Circulation, Vol 85, 1318-1328, Copyright © 1992 by American Heart Association
MR Jazayeri, SL Hempe, JS Sra, AA Dhala, Z Blanck, SS Deshpande, B Avitall, DP Krum, CJ Gilbert and M Akhtar
BACKGROUND. The safety and efficacy of selective fast versus slow pathway
ablation using radiofrequency energy and a transcatheter technique in
patients with atrioventricular nodal reentrant tachycardia (AVNRT) were
evaluated. METHODS AND RESULTS. Forty-nine consecutive patients with
symptomatic AVNRT were included. There were 37 women and 12 men (mean age,
43 +/- 20 years). The first 16 patients underwent a fast pathway ablation
with radiofrequency current applied in the anterior/superior aspect of the
tricuspid annulus. The remaining 33 patients initially had their slow
pathway targeted at the posterior/inferior aspect of the right interatrial
septum. The fast pathway was successfully ablated in the initial 16
patients and in three additional patients after an unsuccessful slow
pathway ablation. A mean of 10 +/- 8 radiofrequency pulses were delivered;
the last (successful) pulse was at a power of 24 +/- 7 W for a duration of
22 +/- 15 seconds. Four of these 19 patients developed complete
atrioventricular (AV) block. In the remaining 15 patients, the post-
ablation atrio-His intervals prolonged from 89 +/- 30 to 138 +/- 43 msec (p
less than 0.001), whereas the shortest 1:1 AV conduction and effective
refractory period of the AV node remained unchanged. Ten patients lost
their ventriculoatrial (VA) conduction, and the other five had a
significant prolongation of the shortest cycle length of 1:1 VA conduction
(280 +/- 35 versus 468 +/- 30 msec, p less than 0.0001). Slow pathway
ablation was attempted initially in 33 patients and in another two who
developed uncommon AVNRT after successful fast pathway ablation. Of these
35 patients, 32 had no AVNRT inducible after 6 +/- 4 radiofrequency pulses
with the last (successful) pulse given at a power of 36 +/- 12 W for a
duration of 35 +/- 15 seconds. After successful slow pathway ablation, the
shortest cycle length of 1:1 AV conduction prolonged from 295 +/- 44 to 332
+/- 66 msec (p less than 0.0005), the AV nodal effective refractory period
increased from 232 +/- 36 to 281 +/- 61 msec (p less than 0.0001), and the
atrio-His interval as well as the shortest cycle length of 1:1 VA
conduction remained unchanged. No patients developed AV block. Among the
last 33 patients who underwent a slow pathway ablation as the initial
attempt and a fast pathway ablation only when the former failed, 32 (97%)
had successful AVNRT abolition with intact AV conduction. During a mean
follow-up of 6.5 +/- 3.0 months, none of the 49 patients had recurrent
tachycardia. Forty patients had repeat electrophysiological studies 4-8
weeks after their successful ablation, and AVNRT could not be induced in 39
patients. CONCLUSIONS. These data suggest that both fast and slow pathways
can be selectively ablated for control of AVNRT. Slow pathway ablation,
however, by obviating the risk of AV block, appears to be safer and should
be considered as the first approach.
ARTICLES
Selective transcatheter ablation of the fast and slow pathways using radiofrequency energy in patients with atrioventricular nodal reentrant tachycardia
Electrophysiology Laboratory, University of Wisconsin Milwaukee Clinical Campus, Sinai Samaritan Medical Center 53233.
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