Supraventricular Tachycardia Diagnosis and Indications for Ablation Prof. Muhammad A. Hammouda, MD Consultant Electrophysiologist Electrophysiology Laboratory, Cairo University & Dar Al-Fouad Hospital
Management of Cardiac Arrhythmias Supraventricular Tachycardias
Management of Cardiac Arrhythmias Supraventricular Tachycardias QRS Width NCT WCT Regular AVNRT Normal AVN/His Conduction Aberration AVRT Orthodromic Orthodromic+Aberration Antidromic MRT AT Normal AVN/His Conduction Aberration AFL Normal AVN/His Conduction Aberration Irregular AF Normal AVN/His Conduction Aberration Antidromic (Px-AF)
Management of Cardiac Arrhythmias RF Ablation
Management of Cardiac Arrhythmias RF Ablation X-Ray film and diagram showing RF ablation of accessory pathway with diagnostic and mapping electrodes (30° RAO projection)
Management of Cardiac Arrhythmias AV Nodal Reentrant Tachycardia
Mechanism of AVNRT (dual AVN pathway) Morady, NEJM, 1999
AVNRT: narrow complex tachycardia (NCT) at a rate of 145/bpm, with retrograde P-wave on terminal part of the QRS complex (arrow)
Management of AVNRT (dual AVN pathway) Mechanism Goals of Pharmaco- Electric- Pacing Surgery Therapy logic Ablation Devices Macro-circuit -Suppress -Digitalis (dual AVN Circuit -Ia, Ic pathway) -Beta Blockers -Ca antagonists - Amiodarone -Interrupt -Slow/ -DDD -Surgical Circuit pacing for dissection / Fast CHB (after cryoablation pathway ablation) of perinodal ablation tissue
ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Symptomatic Mildly Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Symptomatic Mildly Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Symptomatic Mildly Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Symptomatic Mildly Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Indications of RF ablation of AVNRT -RF ablation is Class I indication for all patients with AVNRT. -It is the First Priority in symptomatic patients -It is the Last Priority in asymptomatic or mildly symptomatic patients. -It is Not Performed if the patient does not desire it, irrespective of symptoms.
Intracardiac recording, showing AVNRT with concentric atrial & ventricular activation
Management of AVNRT (dual AVN pathway) SP ablation LAO view
Management of AVNRT (dual AVN pathway) SP ablation RAO view
Site of SP ablation during sinus rhythm (the ablation catheter recorded A :V = 0.5)
During SP ablation, slow junctional rhythm denoting potential successful ablation
Management of Cardiac Arrhythmias AV Reentrant Tachycardia
The Preexcitation Syndrome ( Wolff-Parkinson-White Syndrome) & the Circuit of Reentry
Location of the accessory pathways (From Gallagher et al., 1978) 1.Right anterior paraseptal, 2.Right anterior 3.Right lateral, 4.Right posterior, 5.Right paraseptal, 6.Left posterior paraseptal,7.Left posterior, 8.Left lateral, 9.Left anterior, 10.Left anterior paraseptal
Management of AVRT (accessory pathways) Mechanism Goals of Pharmaco- Electric- Pacing Surgery Therapy logic Ablation Devices Macro-circuit -Suppress -Ia, Ic (AP+AVN- Circuit -Digitalis His – -Beta Purkinje) Blockers -Ca antagonists - Amiodarone -Interrupt -Surgical -AP Circuit division / ablation cryoablation of AP
ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Symptomatic Mildly Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Symptomatic Mildly Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Symptomatic Mildly Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Symptomatic Mildly Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Indications of RF ablation of AVRT -RF ablation is Class I indication for all patients with APs-Mediated AVRT/ PxAF. -It is Class I indication in symptomatic patients -It is the Only indicated Rx in PxAF, untolerated AVRT -It is Class IIa indication in asymptomatic or mildly symptomatic patients.
ECG showing preexcited AF at the rate of @ 220/bpm Location of the AP is left posteroseptal (maximal preexcitation shows +ve delta in V1 & -ve delta in inferior leads)
12-lead ECG in sinus rhythm showing manifest WPW syndrome utilizing left posteroseptal AP (+ve delta in V1 & -ve delta in inferior leads )
Intracardiac tracing showing surface LI and V2 (preexcited) and shortest AV in PCS (in sinus rhythm) denoting the presence of posteroseptal AP. RF ablation was applied via the ablation catheter which recorded shortest AV than that of PCS catheter
During RF ablation, normolization of the QRS complex and AV prolongation denoting successful ablation.
Management of AVRT (accessory pathways) LLAP-RAO-atrial side
Management of AVRT (accessory pathways) LLAP-RAO-ventricular side
Management of Cardiac Arrhythmias Atrial FLutter
Mechanism of Atrial Flutter (AFL) Schematic depicting the entire flutter circuit in red rotating counterclockwise around the TA. Blue arrows represent passive activation outside the circuit. The crista terminalis and the ER act as lines of block preventing activation from "short circuiting" the annulus. Kalman et al., Circulation. 1996;94:398
Diagnosis of Atrial Flutter (AFL)
Diagnosis of Atrial Flutter (AFL) Adenosine in AFL
Management of Atrial Flutter (AFL) Mechanism Goals of Pharmaco- Electric- Pacing Surgery Therapy logic Ablation Devices Macro- -Slow VR -Digitalis -AVJ PM after -Surgical reentrant -Beta ablation AVJ ablation division / circuit Blockers cryoablation (passing -Ca of His through the antagonists bundle IVC-CS - Amiodarone isthmus) -Atrial -Resume -Ia, Ic - External defibrillator -Left atrial SR - Amiodarone CV isolation -Corridor -Antitachy- operation -Prevent -Ia, Ic cardia -Maze -Ablation Recurrence - Amiodarone pacing-ATP operation (IVC-CS block)
ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
MSx Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
MSx Symptomatic ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003
Indications of RF ablation of AFL -RF ablation is indicated in all patients with AFL -It is Class I indication in symptomatic patients -It is Class IIa indication in first episode pts and symptomatic non-CTI dependent AFL
Management of Cardiac Arrhythmias Atrial Fibrillation
Therapy of AF Pharmacologic Treatment 1-Restroration of sinus rhythm 2-Prevention of recurrence of AF 3-Control of ventricular response of AF 4-Anticoagulation Non-pharmacologic Treatment 1-Ablation: Linear ablation, Focal ablation, AVN ablation 2-PM Therapy: Multisite atrial pacing, Atrial Defibrillators 3-Electric Cardioversion: ICV, ECV 4-Surgical Ablation: Corridor operation, Maze operation
Management of Atrial Fibrillation (AF) Mechanism Goals of Pharmaco- Electric- Pacing Surgery Therapy logic Ablation Devices Multiple -Slow VR -Digitalis -AVN PM after -Surgical reentrant -Beta modification AVJ ablation division / wavelets Blockers -AVJ cryoablation (circuits) -Ca Ablation of His antagonists bundle - Amiodarone -Atrial -Resume -Ia, Ic - External CV defibrillator -Left atrial SR - Amiodarone -Internal CV isolation -Corridor -Antitachy- operation -Prevent -Ia, Ic -Maze-like pacing-ATP -Maze Recurrence - Amiodarone Ablation -Biatrial operation -PV pacing-BAP disconnec- tion -Anticoag- -Heparin ulation -Warfarin -ASA -Atrial pacing in -Rx of SSS Cause
Pharmacologic Treatment of AF AF THERAPY ANTITHROMBOTIC RX AND RHYTHM RATE OR ? CONTROL CONTROL
Target sites for different radiofrequency ablation approaches in treating atrial fibrillation: 1 pulmonary vein ectopic foci, 2 proximal bundle of His, 3 atrial walls for linear ablation
AV Node Ablation: Technique • AVN Ablation: -RF catheter positioned at compact AV node -Radiofrequency (RF) energy applied • AVN Modification : involves a more inferoposterior “shaving” approach Maloney et al. In: Interventional electrophysiology; 1997.
AV Node Ablation: Technique Before After
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