Ectopic Atrial Tachycardia

Transcription

1 Europace Madrid, June 2011 Ectopic Atrial Tachycardia P. Loh, MD, PhD University of Utrecht Division Heart & Lungs

2 Epidemiology Nonsustained atrial tachycardia Frequent finding on holter registrations Often asymptomatic Sustained atrial tachycardia 10-15% of patients referred for catheter ablation of SVT Prevalence in asymptomatic subjects 0,34% Blomström-Lundqvist, JACC 2003

3 Clinical Features Atrial rate ca /min ( /min) Symptoms Usually mild: palpitations, dyspnea, fatigue, dizziness, chest pain Syncope (rare) Onset: all ages, cluster years Blomström-Lundqvist, JACC 2003

4 Clinical Features Paroxysmal Sustained Incessant Caveat: Tachycardia-induced cardiomyopathy! Blomström-Lundqvist, JACC 2003

5 Mechanisms Abnormal automaticity Triggered Activity Reentry

6 Diagnosis Patient history Onset: usually sudden or short warm-up ECG Holter Event recording

7 ECG I Atrial tachycardia

8 ECG II Atrial tachycardia, rate 102/min

9 Treatment Acute Vagal maneuvers usually unsuccessful, but may induce AV block and provide a diagnosis Drugs: Adenosine, Verapamil, β-blokker, Class I AA Cardioversion only successful in reentry. Long-Term No treatment Drugs: (Verapamil), β-blokker, Sotalol (Amiodarone) Class Ic: Flecainide, Propafenon Electrophysiologic study and ablation Roberts-Thomson, PACE 2006

10 Catheter Ablation Acute success % Problems: Inducibility Non-sustained Recurrence rate ca. 8% Complications Pericardial effusion / tamponade Phrenic nerve paralysis AV-block, sinus node dysfunction Roberts-Thomson, PACE 2006

11 Catheter Ablation RAO LAO

12 Origin of Atrial Tachycardia RAA LAA SN * * * CT RAFW PV IVC CSO LAFW M. Hamadan, University of Utah

13 Catheter Ablation Non fluoroscopic mapping systems Ensite-NavX Carto (Loca Lisa)

14 Unipolar Signals Unipolar signals along a muscle fiber Initially negative signal at source Biphasic signal Positive signal at location of signal extinction Jacques MT de Bakker; in: Zipes, Jalife eds., Cardiac Electrophysiology

15 Unipolar Signals Mapping 1 Mapping 2 Mapping 3

16 RF-ablation: Warming Up

17 RF-ablation: Termination of AT

18 Atrial Ectopic Tachycardia Differential Diagnosis

19 Supraventricular Tachycardia I II III V1 V6 HRA Differential Diagnosis: - Focal atrial tachycardia - AVRT - Uncommon type AVNRT His 1/2 His 3/4 RVA

20 Differential Diagnosis: Resetting His

21 Differential Diagnosis: Resetting RA LA RV LV

22 Differential Diagnosis: Resetting His

23 Differential Diagnosis: Entrainment CL 360 CL 380

24 Differential Diagnosis: VAAV

25 Origin of Atrial Tachycardia RAA LAA SN * * * Look CT for unusual locations RAFW PV IVC CSO LAFW M. Hamadan, University of Utah

26 Look at Unusual Locations Supravalvular origin: Noncoronary cusp of aortic valve: Tabatabaei et al, Circ A&E 2009

27 Noncoronary Cusp of AoV Liu et al, JACC 2010

28 Noncoronary Cusp of AoV 10 patients with AT and earliest atrial activation in the perinodal region: 7 / 10 - successful RF ablation from the noncoronary aortic cusp. Das et al, JCE 2008

29 Origin of Atrial Tachycardia RAA LAA SN * * * Beware CT of the Phrenic nerve RAFW PV IVC CSO LAFW M. Hamadan, University of Utah

30 Phrenic Nerve Palsy Chest x-ray before and after ablation Vatasescu et al, Europace 2006

31 Phrenic Nerve Anatomy Sanchez-Quintana et al, JCE 2005

32 Phrenic Nerve Anatomy Bunch et al, JCE 2005

33 Phrenic Nerve Protection High output (>10 ma) pace-mapping of Phrenic nerve location and course RF ablation during Phrenic nerve pacing in superior caval vein under continuous fluoroscopy

34 Phrenic Nerve Protection Balloon in epicardial space Lee et al, Heart Rhythm 2009

35 Junctional Ectopic Tachycardia

36 Junctional Ectopic Tachycardia His

37 Junctional Ectopic Tachycardia 1. Inferior AV-nodal approach during atrial overdrive pacing 2. Superior AV-nodal approach during atrial overdrive pacing 3. Hope for success

38 Inappropriate SN Tachycardia Difficult to distinguish from SNT Holter, stress test + Valsalva, drugs Sometimes highly symptomatic patients young women (health care professionals)

39 Inappropriate SN Tachycardia Therapy Drugs: β-blokker, Ivabradine (?) Catheter ablation Sinus node modification / ablation

40 Inappropriate SN Tachycardia Lin et al, PACE 2007

41 Europace Madrid, June 2011 Thank you for your attention P. Loh, MD, PhD University of Utrecht Division Heart & Lungs