Raja

Created: 2024-04-11 Thu 11:17

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

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Dont skip the RA catheter

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RV catheter at base

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Mapping

Use triggered mode

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Use unipolar EGMs

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Identify components of the signal

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Identify components of the signal

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Identify components of the signal

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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

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CS diverticulum

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Mapping in diverticulum

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Mapping in diverticulum

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Mapping in diverticulum

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Mapping in diverticulum - CSE potential most important

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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

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AP slant - Earliest A and earliest V may be distant

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AP slant - Earliest A and earliest V may be distant

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AP slant - Earliest A and earliest V may be distant

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AP slant - AP potential more important

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Try to avoid bumping, but use it when it happens

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Ablation

Ablate septal APs during tachycardia when possible

asap_ablation_tachy.jpg

Entrain when ablating free wall AP during tachycardia

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Isthmus block

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Anteroseptal AP may be ablated from non coronary cusp

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Non annular location of AP

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Non annular location of AP

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Summary

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