SVT and Atrial Flutter Ablation: When to refer?

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Griselda Thomas
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1 SVT and Atrial Flutter Ablation: When to refer? Dr Kim Rajappan Consultant Cardiologist & Electrophysiologist John Radcliffe Hospital, Oxford U.K. Speaker fees and travel grants received from St Jude Medical, Medtronic, Boston Scientific, Hansen Medical, Boehringer Ingelheim, Sanofi Aventis SVT and Atrial Flutter Ablation: When to refer? Dr Kim Rajappan Consultant Cardiologist & Electrophysiologist John Radcliffe Hospital, Oxford U.K. Speaker fees and travel grants received from St Jude Medical, Medtronic, Boston Scientific, Hansen Medical, Boehringer Ingelheim, Sanofi Aventis 1

2 Simple answer... REFER ALL OF THEM IMMEDIATELY Thank you Any questions? 2

3 Question What is the long term success rate for SVT ablation? 1. 80% 2. 90% 3. 95% % SVT/Narrow Complex Tachycardia By definition has to be something arising from above the AV node with ventricular activation through His-Purkinje system Sinus tachycardia Atrial fibrillation Atrial flutter AV nodal re-entrant tachycardia (AVNRT) AV re-entrant tachycardia (AVRT) Atrial tachycardia 3

4 SVT/Narrow Complex Tachycardia By definition has to be something arising from above the AV node with ventricular activation through His- Purkinje system Sinus tachycardia Atrial fibrillation Atrial flutter AV nodal re-entrant tachycardia (AVNRT) AV re-entrant tachycardia (AVRT) Atrial tachycardia 1960s 1970s 1980s s History of catheter ablation Intracardiac recording catheters Drug therapy guided by EP Surgical treatment of arrhythmias First catheter ablation (Scheinman/ Gallagher in 1982) using DC current First VT catheter ablation (Hartzler) First accessory pathway catheter ablation (Weber) First radiofrequency energy catheter ablation Radiofrequency catheter ablation routine 4

5 Atrial flutter Typical atrial flutter ablation Olshansky et al. JACC 1990; 16: ; Feld et al. Circulation 1992; 86:

6 Typical atrial flutter ablation TV IVC Cosio et al. Am J Cardiol 1993; 71: Typical atrial flutter ablation 6

Typical atrial flutter ablation Recurrence rates after DCCV are high Procedure times < 60 minutes Anatomical variants 1 Achieving and assessing block is imperative 2 Recurrence of flutter is low

7 Typical atrial flutter ablation Recurrence rates after DCCV are high Procedure times < 60 minutes Anatomical variants 1 Achieving and assessing block is imperative 2 Recurrence of flutter is low (long term 10%) 3 (probably even better with modern irrigated tip ablation catheters) Subsequent AF 50+% at 2-5 years 4 1.Scaglione et al. Europace 2004; 57(3): ; 2. Anselme et al. Circulation 2001; 103: ; 3. Schmeider et al. Eur Heart J 2003; 24: ; 4. Gilligan et al. PACE 2003; 26: Cardiac electrophysiology 7

Principles of EP study and ablation Pacing manoeuvres Drug challenges (isoprenaline) Tachycardia initiation Identification of arrhythmia Diagnosis made and critical tissue

8 Principles of EP study and ablation Pacing manoeuvres Drug challenges (isoprenaline) Tachycardia initiation Identification of arrhythmia Diagnosis made and critical tissue ablated Catheter ablation of SVT Daycase procedure Sedation High cure rates (90-95%) Serious risk < 1:2000 Risk of PPM 1:1-200 Redo rate 5-10% 8

AVNRT AVNRT Most common regular SVT 75 % Common and uncommon types mainly EP lab diagnosis Dual pathways in AV node (may occur in up to 25% of patients in EP lab) Treatment Vagal

9 AVNRT AVNRT Most common regular SVT 75 % Common and uncommon types mainly EP lab diagnosis Dual pathways in AV node (may occur in up to 25% of patients in EP lab) Treatment Vagal manoeuvres Medication acutely adenosine, later beta blockers, calcium channel blockers, flecainide or amiodarone DC Cardioversion rarely necessary Electrophysiology study & ablation 9

10 AVNRT ablation Jackman et al. NEJM 1992; 327: AVNRT ablation Jackman et al. NEJM 1992; 327: ; Jazayeri et al. Circulation 1992; 85:

11 AVNRT ablation Recurrence rates of arrhythmia without treatment are high Ablation is curative in over % after single procedure 1,2 Incessant AVNRT can cause tacycardia mediated cardiomyopathy cured with ablation Predictors of recurrence: residual echo?, no junctional rhythm during RF, ablation location 3,4 1. Jackman et al. NEJM 1992; 327: ; 2. Jazayeri et al. Circulation 1992; 85: ; 3. Baker et al. Am J Cardiol 1994; 73: ; 4. Manolis et al. Circulation 194; 90: AVNRT ablation Waiting period traditional after ablation Some date suggests not needed 1 79 AVNRT patients in Oxford (age 57 +/- 15; = 63.3%) No recurrence in waiting period No need for further procedure at follow up 1. Steven et al. JCE 2009; 20:

12 Accessory pathway/wpw AVRT (Accessory pathways/wpw) 12

13 Indications for EPS/ablation of WPW/AVRT EPS for all (Symptomatic) AVRT AF (and fast V rates) Asymptomatic patients with ventricular preexcitation whose livelihood, profession, insurability, or mental well-being may be influenced by unpredictable tachyarrhythmias or in whom such tachyarrhythmias would endanger the public safety should have an RF ablation procedure Patients with a family history of sudden cardiac death Summary SVT and flutter are common Treated with drugs for many years Wealth of data supporting ablation Use of ablation as an early strategy 13

14 Thank you Any questions? 14

Presenter Disclosure Information

2:15 3 pm Managing Arrhythmias in Primary Care Presenter Disclosure Information The following relationships exist related to this presentation: Raul Mitrani, MD, FACC, FHRS: Speakers Bureau for Medtronic.