Electrophysiology and Cathether Ablation: Historical Evolution. Saverio Iacopino, MD, FACC, FESC

Transcription

1 Electrophysiology and Cathether Ablation: Historical Evolution Saverio Iacopino, MD, FACC, FESC

2 Historical Evolution ü 1967 ü 1968 ü 1969 ü 1973 ü 1979 Durrer D et al. first described initiation and termination of tachycardia in a patient with WPW syndrome (Ciruculation 1967; 36:644) Cobb FR et al. a surgical procedure for the elimination of an accessory pathway was first published (Circulation 1968; 38:1018) Scherlag BJ et al. the His bundle was first reproducibly recorded using a transvenous electrode catheter (Circulation 1969; 39:13) Coumel P et al. Resection of an atrial focus was described to cure atrial tachycardia (Ann Cardiol Angeiol 1973; 22:189) Pritchett EL surgical dissection was performed to treat AV nodal reentrant tachycardia without causing AV block (Circulation 1979; 60:440) Satti SD, Epstein LM. Cardiologic Interventional Therapy for Atrial and Ventricular Arrhythmias. In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003:

3 Closed-chest electrode-catheter technique for His bundle ablation in dogs R Gonzalez, M Scheinman, W Margaretten and M Rubinstein A modified quadripolar electrode catheter that had two-thirds of the distal surface insulated with high-voltage plastic was inserted in 10 dogs. After a His bundle potential had been recorded, a synchronized direct-current electrical discharge was delivered between the electrodes showing the largest His bundle deflection using a standard direct-current defibrillator, and a metallic plate was positioned over the dog's back. Complete atrioventricular (AV) block was induced in 9 of 10 dogs, which were followed for 3 mo before being killed. During AV block, the QRS complex was broad and not preceded by a His bundle deflection. The mean control cycle length during AV block was 1,441 +/- 223 ms and decreased to 1,151 +/- 181 ms after exercise, a response that was usually abolished by betablockade. Overdrive pacing resulted in pacemaker suppression with gradual rate stabilization after beats. There was no evidence of myocardial or valvular damage. This technique provides for a stable model of complete AV block and is suitable for experiments in which heart rate control is required. In addition, this technique may be of value for patients with tachycardia. Am J Physiol Heart Circ Physiol 241: H283-H287, 1981

4 Catheter technique for closed-chest ablation of the atrioventricular conduction system JJ Gallagher, RH Svenson, JH Kasell, LD German, GH Bardy, A Broughton, and G Critelli This report describes a catheter technique for ablating the His bundle and its application in nine patients with recurrent supraventricular tachycardia that was unresponsive to medical management. A tripolar electrode catheter was positioned in the region of the His bundle, and the electrode recording a large unipolar His-bundle potential was identified. In the first patient, two shocks of 25 and 50 J, respectively, were delivered by a standard cardioversion unit to the catheter electrode, resulting in an intra-his-bundle conduction defect. Subsequent delivery of 300 J resulted in complete heart block. In the next eight patients, an initial shock of 200 J was used. The His bundle was ablated by this single shock in six of these patients and by an additional shock of 300 J in one. In the remaining patient, conduction in the atrioventricular node was modified, resulting in alternating first and second-degree atrioventricular block. A stable escape rhythm was preserved in all patients. The procedure was well tolerated, without complications, and all patients have remained free of arrhythmia, without medication, for follow-up periods of two to six months. New England Journal of Medicine 306: , 1982

5 Closed chest modification of the AV conduction system in for treatment of refractory supraventricular tachycardia Critelli G, Perticone F, Coltorti F, Monda V, Gallagher JJ SN AVN CSO AV GROOVE AP Br Heart J 49: 544, 1983

6 Closed chest modification of the AV conduction system in for treatment of refractory supraventricular tachycardia Critelli G, Perticone F, Coltorti F, Monda V, Gallagher JJ SN AVN CSO AV GROOVE AP Br Heart J 49: 544, 1983

7 Supraventricular arrhythmias are relatively common, often repetitive, occasionally persistent, and rarely life threatening The precipitants of supraventricular arrhythmias vary with age, sex, and associated comorbidity ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias Executive Summary - Circulation 2003;108:

8 The estimated prevalence of paroxysmal supraventricular tachycardia (PSVT) in a 3.5% sample of medical records in the Marshfield (Wisconsin) Epidemiologic Study Area (MESA) was 2.25 per The incidence of PSVT in this survey was 35 per person-years. Orejarena LA, Vidaillet H, Jr, DeStefano F, et al. Paroxysmal supraventricular tachycardia in the general population. J Am Coll Cardiol. 1998;31:

9 Ablazione Transcatetere ü Via percutanea transvenosa o retrograda arteriosa ü Senza anestesia generale (blanda sedazione) ü Energia erogata attraverso un catetere (4-8 mm) ü Il tessuto viene bruciato senza pericolo di perforazione ü Numerose applicazioni di energia possibili

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11 Types of Energy Sources ü Direct current ü Radiofrequency ü Microwave ü Ultrasound ü Laser ü Chemical ü Cryogenic ü Surgical

12 Advantages of Radiofrequency Ablation ü Well defined lesion ü Output easily controlled ü No adverse hemodynamic effect ü Short recovery ü Repeatable ü Cost effective

13 Potential Complications of RF Ablation ü Unintentional AV block ü Recurrence of arrhythmias ü Pericarditis ü Chest pain ACC/AHA Circ. 1995;92: Morady F. N Engl J Med. 1999;340: ü Phrenic nerve damage ü Acute congestive heart failure ü Myocardial infarction ü Persistent hypotension

14 Radiofrequency Catheter Ablation of Supraventricular Arrhythmias ü Ablation is considered as a first line alternative to pharmacologic therapy ü Arrhythmias recur following 3-5% of successful ablation ü Recurrences generally present within the three months following an ablation procedure ü A repeat ablation procedure is associated with a very high likelihood of long term success Calkins H. Heart 2001; 85: