AblativeManagement of AtrialTachycardias in ... · anti-arrhythmic drugs anti-tachycardia pacing catheter ablation Treatment of Post-Operative Atrial TachyArrhythmias possible curative

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Ablative Management of

Atrial Tachycardias

in Adults with Congenital Heart Disease

Natasja MS de Groot, MD, PhD

Department of Cardiology

Unit Translational Electrophysiology

Erasmus Medical Center, Rotterdam

� high incidence of atrial tachycardias in patients with

surgically corrected congenital heart disease

� risk of atrial tachycardias associated with

complexity of congenital heart disease

number of surgical procedures

longer time after cardiac surgery

� clinical problem: improved life expectancy

Atrial TachyArrhythmias in Patients withCongenital Heart Disease

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�anti-arrhythmic drugs

�anti-tachycardia pacing

�catheter ablation

Treatment of Post-Operative

Atrial TachyArrhythmias

✓ possible curative treatment option

✓ localization of the arrhythmogenic substrate: difficult

- distortion of atrial anatomy

- extensive mapping prior to ablation: essential

✓ recurrences of AT after ablation

Ablative Therapy

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What is the Mechanism ?

-macro-reentry circuit

-focal activity

Post-Operative AT

- atrial flutter cavo-tricuspid isthmus dependent

- intra-atrial reentrant tachycardiasreentrant circuit around areas of scar tissue anatomical structuressurgically created barriers

conduits/baffles

- focal atrial tachycardia

- (atrial fibrillation)

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Intra-Atrial Reentrant Tachycardias

Reentry Circuit ?

Incisional Reentrant Tachycardias

- reentrant circuit around

- areas of scar tissue

- anatomical structures

- surgically created barriers

- conduits/baffles

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Focal Atrial Tachycardias

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Cardiac Mapping

inferior caval vein

subclavian vein

jugular vein

transaortic

transseptal

epicardial

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3-D Electro-Anatomical Mapping System

M

RR

M

R

M

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M

R

M

• ••

+ 95 ms

“late”

• • •

- 100 ms

R

M

“early”

-30 ms

60 ms

TV

His

SCV

ICV

Diagnosis ?

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Classification of Regular

Atrial Tachycardias

focal atrial tachycardiaintra-atrial re-entrant tachycardia typical atrial flutter

Diagnosis ?

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-203 ms

220 ms

ICV

Diagnosis ?

Diagnosis ?

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Identification Low Voltage Mapping

Circulation, 2003;108:2099-2106, De Groot et al.

Voltage and Activation Mapping: How the Recording Technique Affects the Outcome of

Catheter Ablation Procedures in Patients With Congenital Heart Disease

construction voltage map : peak-to-peak amplitude

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Voltage Distribution of Bipolar Electrograms100

908070 605040302010

100908070 605040302010

0 1 2 3 4 5 6 7 8 9 10 mv 0 1 2 3 4 5 6 7 8 9 10 mv

0 1 2 3 4 5 6 7 8 9 10 mv0 1 2 3 4 5 6 7 8 9 10 mv

% %

% %

focal atrial tachycardia AV-nodal reentrant tachycardia

atrial flutter intra-atrial reentrant tachycardia

100908070 605040302010

100908070 605040302010

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0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2

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% %

% %

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 mv

focal atrial tachycardia atrio-ventricular reentrant tachycardia

atrial flutterintra-atrial reentrant tachycardia

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Low Voltage Distribution of Bipolar Electrograms

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atrio-ventricular nodal reentrant tachycardia

intra-atrial reentrant tachycardia

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 mv

T= 0 -120 ms T= 120-220 ms T=220-300 ms

T=300-330 ms T=330-430 ms T= 430 ms

TVIVC

IVC

TV

TVIVC

IVC

TV

TV

IVC

IVC

*

TV

TV

IVC

IVC

IVC

IVC

TV

TV

TV

TV

IVC

IVC

TV

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Focal Atrial Tachycardias

SCV

ICV

Heart Rhythm, 2006:3:526 –535, de Groot & Schalij.

Ablation of focal atrial arrhythmia in patients with congenital heart defects after surgery:

Role of circumscribed areas with heterogeneous conduction

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220 ms

220 ms

Focal Activation Pattern Area Delineation Area Ablation

R

M

AP

103 ms

-108 ms

PA

M

(bi)

R

V6

V1

sinus rhythmV1

R

M(bi)

LL

fragmentation

120 ms ablation

fragmentation

18 mm

13 mm

3 mm

*

43

mm

28 mm

SCV

TV

TV

ICV

EA

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Case

Post-Operative Atrial TachyArrhythmias

in a Patient with a

Surgically Corrected Congenital Heart Defect

de Groot & Schalij, Pace 2009; 1-3

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✓ Patient with

complex congenital heart disease

multiple AT

6 year follow-up period

ablation therapy

✓ Identification of the arrhythmogenic substrate

✓ 3-D electro-anatomical mapping (CARTO) prior to ablation

- female patient, born in 1972

type IB tricuspid atresia

(normal related great arteries and pulmonary stenosis)

- 6 yrs: Fontan procedure

(conduit: right atrium - right ventricular outflow tract)

- 16 yrs: modification stenotic part of the conduit

- first episodes of AT : age of 23

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Fontan Procedure Modifcation

conduit

1.IART

AT-PM

CV

1978 1988

1996

1972 AT

ICV

1

AT no.

AT (no. 1)

IART, CL=240 ms

AT (no. 1)

IART, CL=240 ms

area of slow conduction:

middle of the RAFW

area of slow conduction:

middle of the RAFW

SCV

TV

Fontan Procedure Modifcation

conduit

1.IART

AT-PM

CV

2.IART

1978 1988

1996

1972

1999

AT

1

2

SCV

AT no.

macro-reentrant circuit (no. 2, CL 340 ms)

crucial pathway of conduction

areas of scar tissue

upper part of RAFW

SCV

TV

ICV

ICV

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Fontan Procedure Modifcation

conduit

1.IART

AT-PM

CV

3.AF

4.FAT

2.IART

1978 1988

1996

1972

1999

2000

180 ms

AT

Bi

AT no.

1

2

SCV

TV

ICV

3

4

SCV

ICV

SCV

ICV

- 150 ms

+79 ms

180 ms

AP

18 mm

Atrial Fibrillation

Continuous Electrical Activity

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Focal Atrial Tachycardia

143 ms

M (bi)

AP

79 ms

-150 ms

anterior posterior

A B

C D

A B

C D

Focal Atrial Tachycardia

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Fontan Procedure Modifcation

conduit

1.IART

AT-PM

CV

3.AF

4.FAT

2.IART

1978 1988

1996

1972

1999

2000

180 ms

AT

Bi

AT no.

1

2

SCV

TV

ICV

3

4

SCV

ICV

SCV

ICV

- 150 ms

+79 ms

5.IART

5

Fontan Procedure Modifcation

conduit

1.IART

AT-PM

CV

3.AF

4.FAT

2.IART

1978 1988

1996

1972

1999

2000

180 ms

AT

Bi

AT no.

1

2

SCV

TV

ICV

3

4

SCV

ICV

SCV

ICV

- 150 ms

+79 ms

5.IART

6.IART

2003

5

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Fontan Procedure Modifcation

conduit

1.IART

AT-PM

CV

3.AF

4.FAT

2.IART

1978 1988

1996

1972

1999

2000

180 ms

AT

Bi

AT no.

1

2

SCV

TV

ICV

3

4

SCV

ICV

SCV

ICV

- 150 ms

+79 ms

5.IART

6.IART

2003

7. FAT

2005

0

5

1

1

2

1 2 4 5 6 7

sca

rti

ssu

e (

%)

7

5

Ablative Therapy:

Outcome

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Study Population

- 53 patients with congenital defects and post-operative SVT

- 27 male, age 38±15 years

- referred for catheter ablation

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Conclusions

Conclusion

� focal and reentrant mechanism

� successive AT developing over time :

different mechanisms

� Successive AT : different atrial sites

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Conclusion

Arrhythmogenic substrate of successive AT:

distinct atrial sites

1

2

SCV

TV

ICV

3

4

7

5

Conclusion

✓ ablative therapy : curative treatment modality

� catheter ablation :

procedural success rate of 70-79%

� 3-D electro-anatomical mapping system versus

conventional, fluoroscopy based mapping technique

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✓ Right atrial tissue damaged extensively

cardiac surgery

pressure/volume overload

✓ Muscle bundles are separated by fibrous tissue

areas of slow conduction

large areas of scar: center of reentrant circuits

complex reentrant circuits; containing multiple

corridors

Conclusion

Arrhythmogenic Substrate

� prolongation of atrial refractoriness

� chronic bradycardia due to sinoatrial node dysfunction

� areas of intra-atrial conduction delay

� the presence of conduits, long sutures lines

� scar tissue

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Questions ?