Hybrid solution in high-end complex WPW for cases
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1 Hybrid solution in high-end complex WPW for cases Sebastian Stec MD, PhD, FESC &Piotr Suwalski Chair of Electroradiology, Faculty of Medicine, Univ. of Rzeszow, Rzeszow, Poland
2 Potential conflicts of interest Sebastian Stec: I have the following potential conflicts of interest to report: Medinice stocks holder, patents: Cryoapplicator, Cathaio catheter, MiniMAx catheter, PACEPRESS
3 Pre-excitation and WPW syndrome Cohn AE, and Fraser FR. Paroxysmal tachycardia and the effect of stimulation of the vagus nerve by pressure. Heart ;5: Wolff L, Parkinson J and White PD. Bundle branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia Am Heart J 1930 Hanon S et al. Europace 2005;7:28-33
4 Pre-excitation and WPW syndrome All 4 features in sinus rhythm: short PQ interval prolong QRS delta wave ST-T wave abnorms Asymptomatic or LAO RAO associated with paroxysmal tachycardias or palpitations (syndrome)
5 Pre-excitation and WPW syndrome Risk of: syncope tachycardias DCM AF SCD FBI - Fast Broad and Irregular - AF with pre-excitation - DC -> SR
6 Accessory pathways or connections
7 Catheter ablation for WPW syndrome No structural heart disease and defects Gold tip catheters, shealts, cryoablation, irrigated tips, transeptal/epicardial/ coronary sinus approach, 3D- mapping > 99% success rate (redo) No indications/ trials / case series on hybrid/surgical ablation in XXIst century Richard L. Page et al. JACC 2016;67:
8 Catheter and Surgery ablation for SVT/ WPW synd. Adult congenital heart diseases and defects American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society For planned surgical repair only Richard L. Page et al. JACC 2016;67:
9 WPW syndrome for Hybrid ablation Hybrid procedure 1. Past medical history LAO prior several EPs and failed catheter ablations (n=4-6, 3-5 different centers) 2. Pre-procedural examination final failed catheter ablation with 3D-EAM and mapping prior coronary arteries/veins angiography EP-HEART-TEAM consultations RAO 9
10 WPW syndrome for Hybrid ablation Equipment and approach: EP system 3D-EAM 1 decapolar endocardial catheter from jugular vein Cryoapplicator/cryoconsole Bipolar/Unipolar RF generator 1 mapping epicardial catheter Full-thoracoscopic epicardial approach as intention-to -treat Zero-fluoroscopy approach for endocardial mapping 10
11 Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT 220 bpm, 54 failed ablation including epicardial approach 23-year-old sportsman Prior 3 failed RF endocardial, Prior 1 failed epicardial RF catheter ablation Permanent pre-excitation with ERP <230 msek every week palpitation after exercise documented narrow QRS tachycardia > 200 bpm failed several drugs occupation: fitness consultant 11
12 Hybrid approach - Different hopes/dreams of Cardiac surgeon vs Electrophysiologist Cardiac surgeon hopes: Electrophysiologist dreams: fully- thoracoscopic off-pump no artery on the way no bleedings persistent pre-excitation OAVRT inducible no more pathways no cardioplegia no AF/VF during procedure no mechanical block
13 RCA Prior epicardial approach with 3D mapping WPW syndrome, OAVRT 220 bpm, 4 failed ablation including epicardial approach Best epicardial signals recorded from right free wall - courtesy of dr Artur Baszko 4 failed ablation including epicardial approach 13
14 Prior epicardial approach with 3D mapping WPW syndrome, OAVRT 220 bpm, 4 failed ablation including epicardial approach courtesy of dr Artur Baszko
15 Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT 220 bpm, 4 failed ablation including epicardial approach 4 failed ablation including epicardial approach 15
16 Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT 220 bpm, 4 failed ablation including epicardial approach RCA dissection Mapping Deep cryoablation -180
17 Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT 220 bpm, 4 failed ablation including epicardial approach Local activation time = -42 msek prior to pre-excitation First cryapplication - successful Bonus cryoapplications -180 Total application time: 280 sec No retrograde conduction No pre-excitation and SVT induction Adenosine challenge - negative Procedure time: 2 hours Accessory pathway located under 1/2 segm of RCA - bidirectional accessory pathway block 17
18 Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT 220 bpm during exercise, 4 failed ablation including epicardial approach 2015 succesfull cryoablation of accessory pathway located under 1/2 segm of RCA Sportsman/ Fitness consultant Follow-up after 12- months: request from the patient: If I am healthy please Doctor confirm in written that I have no contraindications to anything" 18
19 23-year-old women Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT failed ablation including ablation from RAA Prior 4 failed RF endocardial and endocardial cryoablation The last ablation effective for 30 minutes from RAA Permanent pre-excitation with ERP <240 msek documented narrow QRS tachycardia > 200 bpm failed several drugs, amiodarone effective as a last choice long treatment not accepted occupation: dentist assistent leisure activity: runner (training stopped due to WPW) 19
20 Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT failed ablation including ablation from RAA 20
21 LAO RAO Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT failed ablation including ablation from RAA Zero-fluoroscopy till the first effective application and Angio LAO RAO No pre-excitation after RF ablation in basal RAA Reccurences - bonus application + pre-excitation after 30 minutes
22 Hybrid cryoablation with 3D mapping WPW syndrome, OAVRT failed ablation including ablation from RAA Procedure: at least 2 months after amiodarone removal EP-HEART-TEAM consultation Start with RAA evaluation (RAA-RVOT connection???) If not: 1 segment RCA dissection Mapping, RCA elevation, cryoablation in AV groove Checking anterograde and retrograde cunduction Adenosine challenge 22
23 Hybrid approach - Different hopes/dreams of Cardiac surgeon vs Electrophysiologist Cardiac surgeon hopes: Electrophysiologist dreams: fully- thoracoscopic off-pump no artery on the way no bleedings persistent pre-excitation OAVRT inducible no more pathways no cardioplegia no AF/VF during procedure no mechanical block
24 XX century story - Surgery ablation of WPW syndrome Largest series < 310 pts, > 3000 cases worldwide (<1995) endocardial epicardial efficacy % fulguration mortality % cryoablation re-do procedures % Ethanol injection complications % laser etc Suwalski K Ph. D. Thesis 1995
25 Catheter and Surgery ablation for SVT/ WPW synd. Adult congenital heart diseases and defects American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society For planned surgical repair only Richard L. Page et al. JACC 2016;67:
26 Accessory pathways or connections RV LV
27 Zero-fluoroscopy ablation in pregnancy in WPW syndrome - Accessory pathway ablated from non-coronary aortic cusp 22-year old women, parahisian WPW syndrome, failed previous right-sided ablation in another institution, April th week of pregnancy, recurrences of palpitation and syncope (x3). pictures with acceptance and permission of patient Karbarz D,,, S Stec, Pol Heart 27 J 2017: in press
28 Zero-fluoroscopy ablation in pregnancy in WPW syndrome - Accessory pathway ablated from non-coronary aortic cusp left-sided mapping pictures with acceptance and permission of patient n=6 application in NCC (240 sec) 0,5 cmabove His potential recordings no junctional rhythms, no complication, no-fluoro procedure time: 71 min LAO RAO 0 sec fluoro, successful application from non- coronary cusp, Ensite Velocity No recurrences, caesarian section in 34 weeek of pregnancy (non cardiac reason), 28 APGAR 10, no recurrences and no pre-excitation within 16 months
29 Zero-fluoroscopy ablation in pregnancy in WPW syndrome - Accessory pathway ablated from non-coronary aortic cusp LAO RAO 29 Karbarz D,,, S Stec, Pol Heart J 2017: in press
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