ablativemanagement of atrialtachycardias in ... · anti-arrhythmic drugs anti-tachycardia pacing...
TRANSCRIPT
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Ablative Management of
Atrial Tachycardias
in Adults with Congenital Heart Disease
Natasja MS de Groot, MD, PhD
Department of Cardiology
Unit Translational Electrophysiology
Erasmus Medical Center, Rotterdam
� high incidence of atrial tachycardias in patients with
surgically corrected congenital heart disease
� risk of atrial tachycardias associated with
complexity of congenital heart disease
number of surgical procedures
longer time after cardiac surgery
� clinical problem: improved life expectancy
Atrial TachyArrhythmias in Patients withCongenital Heart Disease
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�anti-arrhythmic drugs
�anti-tachycardia pacing
�catheter ablation
Treatment of Post-Operative
Atrial TachyArrhythmias
✓ possible curative treatment option
✓ localization of the arrhythmogenic substrate: difficult
- distortion of atrial anatomy
- extensive mapping prior to ablation: essential
✓ recurrences of AT after ablation
Ablative Therapy
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What is the Mechanism ?
-macro-reentry circuit
-focal activity
Post-Operative AT
- atrial flutter cavo-tricuspid isthmus dependent
- intra-atrial reentrant tachycardiasreentrant circuit around areas of scar tissue anatomical structuressurgically created barriers
conduits/baffles
- focal atrial tachycardia
- (atrial fibrillation)
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Intra-Atrial Reentrant Tachycardias
Reentry Circuit ?
Incisional Reentrant Tachycardias
- reentrant circuit around
- areas of scar tissue
- anatomical structures
- surgically created barriers
- conduits/baffles
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Focal Atrial Tachycardias
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Cardiac Mapping
inferior caval vein
subclavian vein
jugular vein
transaortic
transseptal
epicardial
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3-D Electro-Anatomical Mapping System
M
RR
M
R
M
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M
R
M
• ••
+ 95 ms
“late”
• • •
- 100 ms
R
M
“early”
-30 ms
60 ms
TV
His
SCV
ICV
Diagnosis ?
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Classification of Regular
Atrial Tachycardias
focal atrial tachycardiaintra-atrial re-entrant tachycardia typical atrial flutter
Diagnosis ?
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-203 ms
220 ms
ICV
Diagnosis ?
Diagnosis ?
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Identification Low Voltage Mapping
Circulation, 2003;108:2099-2106, De Groot et al.
Voltage and Activation Mapping: How the Recording Technique Affects the Outcome of
Catheter Ablation Procedures in Patients With Congenital Heart Disease
construction voltage map : peak-to-peak amplitude
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Voltage Distribution of Bipolar Electrograms100
908070 605040302010
100908070 605040302010
0 1 2 3 4 5 6 7 8 9 10 mv 0 1 2 3 4 5 6 7 8 9 10 mv
0 1 2 3 4 5 6 7 8 9 10 mv0 1 2 3 4 5 6 7 8 9 10 mv
% %
% %
focal atrial tachycardia AV-nodal reentrant tachycardia
atrial flutter intra-atrial reentrant tachycardia
100908070 605040302010
100908070 605040302010
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0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2
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0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 mv 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0. 8 0.9 1 mv
% %
% %
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 mv
focal atrial tachycardia atrio-ventricular reentrant tachycardia
atrial flutterintra-atrial reentrant tachycardia
0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1
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Low Voltage Distribution of Bipolar Electrograms
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0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0. 8 0.9 1 mv
atrio-ventricular nodal reentrant tachycardia
intra-atrial reentrant tachycardia
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 mv
T= 0 -120 ms T= 120-220 ms T=220-300 ms
T=300-330 ms T=330-430 ms T= 430 ms
TVIVC
IVC
TV
TVIVC
IVC
TV
TV
IVC
IVC
*
TV
TV
IVC
IVC
IVC
IVC
TV
TV
TV
TV
IVC
IVC
TV
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Focal Atrial Tachycardias
SCV
ICV
Heart Rhythm, 2006:3:526 –535, de Groot & Schalij.
Ablation of focal atrial arrhythmia in patients with congenital heart defects after surgery:
Role of circumscribed areas with heterogeneous conduction
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220 ms
220 ms
Focal Activation Pattern Area Delineation Area Ablation
R
M
AP
103 ms
-108 ms
PA
M
(bi)
R
V6
V1
sinus rhythmV1
R
M(bi)
LL
fragmentation
120 ms ablation
fragmentation
18 mm
13 mm
3 mm
*
43
mm
28 mm
SCV
TV
TV
ICV
EA
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Case
Post-Operative Atrial TachyArrhythmias
in a Patient with a
Surgically Corrected Congenital Heart Defect
de Groot & Schalij, Pace 2009; 1-3
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✓ Patient with
complex congenital heart disease
multiple AT
6 year follow-up period
ablation therapy
✓ Identification of the arrhythmogenic substrate
✓ 3-D electro-anatomical mapping (CARTO) prior to ablation
- female patient, born in 1972
type IB tricuspid atresia
(normal related great arteries and pulmonary stenosis)
- 6 yrs: Fontan procedure
(conduit: right atrium - right ventricular outflow tract)
- 16 yrs: modification stenotic part of the conduit
- first episodes of AT : age of 23
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Fontan Procedure Modifcation
conduit
1.IART
AT-PM
CV
1978 1988
1996
1972 AT
ICV
1
AT no.
AT (no. 1)
IART, CL=240 ms
AT (no. 1)
IART, CL=240 ms
area of slow conduction:
middle of the RAFW
area of slow conduction:
middle of the RAFW
SCV
TV
Fontan Procedure Modifcation
conduit
1.IART
AT-PM
CV
2.IART
1978 1988
1996
1972
1999
AT
1
2
SCV
AT no.
macro-reentrant circuit (no. 2, CL 340 ms)
crucial pathway of conduction
areas of scar tissue
upper part of RAFW
SCV
TV
ICV
ICV
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Fontan Procedure Modifcation
conduit
1.IART
AT-PM
CV
3.AF
4.FAT
2.IART
1978 1988
1996
1972
1999
2000
180 ms
AT
Bi
AT no.
1
2
SCV
TV
ICV
3
4
SCV
ICV
SCV
ICV
- 150 ms
+79 ms
180 ms
AP
18 mm
Atrial Fibrillation
Continuous Electrical Activity
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Focal Atrial Tachycardia
143 ms
M (bi)
AP
79 ms
-150 ms
anterior posterior
A B
C D
A B
C D
Focal Atrial Tachycardia
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Fontan Procedure Modifcation
conduit
1.IART
AT-PM
CV
3.AF
4.FAT
2.IART
1978 1988
1996
1972
1999
2000
180 ms
AT
Bi
AT no.
1
2
SCV
TV
ICV
3
4
SCV
ICV
SCV
ICV
- 150 ms
+79 ms
5.IART
5
Fontan Procedure Modifcation
conduit
1.IART
AT-PM
CV
3.AF
4.FAT
2.IART
1978 1988
1996
1972
1999
2000
180 ms
AT
Bi
AT no.
1
2
SCV
TV
ICV
3
4
SCV
ICV
SCV
ICV
- 150 ms
+79 ms
5.IART
6.IART
2003
5
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Fontan Procedure Modifcation
conduit
1.IART
AT-PM
CV
3.AF
4.FAT
2.IART
1978 1988
1996
1972
1999
2000
180 ms
AT
Bi
AT no.
1
2
SCV
TV
ICV
3
4
SCV
ICV
SCV
ICV
- 150 ms
+79 ms
5.IART
6.IART
2003
7. FAT
2005
0
5
1
1
2
1 2 4 5 6 7
sca
rti
ssu
e (
%)
7
5
Ablative Therapy:
Outcome
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Study Population
- 53 patients with congenital defects and post-operative SVT
- 27 male, age 38±15 years
- referred for catheter ablation
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Conclusions
Conclusion
� focal and reentrant mechanism
� successive AT developing over time :
different mechanisms
� Successive AT : different atrial sites
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Conclusion
Arrhythmogenic substrate of successive AT:
distinct atrial sites
1
2
SCV
TV
ICV
3
4
7
5
Conclusion
✓ ablative therapy : curative treatment modality
� catheter ablation :
procedural success rate of 70-79%
� 3-D electro-anatomical mapping system versus
conventional, fluoroscopy based mapping technique
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✓ Right atrial tissue damaged extensively
cardiac surgery
pressure/volume overload
✓ Muscle bundles are separated by fibrous tissue
areas of slow conduction
large areas of scar: center of reentrant circuits
complex reentrant circuits; containing multiple
corridors
Conclusion
Arrhythmogenic Substrate
� prolongation of atrial refractoriness
� chronic bradycardia due to sinoatrial node dysfunction
� areas of intra-atrial conduction delay
� the presence of conduits, long sutures lines
� scar tissue
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Questions ?