When Catheter Ablation Should Be First Line Therapy

1. When Catheter Ablation Should Be First Line Therapy Neil K. Sanghvi, M.D.

3. Common Symptoms • Palpitations (often sudden on & off) • Anxiety • Light-headedness • Chest pain • Neck Pounding • Dyspnea • Polyuria in prolonged cases secondary to ANP release

4. Types of Supraventricular Tachycardias • AVNRT (AV nodal reentrant tachycardia) • AVRT (AV reciprocating tachycardia) • Atrial tachycardia • Multifocal atrial tachycardia • Atrial flutter • Atrial fibrillation • Junctional tachycardia • Sinus tachycardia

5. Cardiac Electrical System • SA Node • AV Node • His Bundle • Left Bundle • Right Bundle

6. Frequency of various types of SVT • 60% due to AVNRT (AV-nodal reentrant tachycardia) • 30% due to AVRT (AV reciprocating tachycardia) • <10% due to atrial tachycardia

7. Reentrant tachycardias • Usually precipitated by a PVC or PAC May also occur secondary to: • Excessive caffeine intake • Alcohol intake • Recreational drug use • Hyperthyroidism • Exercise

8. Initial Workup • History, history, history… • 12 lead EKG • Echocardiogram • Holter monitoring • Thyroid function • CBC (looking for anemia, infection)

9. Observations From An EKG • Observe zones of transition for clues towards the mechanism: • onset • termination • slowing, AV nodal block • bundle branch block (what happens to the cycle length of the tachycardia)

10. Understanding Reentry Panel A: Most impulses conduct down both pathways. Panel B: Unidirectional block, due to longer refractoriness in one pathway. Panel C: Potential to have reentry back up the previously refractory pathway Panel D: Reentry then can persist.

11. Orthodromic AVRT A. Sinus impulses travel down both the accessory pathway and AV node. B. Premature beat finds the accessory pathway refractory but is able to travel down the AV node. C. Impulses are able to traverse the myocardium and find the accessory pathway excitable thereby sustaining the tachycardia.

12. Short RP>PR tachycardias • AVNRT • AVRT • Junctional tachycardia • Atrial tachycardia with 1o AVB

13. Long RP>PR tachycardias • Atrial tachycardia • Atypical AVNRT • Sinus Tachycardia

14. QRS morphology based on the mechanism of the tachycardia

16. 33yo with sudden onset of palpitations and SOB after driving from NY to FL.

17. Sinus Tachycardia • Note the classic S1Q3T3 seen with pulmonary emboli

18. 40yo with sudden onset of palpitations while mowing the lawn.

19. AVNRT • Look for “pseudo S-wave” in inferior leads and “pseudo-R prime” in V1 which actually indicate retrograde P-waves • Terminates with vagal maneuvers in 1/3 cases • Responsive to AV nodal blocking agents such as beta blockers, CA channel blockers, adenosine. • Recurrences are the norm on medical therapy • Catheter ablation 95% successful with 1-2% major complication rate (including heart block)

20. AVNRT Ablation – Catheter Position HRA His Abl

21. Tendon of Todaro Triangle of Koch HB CS Septal TV

22. 31yo man presenting with palpitations after a night on the town.

23. How would you treat this man? • Verapamil/Diltiazem • Beta Blocker • Adenosine • Digoxin • Procainamide/Amiodarone

24. Atrial fibrillation with Wolf-Parkinson-White • Never use nodal agents when evidence of pre-excitation exists and the accessory pathway is capable of rapid conduction • >95% cure rate for ablation of accessory pathway

25. Baseline EKG for Previous Patient

26. EKG requirements to diagnose Pre-excitation (WPW) • P-R < 120ms • Delta wave • QRS > 100ms • Normal P-wave axis

27. 72yo woman with history of HTN p/w palpitations and SOB.

28. Atrial Flutter with variable block • “Typical” since flutter waves are negative in inferiorly and upright in V1 which implies a right atrial isthmus-related tachycardia

29. 66yo woman with rapid heart rate and anxiety.

30. Atrial flutter with 2:1 conduction • >95% cure rate with catheter ablation with a major complication rate of < 1% • Will be able to stop anticoagulation within 1 month

31. Activation on Halo Catheter During Typical Atrial Flutter V1 II aVF TA 1,2 TA 3,4 TA 19,20 TA 5,6 TA 9,10 TA 7,8 TA 9,10 CS Os TA 11,12 TA 1,2 TA 13,14 TA 17,18 TA 19,20 Typical = CCW CS Os

32. V1 II aVF TA 1,2 TA 3,4 TA 5,6 TA 7,8 TA 9,10 TA 11,12 TA 13,14 TA 17,18 19,20 CS Os Activation on Halo Catheter TA 19,20 TA 9,10 CS Os TA 1,2 Atypical = Clockwise

33. 3D Propagation Map of Atrial Flutter

34. Atrial Flutter CTI Ablation - LAO

35. Atrial Flutter CTI Ablation - RAO

36. 68yo woman with severe COPD exacerbation.

37. Atrial tachycardia with variable block • Atrial rates typically 150 -250bpm • Often treated with AAD for rhythm control, nodal agents for rate control • Catheter ablation has success rates of > 80%

38. Atrial Tachycardia Carto map revealing a focal atrial tachycardia originating from the SVC

39. 25yo man with fever of 102.

40. Sinus tachycardia

41. 65yo man presenting with palpitations.

42. Atrial fibrillation with rapid ventricular response • Typically managed with AAD or nodal agents for rate control • Ablation with success rates in the 70—75% range if no other risk factors

43. 2014Guidelines

44. AF Success w/ Ablation Device insertion Pre- ablation Post- ablation

45. Conclusion • Most SVTs should be referred for ablation even with a first occurrence since there is a high recurrence rate (anywhere from 25-80%) • Ablation may be considered first line therapy for certain AF patients – young, few to no comorbidities, not interested in AAD • Frequent PVCs may be ablated with > 90% cure • VT should be referred for ablation if failing AAD