Circulation, Vol 83, 1562-1576, Copyright © 1991 by American Heart Association
WM Jackman, XZ Wang, KJ Friday, DM Fitzgerald, C Roman, K Moulton, PD Margolis, AJ Bowman, KH Kuck and GV Naccarelli
BACKGROUND. Two catheter electrode systems were compared for delivering
radiofrequency current for ablation of the atrioventricular junction.
Seventeen patients with drug-resistant supraventricular tachyarrhythmias
were studied. METHODS AND RESULTS. A 6F or 7F catheter with six or eight
standard electrodes (1.25 mm wide, 2.5-mm spacing) was used in the first
seven patients (group 1). A 7F quadripolar catheter with a large-tip
electrode (4 mm long; surface area, 27 mm2) was used in the final 10
patients (group 2). Both ablation catheters were positioned to record a
large atrial potential and a small but sharp His bundle potential from the
distal bipolar electrode pair. Radiofrequency current was applied between a
large skin electrode on the left posterior chest and either 1) each
individual electrode on the standard-tip electrode catheter at 40 V (group
1) or 2) the large-tip electrode at 50-60 V (group 2). Radiofrequency
current was limited to 40 V in group patients because of the strong
potential for an early impedance rise when higher voltage is applied
through standard electrodes. Complete atrioventricular block was achieved
in six of seven group 1 patients and all 10 group 2 patients. A junctional
escape rhythm followed ablation in five or six group 1 patients (mean cycle
length, 1,066 +/- 162 msec) and eight of 10 group 2 patients (mean cycle
length, 1,281 +/- 231 msec). Atrioventricular block was produced in a mean
of 4.7 +/- 4.6 radiofrequency current applications delivered over a period
of 42 +/- 45 minutes using the large-tip electrode (group 2) compared with
46 +/- 22 applications using standard electrodes (15.9 +/- 10.2
applications delivered through the standard-tip electrode) over a period of
147 +/- 59 minutes (group 1). For the application producing
atrioventricular block, the large-tip electrode used higher voltage (58 +/-
17 versus 38 +/- 5 V, p less than 0.03) and had lower impedance (103 +/- 22
versus 148 +/- 40 omega, p less than 0.01), resulting in greater power
(33.0 +/- 13.0 versus 10.2 +/- 0.6 W, p less than 0.003) and shorter time
to block (8 +/- 3 versus 22 +/- 3 seconds, p less than 0.001). Current
delivery through standard electrodes was limited by an impedance rise
occurring 7 +/- 7 seconds after the onset of one or more radiofrequency
current applications at 10 +/- 1 W in six of seven patients. Using the
large-tip electrode, an impedance rise occurred in five of 10 patients, but
at 25 +/- 10 W and after 21 +/- 9 seconds. Atrioventricular block occurred
before the impedance rise in three of these five patients. Complete
atrioventricular block persisted in 15 of 16 patients at a mean follow-up
of 8.7 months. Atrioventricular conduction returned at 1 month in one group
2 patient and was successfully ablated by a second procedure. Three group 1
patients died 0.5-2 months after ablation, and a fourth patient underwent
cardiac transplantation after 10 months. Pathological examination of the
heart in two of these patients showed necrosis of the atrioventricular node
and origin of the His bundle, without injury to the middle or distal His
bundle. All 10 group 2 patients are alive and subjectively improved after
ablation. CONCLUSIONS. We conclude that catheter-delivered radiofrequency
current effectively produces complete atrioventricular block (94%) without
requiring general anesthesia or the risk of ventricular dysfunction or
cardiac perforation. The large- tip electrode allows a threefold increase
in delivered power and markedly decreases the number of pulses and time
required to produce atrioventricular block.
ARTICLES
Catheter ablation of atrioventricular junction using radiofrequency current in 17 patients. Comparison of standard and large-tip catheter electrodes
Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City 73190.
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