Uso de ivabradina en el tratamiento de la taquicardia ectópica de la unión tras cirugía cardiaca / Use of ivabradine in pediatric post-operative junctional ectopic tachycardia

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Outcomes of junctional ectopic tachycardia ablation in adult population-a multicenter experience.

PURPOSE: Idiopathic junctional ectopic tachycardia (JET) is typically refractory to antiarrhythmic agents. Catheter ablation for JET is feasible but is associated with high risk of unintended atrioventricular (AV) block. There is limited data on the appropriate procedural technique and clinical outcomes with catheter ablation for idiopathic JET in adults. METHODS: This is a multicenter, retrospective study of all adult patients (age ≥ 18 years) who underwent catheter ablation for idiopathic JET. Patient, procedural characteristics, and long-term outcomes were evaluated. RESULTS: Fifteen patients [radiofrequency ablation (RF) = 14 and cryoablation = 1) were treated with catheter ablation. The median age was 58 years with 67% males. All patients underwent mapping of the right atrium and the aortic cusps prior to energy delivery. The location of earliest activation in relation to the atrioventricular (AV) node was postero-superior in 73% (11/15), posterior in 13% (2/15), and superior in 13% (2/15) respectively. Acute success was 100%. Arrhythmia recurrence occurred in 53% (8/15) all of whom underwent a repeat ablation. High-grade AV block requiring permanent pacemaker occurred in 20% (3/15). At 12-month follow-up in the redo-ablation group, 37.5% (3/8) had recurrence of the arrhythmia two of which underwent a third ablation procedure. CONCLUSION: Catheter ablation of idiopathic JET in adults is associated with a high rate of recurrence requiring multiple procedures and high risk of AV block requiring a permanent pacemaker. Mapping and ablation of the non-coronary cusp can be considered as the arrhythmia was controlled in 3 patients with no inadvertent AV block.

Junctional ectopic rhythm after AVNRT ablation: An underrecognized complication.

BACKGROUND: Ablation is an effective treatment for atrioventricular nodal reentrant tachycardia (AVNRT). The occurrence of junctional ectopic rhythm (JER), including junctional ectopic tachycardia, following AVNRT ablation has been described as an extremely rare phenomenon, but may be underestimated. We aimed to determine the incidence of JER following AVNRT ablation within our institution, as well as that reported in the literature via an extensive review. METHODS: We reviewed our adult ablation institutional experience for the occurrence of JER after AVNRT ablation from 2009 to 2016. Additionally, we conducted an extensive literature search using different databases looking for AVNRT ablation case series. The individually reported complications of these studies were reviewed, with a primary endpoint defined as the occurrence of JER shortly after AVNRT ablation. The study was approved by our institutional review board. RESULTS: Our institutional data revealed 6/126 patients (prevalence 4.8%) developed non-preexisting JER post-AVNRT ablation. Four patients were asymptomatic. Two patients had persistent symptoms lasting over a year, with one patient requiring repeat ablation. The literature review included 149 adult and pediatric studies. There were three cases of reported JER, out of a total of 37,541 patients (31,768 adults and 5,773 pediatric; prevalence 0.008%). The three JER patients were pediatric, and all required further therapeutic intervention. CONCLUSION: JER might be an underreported complication of AVNRT ablation. It seems most often to be transient and self-limited, occurring days to weeks after ablation, but may also be debilitating, requiring more aggressive management.

Junctional Ectopic Tachycardia Localization and Procedural Approach using Cryoablation.

BACKGROUND: Idiopathic junctional ectopic tachycardia (JET) may still be difficult to control with antiarrhythmic therapy. Transcatheter ablation can be challenging and may be associated with a high risk of unintended atrioventricular block. The objective of this manuscript is to report the procedural technique, the location of the successful ablation, and the procedural characteristics while utilizing 3D mapping for cryoablation of JET. METHODS: A retrospective analysis was performed on all patients who had undergone cryothermal ablation for the treatment of JET at a single center. Patient, arrhythmia, and procedural information and long-term outcomes were evaluated. RESULTS: Thirteen patients with JET were treated by cryothermal ablation. The JET arrhythmia burden varied greatly, generally with inadequate control on medications. Left ventricular dilation was present in three patients, and one patient had dilated cardiomyopathy. The median age at the time of procedure was 13 years, with median weight of 54.1 kg. The ectopic focus was ablated in 11/13 patients within the lower 2/3 of the triangle of Koch (TOK) with cryotherapy. Ablations, which were not successful, low in the TOK were associated with substantially longer procedures, and had a higher risk of recurrence. There was late resolution of the arrhythmia in two of three acutely unsuccessful ablations. There were no complications. CONCLUSION: In the majority of patients JET can be safely ablated with the use of cryotherapy. Foci not identified in the lower 2/3 of the TOK are associated with longer procedures, more lesions, and decreased chance for long-term success.

[Permanent junctional reciprocating tachycardia causing cardiomyopathy in an adult woman]. / Permanente junktionale Reentrytachykardie als Kardiomyopathie-Ursache bei einer erwachsenen Frau.

A 35-year-old female was referred with progressive dyspnoea and elevated heart rate. Surface electrocardiography (ECG) showed supraventricular tachycardia (SVT) with long RP interval and inverse P waves. ECG revealed left ventricular dilation and severe systolic dysfunction. An electrophysiological (EP) examination was performed due to incessant SVT despite betablocker medication. Permanent junctional reciprocating tachycardia (PJRT) was diagnosed and successfully ablated. During follow-up, the patient's symptoms abated and ECG parameters normalized. PJRT is usually found in infants and children, but should also be considered as a rare cause of incessant SVT and tachycardiomyopathy in adults.

Paradoxical responses to pacing maneuvers differentiating atrioventricular node reentrant tachycardia and junctional tachycardia.

A 40-year-old female presented at our hospital because of heart palpitations. During an electrophysiological study, atrioventricular (AV) conduction showed dual AV nodal physiology. Three types of supraventricular tachycardia (SVT) were induced. The initiation of SVT was reproducibility dependent on a critical A-H interval prolongation. An early premature atrial contraction during SVT repeatedly advanced the immediate His potential with termination of the tachycardia, indicating AV node reentrant tachycardia (AVNRT). However, after atrial overdrive pacing during SVT without termination of the tachycardia, the first return electrogram resulted in an AHHA response, consistent with junctional tachycardia. The mechanism of paradoxical responses to pacing maneuvers differentiating AVNRT and junctional tachycardia was discussed.

[Permanent junctional reciprocating tachycardia (Coumel type): a rare but curable form of tachycardia]. / Tachycardie incessante révélant une tachycardie réentrante de type Coumel.

We report the case of a 52 year-old man experiencing recurrent and incessant tachycardias despite antiarrhythmic drugs. Electrophysiological exploration confirmed the diagnosis of permanent junctional reentrant tachycardias (Coumel tachycardia). This tachycardia has been treated successfully by catheter ablation. The mechanisms of this tachycardias are explained.

High-amplitude pace mapping increases safety of radiofrequency catheter ablation of parahisian ectopic foci.

BACKGROUND: The objective of the study is to assess the efficacy of high-amplitude pace mapping in terms of the atrioventricular (AV) block risk after radiofrequency catheter ablation (RCA) of parahisian ectopic foci. METHODS: Twenty patients aged 38 ± 14 years with no structural heart disease underwent RCA of parahisian ectopic foci. All the patients were randomized into two groups: Group I (n = 11) had RCA performed in the region defined as ectopic focus by electrophysiology study and Group II (n = 9) had high-amplitude pacing performed in the region of "perfect" mapping. RCA was done only at the sites where high-amplitude pacing revealed the absence of His bundle capture. RESULTS: In group I, the efficacy of RCA was 54.5% and it was 100% in group II (P = 0.0195). Group II had no complications; in group I there were 27% of AV blocks (P = 0.0893). The late recurrence of ectopic activity was comparable in both groups: 3 (27%) and 2 (22%), respectively (P = 0.7953). In all the cases of recurrent ectopic activity and in all the cases of ineffective primary procedure, group I had effective reablation procedures performed using high-amplitude pace mapping. The overall efficacy in terms of repeated procedures was 90%. CONCLUSION: High-amplitude pace mapping increases primary and secondary efficacy of parahisian ectopic foci RCA and decreases the risk of AV block development. (PACE 2012;35:1458-1463).

[Cryoenergy for the ablation of arrhythmogenic paraseptal substrates in children and adolescents with heart rhythm disorders]. / Kryoenergie zur Ablation arrhythmogener paraseptaler Substrate bei Herzrhythmusstörungen im Kindes- und Jugendalter.

BACKGROUND AND OBJECTIVE: Cryoablation is safe for the ablation of substrates in proximity to the AV node, because the initial lesion is reversible. We report our results of cryoablation in a transregional center for ablation in children and adolescents. PATIENTS AND METHODS: Data on 39 children and adolescents (4 - 18 years of age) who had been treated with cryo energy were analyzed retrospectively. The diagnosis was AV nodal reentry tachycardia (AVNRT; n = 30), para-Hisian accessory pathway (AP; n = 6) and congenital junctional ectopic tachycardia (JET; n = 4). In addition to non-inducibility, the targeted endpoint for AP-ablation was a missing or decremental concentric retrograde conduction, for ablation of AVNRT the endpoint was no slow pathway, no AH jumps and no echo-beats. The median follow-up was 3 years (270 - 1919 days). RESULTS: The targeted endpoint was reached in 35/39 patients (90 %), in four patients (10 %) RF energy had to be applied. A recurrence occurred in 7/35 (20 %) successfully treated patients. Two patients had a pre-excitation again after AP ablation, but no symptoms. Thus, 28/35 patients (80 %) remained asymptomatic after cryoablation, and 26/35 (74 %) are definitively cured, regarding all follow-up data. The subgroup of AVNRT patients does not differ from the entire group. There was no AV block in the cryoablation group. CONCLUSIONS: Cryoablation is very safe and effective for the definitive treatment of arrhythmias in children and adolescents. The price for the high safety is a reduced efficacy and a higher recurrence rate.

Successful catheter ablation of reentrant junctional tachycardia in a patient with asplenia syndrome before total cavo-pulmonary connection.

Asplenia syndrome is commonly associated with complex structural cardiac malformations, and junctional tachycardia (JT), which may compromise hemodynamic status, has been reported in association with asplenia syndrome.(1) We report successful radiofrequency catheter ablation of reentrant JT in a patient with asplenia syndrome.

Differentiating junctional tachycardia and atrioventricular node re-entry tachycardia based on response to atrial extrastimulus pacing.

OBJECTIVES: The purpose of this study was to differentiate non-re-entrant junctional tachycardia (JT) and typical atrioventricular node re-entry tachycardia (AVNRT). BACKGROUND: JT may mimic AVNRT. Ablation of JT is associated with a lower success rate and a higher incidence of heart block. Electrophysiologic differentiation of these tachycardias is often difficult. METHODS: We hypothesized that JT can be distinguished from AVNRT based on specific responses to premature atrial complexes (PACs) delivered at different phases of the tachycardia cycle: when a PAC is timed to His refractoriness, any perturbation of the subsequent His indicates that anterograde slow pathway conduction is involved and confirms a diagnosis of AVNRT. A PAC that advances the His potential immediately after it without terminating tachycardia indicates that retrograde fast pathway is not essential for the circuit and confirms a diagnosis of JT. This protocol was tested in 39 patients with 44 tachycardias suggesting either JT or AVNRT based on a short ventriculo-atrial interval and apparent AV node dependence. Tachycardias were divided into 3 groups: clinically obvious AVNRT, clinically obvious JT, and clinically indeterminate rhythm. RESULTS: In the 26 cases of clinically obvious AVNRT, the sensitivity and specificity of the test were 61% and 100%, respectively. In the 9 cases of clinically obvious JT, the sensitivity and specificity were 100% and 100%, respectively. In the 9 cases of clinically indeterminate rhythm, the technique indicated AVNRT in 1 patient and JT in 7 patients, and the test was indeterminate in 1 patient. CONCLUSIONS: The response to PACs during tachycardia can distinguish JT and AVNRT with 100% specificity in adult patients.

Cryoablation of junctional tachycardia at high risk of atrio-ventricular block.

INTRODUCTION: Transcatheter cryoablation is an alternative option for the treatment of supraventricular tachycardia, due to its very low risk of permanent atrio-ventricular block. However, the overcost of cryocatheter and the high recurrence rate of this emerging technology braked its large use. This study reports the results of an approach using cryoablation for the treatment of junctional tachycardia (JT) in selected patients at high risk of atrio-ventricular (AV) block. PATIENTS AND METHODS: Out of a series of 199 patients with JT treated by catheter ablation, 26 benefited from cryoablation (mean age 32.8+/-15 years, 15 males). The indications were the presence of an accessory pathway with a high risk of atrio-ventricular block (n=7), a slow pathway difficult to ablate, with a risk of atrio-ventricular block (n=7), a recurrence after a RF procedure, during which a transient atrio-ventricular block has occurred (n=4), and finally patients at young age (n=8). RESULTS: The primary success rate was 92%. No permanent AV block has been reported, neither with RF nor with cryoablation. The recurrence rate at 9+/-10 months was at 29% after cryoablation and 8.6% after RF. In case of AV nodal reentrant tachycardia, the additional cost of cryotherapy catheter has been avoided in 76.85% of cases. The use of a cryotherapy catheter and RF catheter has been necessary for the remaining cases. CONCLUSION: This study demonstrates that an approach, reserving cryoablation in selected patients at high risk of AV block is an alternative strategy to "the systematic use" of cryotherapy in the ablation of JT with a high efficacy, an excellent safety and a reduced cost.

[Permanent junctional reciprocating tachycardia (PJRT) and dilated cardiomyopathy]. / Trajna spojna kruzna tahikardija (PJRT) i dilatacijska kardiomiopatija.

We present 14-year-old girl with permanent junctional reciprocating tachycardia which was refractory to medicamentous therapy, who also had dilated cardiomyopathy. She underwent successful radiofrequent catheter ablation of accessory pathway after wich the histologic changes in the myocardium were observed in the form of compensatory hypertrophy of cardiac muscle (cardiac remodelling). The question of cause and consequence appeared: whether the arrhythmia is a consequence of dilated cardiomyopathy, or it is tachycardia- induced cardiomyopathy. This particular issue is discussed in this article. Based on the diagnostic procedure and complete recovery of myocardium after catheter ablation of accessory pathway, it is obvious that the tachycardia was due to tachicardiomyopathy, i.e. cardiomyopathy caused by permanent reciprocating junctional tachycardia.

Remote magnetic catheter mapping and ablation of permanent junctional reciprocating tachycardia in a seven-year-old child.

BACKGROUND: Mapping and catheter ablation of permanent junctional reciprocating tachycardia (PJRT) in children can be challenging. Remote magnetic navigation may improve precise mapping and catheter stability during ablation, as well as reduce fluoroscopy time, especially in conjunction with a non-fluoroscopic mapping system. OBJECTIVE: We report a case of PJRT ablation in a 7-year-old child using remote magnetic navigation. METHODS AND RESULTS: Mapping of the right atrium (RA) and the coronary sinus (CS) and catheter ablation were performed using remote magnetic navigation in conjunction with a non-fluoroscopic mapping system (NavX). We observed excellent catheter steering abilities and constant wall contact during ablation, allowing a short and safe procedure. CONCLUSIONS: Remote magnetic navigation may be used for mapping and ablation of PJRT in children.

Cryoablation of congenital familial ectopic tachycardia with preservation of atrioventricular nodal function in an infant.

A 1-year-old child weighing 8 kg with familial congenital junctional ectopic tachycardia that was difficult to treat with antiarrhythmic medications underwent successful cryoablation with preservation of atrioventricular (AV) nodal function. This report describes a strategy of cryoablation in conjunction with a 3-D mapping system and the use of atrial overdrive pacing during cryothermal application to assess AV nodal function.

Transcatheter cryothermal ablation of junctional ectopic tachycardia in the normal heart.

BACKGROUND: Junctional ectopic tachycardia in the normal heart is rare and often is resistant to pharmacologic management. Transcatheter ablation using radiofrequency energy places the AV node at risk. OBJECTIVES: The purpose of this study was to report our experience with transcatheter cryothermal ablation using three-dimensional mapping in six patients with junctional ectopic tachycardia. METHODS: A review of clinical and electrophysiologic data was performed on all patients with structurally normal hearts who underwent cryothermal ablation for treatment of junctional ectopic tachycardia at two institutions. RESULTS: Six patients (age 7.7-36.5 years) underwent attempted transcatheter cryothermal ablation using three-dimensional mapping. Only one patient had achieved arrhythmia suppression on medical management. Cryothermal mapping (-30 degrees C) localized the junctional focus while normal conduction was monitored. The junctional focus was high in the triangle of Koch in four patients and was low in one patient. The sixth patient had only one run of junctional ectopic tachycardia during the procedure and therefore received an empiric cryoablation (-70 degrees C) lesion. Subsequent cryoablation lesions were delivered at and around the junctional focus. In one patient, cryomapping eliminated the junctional focus but resulted in transient complete AV block; therefore, cryoablation was not performed. All patients who received the cryoablation lesions had elimination of their junctional ectopic tachycardia at 6-week follow-up. The patient who did not receive a cryoablation lesion remained in a slower junctional rhythm at follow-up. CONCLUSION: Cryoablation of junctional ectopic tachycardia is safe and effective. Nonetheless, proximity to the His-Purkinje system may preclude success. Empiric cryoablation can be effective; cryotherapy may not yield immediate success, but a delayed salutary effect can follow.