Technology Update for Mapping, Imaging, and Ablation

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Citation
US Cardiology, 2007;4(2):43-6

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Since the 1980s, dramatic advances in electrophysiology procedures have occurred. Catheter positioning is most often assisted by fluoroscopy. Sophisticated electroanatomical mapping systems can also display catheter position and create a 3D depiction of the anatomy. Magnetic resonance imaging (MRI) and computed tomography (CT) data can also be integrated, facilitating complex ablation procedures. Ablation is most commonly achieved with application of radiofrequency (RF) energy. Freezing with catheter-based cryoablation is also widely available. Serious complications of catheter ablation are infrequent and most often related to the catheterization procedure, most commonly including vascular injury, and cardiac perforation with tamponade.

Re-entrant Supraventricular Tachycardia
Atrioventricular Nodal Re-entrant Tachycardia

Catheter ablation for atrioventricular nodal re-entrant tachycardia (AVNRT) is recommended when episodes are poorly tolerated or resistant to medical therapy.1 In patients with AVNRT, tachycardia can be eliminated in more than 95% of patients by ablating a functional pathway for slow conduction between the os of the coronary sinus and the septal leaflet of the tricuspid valve.2 Heart block is the major risk, requiring a permanent pacemaker in 0.8% of patients. Cryoablation may be associated with a lower risk of heart block, but lower long-term success rates.3

Atrioventricular Reciprocating Tachycardia Due to Accessory Pathways

Patients with AV reciprocating tachycardia (AVRT) have an accessory pathway (AP). If the AP can conduct from atrium to ventricle, the electrocardiogram (ECG) shows pre-excitation, consistent with Wolff- Parkinson-White (WPW) syndrome. APs that are able to conduct only from ventricle to atrium are considered ‘concealed’ because during sinus rhythm pre-excitation is absent, but AVRT still can occur. Catheter ablation is the standard of care for symptomatic WPW syndrome, or for concealed accessory pathways causing symptomatic tachycardias when pharmacological therapy is ineffective or not desirable.1 AP location determines whether an arterial, venous, or trans-septal approach is required. Success rates are 90–95%, with a risk of recurrent pathway conduction after healing of 3–10%.1 Serious complications related to left or right heart catheterization can occur, but are uncommon.

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