NO CONFLICT OF Associate Chief, Cardiac Electrophysiology Director, - - PowerPoint PPT Presentation

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NO CONFLICT OF Associate Chief, Cardiac Electrophysiology Director, - - PowerPoint PPT Presentation

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Mapping and ablation of Junctional Mapping and ablation of Junctional Mapping and ablation of Junctional Mapping and ablation of Junctional Tachycardias Tachycardias Tachycardias Tachycardias Nitish Badhwar, MD, FACC, FHRS NO CONFLICT OF

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Mapping and ablation of Junctional Tachycardias Mapping and ablation of Junctional Tachycardias

Nitish Badhwar, MD, FACC, FHRS Associate Chief, Cardiac Electrophysiology Director, Cardiac Electrophysiology Training Program University of California, San Francisco

California Heart Rhythm Symposium Sep 7, 2012

Mapping and ablation of Junctional Tachycardias Mapping and ablation of Junctional Tachycardias

NO CONFLICT OF INTEREST TO DECLARE

Disclosures Disclosures

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SVT: What is the diagnosis? SVT: What is the diagnosis?

A V N R T A V R T A T J T r . S c h i e . . .

29% 13% 23% 26% 10%

1. AVNRT 2. AVRT 3. AT 4. JT 5. Call Dr. Schienman 1. AVNRT 2. AVRT 3. AT 4. JT 5. Call Dr. Schienman

  • Para-hisian AT
  • Focal Junctional Tachycardia
  • Concealed Nodofascicular

(Nodoventricular) tachycardia

  • Para-hisian AT
  • Focal Junctional Tachycardia
  • Concealed Nodofascicular

(Nodoventricular) tachycardia Para-hisian AT Para-hisian AT

R parahis R parahis NCC

Iwai S, Badhwar N et al. Heart Rhythm. 2011;8(8).1245-53. .

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  • Narrower P waves during AT than in sinus rhythm
  • Negative P waves in II, III, avF (Ocassionally can be

positive)

  • Positive P waves in avL and I
  • Biphasic in V1 (initial isoelectric/negative followed by

positive)

  • Narrower P waves during AT than in sinus rhythm
  • Negative P waves in II, III, avF (Ocassionally can be

positive)

  • Positive P waves in avL and I
  • Biphasic in V1 (initial isoelectric/negative followed by

positive)

Para-hisian AT: ECG findings Para-hisian AT: ECG findings

Iwai S, Badhwar N et al. Heart Rhythm. 2011;8(8).1245-53. .

Transition from short RP to long RP SVT with low dose adenosine Transition from short RP to long RP SVT with low dose adenosine AT termination with Adenosine AT termination with Verapamil AT termination with Verapamil

500 ms I aVF V1 V6 HRA HB CSp CSd II III Verapamil 10 mg + 8 sec

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I V1 aVF CSd CSp HB NCC

Para-hisian AT: Non coronary cusp

Iwai S, Badhwar N et al. Heart Rhythm. 2011;8(8).1245-53. . NCC HB CS Halo

Para-hisian AT: Non coronary cusp

RAO View PA View

Para-hisian AT: Activation Map

Iwai S, Badhwar N et al. Heart Rhythm. 2011;8(8).1245-53. .

Para-hisian AT Para-hisian AT

  • Parahisian AT has characteristic P wave

morphology (narrower than NSR)

  • Electrophysiological characteristics are

similar to other annular ATs and most consistent with cyclic AMP-mediated triggered activity

  • Catheter ablation guided by 3D mapping is

safe and effective in majority of the patients

  • Parahisian AT has characteristic P wave

morphology (narrower than NSR)

  • Electrophysiological characteristics are

similar to other annular ATs and most consistent with cyclic AMP-mediated triggered activity

  • Catheter ablation guided by 3D mapping is

safe and effective in majority of the patients

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Sinus rhythm SVT

Narrow complex tachycardia with VA block Narrow complex tachycardia with VA block

AV nodal reentrant tachcyardia Concealed nodofascicular tachycardia Junctional tachycardia

  • Para-hisian AT
  • Focal Junctional Tachycardia
  • Concealed Nodofascicular

(Nodoventricular) tachycardia

  • Para-hisian AT
  • Focal Junctional Tachycardia
  • Concealed Nodofascicular

(Nodoventricular) tachycardia

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  • 18 pts (7 males); ages 22-78
  • Predominantly 1:1 AV relationship with earliest

retrograde A preceded or buried in the QRS

  • Occasional narrow complex SVT with AV dissociation
  • Paroxysmal in nature
  • Symptoms despite maximally tolerated AV nodal

blockers; referred for ablation

  • 18 pts (7 males); ages 22-78
  • Predominantly 1:1 AV relationship with earliest

retrograde A preceded or buried in the QRS

  • Occasional narrow complex SVT with AV dissociation
  • Paroxysmal in nature
  • Symptoms despite maximally tolerated AV nodal

blockers; referred for ablation

Focal Junctional Tachycardia Clinical Presentation Focal Junctional Tachycardia Clinical Presentation

Zhong et al. HRS 2011 (abstract)

  • Mean tachycardia CL 450+/-64 ms
  • Initiation with ventricular overdrive pacing in 72% pts

(triggered); isoproterenol required in 17% of pts

  • Spontaneous sustained tachycardia in 5 pts
  • Termination with adenosine and carotid massage

(triggered)

  • 3D mapping system showed focal activation pattern

from the right atrial septal region

  • Mean tachycardia CL 450+/-64 ms
  • Initiation with ventricular overdrive pacing in 72% pts

(triggered); isoproterenol required in 17% of pts

  • Spontaneous sustained tachycardia in 5 pts
  • Termination with adenosine and carotid massage

(triggered)

  • 3D mapping system showed focal activation pattern

from the right atrial septal region

Zhong et al. HRS 2011 (abstract)

Focal Junctional Tachycardia: Mechanism Focal Junctional Tachycardia: Mechanism

His I II avF V1 V6 CSp CSd Abl His I avF V1

JT- Initiation with atrial overdrive pacing JT- Initiation with atrial overdrive pacing

RVA His I II avF V1 V6 CSd CSp Abl His V1 V3 V6

JT - Initiation with ventricular overdrive pacing JT - Initiation with ventricular overdrive pacing

RVA

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  • Pulls in the next His---- non diagnostic
  • Push out the next His or terminate SVT-

diagnostic

  • Dissociate the His from atrium--- rule out

Parahisian AT

  • Pulls in the next His---- non diagnostic
  • Push out the next His or terminate SVT-

diagnostic

  • Dissociate the His from atrium--- rule out

Parahisian AT

Role of Late APC during SVT to differentiate AVNRT from JT / Parahis AT Role of Late APC during SVT to differentiate AVNRT from JT / Parahis AT

His I II avF V1 V6 CSp CSd Abl His II avF V1 V6

Late PAC pulls in the next His- non diagnostic Late PAC pulls in the next His- non diagnostic

RVA

Poster presentation, HRS 2007

Viswanathan MN et al. HRS abstract. 2007.

Late PAC (His A is committed) terminates SVT Late PAC (His A is committed) terminates SVT Late PAC terminates SVT without affecting the V Late PAC terminates SVT without affecting the V

Viswanathan MN et al. Card Electrophysiol Clin. 2010.

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Late PAC pushes out the next His Late PAC pushes out the next His

Nguyen DT et al. J Cardiovasc Electrophysiol. 2010 Jul 23 (Epub) Nguyen DT et al. Circ Arrhythm Electrophysiol. 2010;3(6):671-3

Wenckebach during SVT Wenckebach during SVT

His I II avF V1 V6 CSp CSd Abl His II avF V1 V6

Late PAC dissociates the next His Late PAC dissociates the next His

Nguyen DT et al. Circ Arrhythm Electrophysiol. 2010;3(6):671-3

380 ms 380 ms

Catheter Ablation Catheter Ablation

  • Map the earliest A during JT with 1:1 VA relationship
  • Stepwise approach in patients with no VA relationship
  • Atrial overdrive pacing to ensure intact AV conduction

during ablation

  • 3D mapping system used to mark earliest A as well as

His

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His I II avF V1 V6 CSp CSd Abl His I avF V1

JT- single PVC to reveal the site of earliest atrial activation JT- single PVC to reveal the site of earliest atrial activation

RVA

JT- 3D Mapping JT- 3D Mapping

  • 17/18 underwent radiofrequency catheter ablation (1 refused)
  • Ablation sites

– Posteroseptal (10) – Midseptal (2) – Anteroseptal (5)

  • 2 patients had transient AV block; conduction returned at the

end of the case, no long term AV block

  • Long term success with no recurrence of JT over 80 month

follow up off drugs

  • 17/18 underwent radiofrequency catheter ablation (1 refused)
  • Ablation sites

– Posteroseptal (10) – Midseptal (2) – Anteroseptal (5)

  • 2 patients had transient AV block; conduction returned at the

end of the case, no long term AV block

  • Long term success with no recurrence of JT over 80 month

follow up off drugs

Zhong et al. HRS 2011 (abstract)

Focal Junctional Tachycardia: Results of Ablation Focal Junctional Tachycardia: Results of Ablation SVT- What is the diagnosis? SVT- What is the diagnosis?

  • 1. AVNRT
  • 2. AVRT
  • 3. AT
  • 4. JT
  • 5. Call Dr. Schienman
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  • Para-hisian AT
  • Focal Junctional Tachycardia
  • Concealed Nodofascicular

(Nodoventricular) tachycardia

  • Para-hisian AT
  • Focal Junctional Tachycardia
  • Concealed Nodofascicular

(Nodoventricular) tachycardia Nodofascicular (Nodoventricular) fibers

  • Double fire
  • Manifest

nodofascicular / nodoventricular

  • Concealed

nodofascicular /nodoventricular tachycardia

  • Double fire
  • Manifest

nodofascicular / nodoventricular

  • Concealed

nodofascicular /nodoventricular tachycardia

CS d CS p V6 HRA His

Baseline split His Baseline split His

II RVA V1

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CS d CS p V6 Abl His

A on V tachycardia A on V tachycardia

II RVA V1 CS d CS p V6 HRA His

VOD terminates SVT VOD terminates SVT

II RVA V1 CS d CS p V6 His

PVC on His advances the next V PVC on His advances the next V

RVA V1 aVF I

380 ms 360 ms

II I V6 His avF V1 CSp CSd

Prolongation of tachycardia CL with LBBB

340 ms 360 ms

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II CS d CS p V1 Abl His

Discrete potential on the ablator at the successful site within the Cs Discrete potential on the ablator at the successful site within the Cs

I RVA CS d CS p V6 ABL

Ablator signal within CS in sinus rhythm Ablator signal within CS in sinus rhythm

RVA V1 aVF I

  • Evidence of AV dissociation during SVT (rules out

extranodal AP)

  • PVC on His during SVT advanced / delayed the

next His and V or terminated SVT

  • Bundle branch block leads to prolongation of VA

interval or tachycardia cycle length

  • Evidence of AV dissociation during SVT (rules out

extranodal AP)

  • PVC on His during SVT advanced / delayed the

next His and V or terminated SVT

  • Bundle branch block leads to prolongation of VA

interval or tachycardia cycle length

Concealed nodofascicular(nodoventricular) tachycardia

Badhwar N…..Scheinman MM. HRS 2009 (abstract)

  • Critical infranodal delay often needed for SVT
  • Fusion during ventricular pacing favors diagnosis
  • f nodoventricular SVT
  • Proximal end of tract (perinodal or within CS)

targeted for RFA

  • Critical infranodal delay often needed for SVT
  • Fusion during ventricular pacing favors diagnosis
  • f nodoventricular SVT
  • Proximal end of tract (perinodal or within CS)

targeted for RFA

Concealed nodofascicular(nodoventricular) tachycardia

Badhwar N…..Scheinman MM. HRS 2009 (abstract)

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Proposed circuit for concealed right sided nodofascicular tachycardia Proposed circuit for concealed right sided nodofascicular tachycardia Proposed circuit for left sided concealed nodofascicular tachycardia Proposed circuit for left sided concealed nodofascicular tachycardia Wide complex Tachycardia Wide complex Tachycardia

  • 1. SVT
  • 4. WPW with preexcited tachycardia

3.Artifact

  • 2. Pacemaker mediated tachycardia

5.Call Dr. Scheinman

Narrow complex tachycardia Narrow complex tachycardia

  • 1. AVNRT
  • 2. AVRT
  • 3. AT
  • 4. Concealed nodofascicular
  • 5. Call Dr. Schienman
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Thank you