Cardiac Electrophysiology Director, Cardiac Electrophysiology Training Program INTEREST TO University of California, San Francisco DECLARE California Heart Rhythm Symposium Sep 7, 2012 Disclosures Disclosures 1
SVT: What is the diagnosis? SVT: What is the diagnosis? • Para-hisian AT • Para-hisian AT • Focal Junctional Tachycardia • Focal Junctional Tachycardia • Concealed Nodofascicular • Concealed Nodofascicular (Nodoventricular) tachycardia (Nodoventricular) tachycardia 1. 1. AVNRT AVNRT 29% 26% 2. 2. AVRT AVRT 23% 3. 3. AT AT 13% 4. 4. JT JT 10% 5. 5. Call Dr. Schienman Call Dr. Schienman . T T . . R R T T e N A J h i V V A c A S . r Para-hisian AT Para-hisian AT R parahis R parahis NCC Iwai S, Badhwar N et al. Heart Rhythm. 2011;8(8).1245-53. . 2
Transition from short RP to long RP SVT Transition from short RP to long RP SVT Para-hisian AT: ECG findings Para-hisian AT: ECG findings with low dose adenosine with low dose adenosine • Narrower P waves during AT than in sinus rhythm • Narrower P waves during AT than in sinus rhythm • Negative P waves in II, III, avF (Ocassionally can be • Negative P waves in II, III, avF (Ocassionally can be positive) positive) • Positive P waves in avL and I • Positive P waves in avL and I • Biphasic in V 1 (initial isoelectric/negative followed by • Biphasic in V 1 (initial isoelectric/negative followed by positive) positive) Iwai S, Badhwar N et al. Heart Rhythm. 2011;8(8).1245-53. . AT termination with Adenosine AT termination with Verapamil AT termination with Verapamil Verapamil 10 mg + 8 sec I II III aVF V 1 V 6 HRA HB CS p CS d 500 ms 3
Para-hisian AT: Non coronary cusp Para-hisian AT: Non coronary cusp I aVF V1 HB CS p Halo NCC HB CS d NCC CS Iwai S, Badhwar N et al. Heart Rhythm. 2011;8(8).1245-53. . Para-hisian AT: Activation Map Para-hisian AT Para-hisian AT • Parahisian AT has characteristic P wave • Parahisian AT has characteristic P wave morphology (narrower than NSR) morphology (narrower than NSR) • Electrophysiological characteristics are • Electrophysiological characteristics are RAO View similar to other annular ATs and most similar to other annular ATs and most consistent with cyclic AMP-mediated consistent with cyclic AMP-mediated triggered activity triggered activity • Catheter ablation guided by 3D mapping is • Catheter ablation guided by 3D mapping is safe and effective in majority of the patients safe and effective in majority of the patients PA View Iwai S, Badhwar N et al. Heart Rhythm. 2011;8(8).1245-53. . 4
Sinus rhythm SVT Narrow complex tachycardia with VA Narrow complex tachycardia with VA block block • Para-hisian AT • Para-hisian AT • Focal Junctional Tachycardia • Focal Junctional Tachycardia • Concealed Nodofascicular • Concealed Nodofascicular (Nodoventricular) tachycardia (Nodoventricular) tachycardia AV nodal Junctional Concealed reentrant tachycardia nodofascicular tachcyardia tachycardia 5
Focal Junctional Tachycardia Focal Junctional Tachycardia Focal Junctional Tachycardia: Focal Junctional Tachycardia: Clinical Presentation Clinical Presentation Mechanism Mechanism • 18 pts (7 males); ages 22-78 • 18 pts (7 males); ages 22-78 • Mean tachycardia CL 450+/-64 ms • Mean tachycardia CL 450+/-64 ms • Predominantly 1:1 AV relationship with earliest • Predominantly 1:1 AV relationship with earliest • Initiation with ventricular overdrive pacing in 72% pts • Initiation with ventricular overdrive pacing in 72% pts retrograde A preceded or buried in the QRS retrograde A preceded or buried in the QRS (triggered); isoproterenol required in 17% of pts (triggered); isoproterenol required in 17% of pts • Occasional narrow complex SVT with AV dissociation • Occasional narrow complex SVT with AV dissociation • Spontaneous sustained tachycardia in 5 pts • Spontaneous sustained tachycardia in 5 pts • Paroxysmal in nature • Paroxysmal in nature • Termination with adenosine and carotid massage • Termination with adenosine and carotid massage (triggered) (triggered) • Symptoms despite maximally tolerated AV nodal • Symptoms despite maximally tolerated AV nodal blockers; referred for ablation blockers; referred for ablation • 3D mapping system showed focal activation pattern • 3D mapping system showed focal activation pattern from the right atrial septal region from the right atrial septal region Zhong et al. HRS 2011 (abstract) Zhong et al. HRS 2011 (abstract) JT - Initiation with ventricular overdrive JT - Initiation with ventricular overdrive JT- Initiation with atrial overdrive pacing JT- Initiation with atrial overdrive pacing pacing pacing I I I V 1 II avF II V 3 avF V 1 avF V 6 V 1 V 1 V 6 V 6 Abl Abl His His His His CS d CS p CS p CS d RVA RVA 6
Late PAC pulls in the next His- non Late PAC pulls in the next His- non Role of Late APC during SVT to Role of Late APC during SVT to diagnostic diagnostic differentiate AVNRT from JT / Parahis AT differentiate AVNRT from JT / Parahis AT II I • Pulls in the next His---- non diagnostic • Pulls in the next His---- non diagnostic avF II V 1 avF V 6 V 1 V 6 Abl • Push out the next His or terminate SVT- • Push out the next His or terminate SVT- His diagnostic diagnostic His CS p • Dissociate the His from atrium--- rule out • Dissociate the His from atrium--- rule out CS d Parahisian AT Parahisian AT RVA Poster presentation, HRS 2007 Late PAC (His A is committed) terminates Late PAC (His A is committed) terminates Late PAC terminates SVT without Late PAC terminates SVT without SVT SVT affecting the V affecting the V Viswanathan MN et al. HRS abstract. 2007. Viswanathan MN et al. Card Electrophysiol Clin. 2010. 7
Late PAC pushes out the next His Late PAC pushes out the next His Wenckebach during SVT Wenckebach during SVT Nguyen DT et al. Circ Arrhythm Electrophysiol. 2010;3(6):671-3 Nguyen DT et al. J Cardiovasc Electrophysiol. 2010 Jul 23 (Epub) Late PAC dissociates the next His Late PAC dissociates the next His Catheter Ablation Catheter Ablation II I • Map the earliest A during JT with 1:1 VA relationship avF II V 1 avF • Stepwise approach in patients with no VA relationship V 6 V 1 V 6 Abl • Atrial overdrive pacing to ensure intact AV conduction 380 ms during ablation His His 380 ms • 3D mapping system used to mark earliest A as well as CS p His CS d Nguyen DT et al. Circ Arrhythm Electrophysiol. 2010;3(6):671-3 8
JT- single PVC to reveal the site of JT- single PVC to reveal the site of JT- 3D Mapping JT- 3D Mapping earliest atrial activation earliest atrial activation I I II avF avF V 1 V 1 V 6 Abl His His CS d CS p RVA Focal Junctional Tachycardia: Focal Junctional Tachycardia: SVT- What is the diagnosis? SVT- What is the diagnosis? Results of Ablation Results of Ablation • 17/18 underwent radiofrequency catheter ablation (1 refused) • 17/18 underwent radiofrequency catheter ablation (1 refused) • Ablation sites • Ablation sites – Posteroseptal (10) – Posteroseptal (10) – Midseptal (2) – Midseptal (2) – Anteroseptal (5) – Anteroseptal (5) • 2 patients had transient AV block; conduction returned at the • 2 patients had transient AV block; conduction returned at the 1. AVNRT 2. AVRT end of the case, no long term AV block end of the case, no long term AV block 3. AT 4. JT • Long term success with no recurrence of JT over 80 month • Long term success with no recurrence of JT over 80 month follow up off drugs follow up off drugs 5. Call Dr. Schienman Zhong et al. HRS 2011 (abstract) 9
• Para-hisian AT • Para-hisian AT • Focal Junctional Tachycardia • Focal Junctional Tachycardia • Concealed Nodofascicular • Concealed Nodofascicular (Nodoventricular) tachycardia (Nodoventricular) tachycardia Nodofascicular (Nodoventricular) fibers Baseline split His Baseline split His • Double fire • Double fire II V 1 V 6 • Manifest • Manifest HRA nodofascicular / nodofascicular / nodoventricular nodoventricular His CS p • Concealed • Concealed nodofascicular nodofascicular CS d /nodoventricular /nodoventricular RVA tachycardia tachycardia 10
A on V tachycardia A on V tachycardia VOD terminates SVT VOD terminates SVT II II V 1 V 1 V 6 V 6 Abl HRA His His CS p CS p CS d CS d RVA RVA Prolongation of tachycardia CL with PVC on His advances the next V PVC on His advances the next V LBBB II I I aVF avF V 1 V 1 V 6 V 6 CS p 340 ms 360 ms His CS d CS p 380 ms 360 ms His RVA CS d 11
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