Circulation, Vol 90, 2299-2307, Copyright © 1994 by American Heart Association
GK Feld, RP Fleck, O Fujimura, DL Prothro, TD Bahnson and M Ibarra
BACKGROUND--Pharmacological control of rapid ventricular response to atrial
fibrillation may be difficult in some patients. Alternative treatments,
including curative surgery or atrioventricular (AV) node ablation with
pacemaker implantation, have significant potential morbidity. In view of
evidence that dual AV nodal physiology may exist in a significant
percentage of the population, even in those without AV nodal reentrant
tachycardia, we postulated that control of ventricular response might be
achieved by radiofrequency (RF) catheter ablation in the region of the AV
nodal slow pathway with its short refractory period. METHODS AND
RESULTS--Ten patients underwent attempted AV node modification using a
4-mm-tipped electrode catheter positioned in the middle or posterior
septum, between the His bundle and coronary sinus ostium on the tricuspid
valve annulus. RF energy was applied at 16 to 30 W for up to 60 seconds,
until average ventricular response fell below 100 beats per minute.
Reduction of maximal ventricular response below 120 beats per minute was
confirmed with atropine 1 mg IV. If required, additional ablations were
performed progressively more posteriorly up to the coronary sinus ostium.
Patients with successful AV node modification were discharged off AV
node-blocking drugs and followed in the clinic at regular intervals.
Twenty-four-hour ambulatory ECG recordings and/or treadmill stress tests
were obtained before and after ablation for statistical comparison of
maximum ventricular rate. Resting average ventricular rate was determined
during electrophysiology study before and after ablation. In 7 of 10
patients (70%), maximum ventricular rate was reduced from a mean of 164 +/-
12 to 123 +/- 16 beats per minute (P < .01) and average ventricular rate
from a mean of 128 +/- 11 to 83 +/- 10 beats per minute after ablation.
Mean minimum ventricular rate was 54 +/- 11 beats per minute after
ablation. These 7 patients have remained symptom free from rapid
ventricular response for a mean of 14 +/- 8 months (range, 1 to 22). Three
remain off all AV node-blocking drugs, 3 remain on digoxin alone, which was
previously ineffective, and 1 remains on a beta-blocker for angina. In the
3 patients who did not respond to AV node modification, complete AV node
ablation and permanent pacemaker implantation was performed in 2 and DC
cardioversion after amiodarone loading was performed in 1. CONCLUSIONS--RF
catheter modification of AV node conduction is effective in controlling
rapid ventricular response to atrial fibrillation in a significant
percentage of medically refractory patients. A possible mechanism of RF
modification of AV node conduction is AV nodal slow pathway ablation.
Large-scale clinical trials will be needed to determine the overall
efficacy and safety of this technique.
ARTICLES
Control of rapid ventricular response by radiofrequency catheter modification of the atrioventricular node in patients with medically refractory atrial fibrillation
Department of Medicine, University of California San Diego.
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