Difficult Accessory Pathway Ablation

jipmer.jpg

Raja Selvaraj

Professor of Cardiology, JIPMER

Rules

  • Do not ablate without making a diagnosis
  • Do not ablate without mapping completely
  • Do not ablate unless you are sure you can recognize and avoid AV block
  • Except specific situations, high power ablation does not succeed where low power fails
  • Do not ablate for cosmetic reasons

Diagnosis

Dont skip the RA catheter

rfw_no_ra.jpg

Dont skip the RA catheter

rfw_with_ra.jpg

RV catheter at base

apex_vs_base.jpg

Mapping

Use triggered mode

trigger.jpg

Use unipolar EGMs

uni.jpg

Identify components of the signal

mask1.jpg

Identify components of the signal

mask2.jpg

Identify components of the signal

mask3.jpg

Identify components of the signal

mask4.jpg

LA-CS potential to identify endocardial / epicardial

epicardial_ap_signal_sequence.jpg

LA-CS potential to identify endocardial / epicardial

la_cs_block.jpg

CS diverticulum

ecg.jpg

Mapping in diverticulum

diverticulum.jpg

Mapping in diverticulum

med_lat_div.jpg

Mapping in diverticulum

signals.jpg

Mapping in diverticulum - CSE potential most important

div_schematic.jpg

Selvaraj RJ et al. Radiofrequency ablation of posteroseptal accessory pathways associated with coronary sinus diverticula. J Interv Card Electrophysiol. 2016 Nov;47(2):253-259. doi: 10.1007/s10840-016-0113-x.

In absence of diverticulum, map along tributaries

no_diverticulum.jpg

AP slant - Earliest A and earliest V may be distant

ap_med_lat.jpg

AP slant - AP potential more important

pot_late_a.jpg

Try to avoid bumping, but use it when it happens

mahaim_bump.jpg

Ablation

Ablate septal APs during tachycardia when possible

asap_ablation_tachy.jpg

Entrain when ablating free wall AP during tachycardia

entrain_ablate.jpg

Isthmus block

isthmus_block.jpg

Anteroseptal AP may be ablated from non coronary cusp

ncc.jpg

Non annular location of AP

fig2.jpg

Non annular location of AP

fig3.jpg

Summary

  • Dont make easy ablations difficult
    • Accurate diagnosis
    • Precise mapping
  • Difficult ablations
    • Risk of AV injury
    • CS diverticulum
    • Non annular locations