Supraventricular Tachycardia Diagnosis and Indications for Ablation - - PowerPoint PPT Presentation

▶
supraventricular tachycardia
SMART_READER_LITE
LIVE PREVIEW

Supraventricular Tachycardia Diagnosis and Indications for Ablation - - PowerPoint PPT Presentation

Dec 31, 2022 201 likes •872 views

Supraventricular Tachycardia Diagnosis and Indications for Ablation Prof. Muhammad A. Hammouda, MD Consultant Electrophysiologist Electrophysiology Laboratory, Cairo University & Dar Al-Fouad Hospital Management of Cardiac Arrhythmias

slide-1
SLIDE 1

Supraventricular Tachycardia

Diagnosis and Indications for Ablation

  • Prof. Muhammad A. Hammouda, MD

Consultant Electrophysiologist Electrophysiology Laboratory, Cairo University & Dar Al-Fouad Hospital

slide-2
SLIDE 2

Management of Cardiac Arrhythmias

Supraventricular Tachycardias

slide-3
SLIDE 3

Management of Cardiac Arrhythmias

Supraventricular Tachycardias

QRS Width

NCT WCT

Regular

AVNRT

Normal AVN/His Conduction Aberration

AVRT

Orthodromic Orthodromic+Aberration Antidromic MRT

AT

Normal AVN/His Conduction Aberration

AFL

Normal AVN/His Conduction Aberration

Irregular

AF

Normal AVN/His Conduction Aberration Antidromic (Px-AF)

slide-4
SLIDE 4

Management of Cardiac Arrhythmias

RF Ablation

slide-5
SLIDE 5

X-Ray film and diagram showing RF ablation of accessory pathway with diagnostic and mapping electrodes (30° RAO projection)

Management of Cardiac Arrhythmias RF Ablation

slide-6
SLIDE 6

Management of Cardiac Arrhythmias

AV Nodal Reentrant Tachycardia

slide-7
SLIDE 7

Mechanism of AVNRT (dual AVN pathway)

Morady, NEJM, 1999

slide-8
SLIDE 8

AVNRT: narrow complex tachycardia (NCT) at a rate of 145/bpm, with retrograde P-wave on terminal part of the QRS complex (arrow)

slide-9
SLIDE 9

Mechanism Goals of Therapy Pharmaco- logic Electric- Ablation Pacing Devices Surgery Macro-circuit (dual AVN pathway)

  • Suppress

Circuit

  • Interrupt

Circuit

  • Digitalis
  • Ia, Ic
  • Beta

Blockers

  • Ca

antagonists

  • Amiodarone
  • Slow/

Fast pathway ablation

  • DDD

pacing for CHB (after ablation)

  • Surgical

dissection / cryoablation

  • f perinodal

tissue

Management of AVNRT (dual AVN pathway)

slide-10
SLIDE 10

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-11
SLIDE 11

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-12
SLIDE 12

Symptomatic Mildly Symptomatic

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-13
SLIDE 13

Symptomatic Mildly Symptomatic

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-14
SLIDE 14

Symptomatic Mildly Symptomatic

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-15
SLIDE 15

Symptomatic Mildly Symptomatic

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-16
SLIDE 16

Indications of RF ablation of AVNRT

  • RF ablation is Class I indication for all

patients with AVNRT.

  • It is the First Priority in symptomatic patients
  • It is the Last Priority in asymptomatic or mildly

symptomatic patients.

  • It is Not Performed if the patient does not desire

it, irrespective of symptoms.

slide-17
SLIDE 17

Intracardiac recording, showing AVNRT with concentric atrial & ventricular activation

slide-18
SLIDE 18

Management of AVNRT (dual AVN pathway)

SP ablation LAO view

slide-19
SLIDE 19

Management of AVNRT (dual AVN pathway)

SP ablation RAO view

slide-20
SLIDE 20

Site of SP ablation during sinus rhythm (the ablation catheter recorded A :V = 0.5)

slide-21
SLIDE 21

During SP ablation, slow junctional rhythm denoting potential successful ablation

slide-22
SLIDE 22

Management of Cardiac Arrhythmias

AV Reentrant Tachycardia

slide-23
SLIDE 23

The Preexcitation Syndrome ( Wolff-Parkinson-White Syndrome) & the Circuit of Reentry

slide-24
SLIDE 24

Location of the accessory pathways (From Gallagher et al., 1978) 1.Right anterior paraseptal, 2.Right anterior 3.Right lateral, 4.Right posterior, 5.Right paraseptal, 6.Left posterior paraseptal,7.Left posterior, 8.Left lateral, 9.Left anterior, 10.Left anterior paraseptal

slide-25
SLIDE 25

Mechanism Goals of Therapy Pharmaco- logic Electric- Ablation Pacing Devices Surgery Macro-circuit (AP+AVN- His – Purkinje)

  • Suppress

Circuit

  • Interrupt

Circuit

  • Ia, Ic
  • Digitalis
  • Beta

Blockers

  • Ca

antagonists

  • Amiodarone
  • AP

ablation

  • Surgical

division / cryoablation

  • f AP

Management of AVRT (accessory pathways)

slide-26
SLIDE 26

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-27
SLIDE 27

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-28
SLIDE 28

Symptomatic

Mildly Symptomatic

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-29
SLIDE 29

Symptomatic

Mildly Symptomatic

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-30
SLIDE 30

Symptomatic

Mildly Symptomatic

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-31
SLIDE 31

Symptomatic

Mildly Symptomatic

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-32
SLIDE 32

Indications of RF ablation of AVRT

  • RF ablation is Class I indication for all

patients with APs-Mediated AVRT/ PxAF.

  • It is Class I indication in symptomatic patients
  • It is the Only indicated Rx in PxAF, untolerated

AVRT

  • It is Class IIa indication in asymptomatic or

mildly symptomatic patients.

slide-33
SLIDE 33

ECG showing preexcited AF at the rate of @ 220/bpm Location of the AP is left posteroseptal (maximal preexcitation shows +ve delta in V1 & -ve delta in inferior leads)

slide-34
SLIDE 34

12-lead ECG in sinus rhythm showing manifest WPW syndrome utilizing left posteroseptal AP (+ve delta in V1 & -ve delta in inferior leads)

slide-35
SLIDE 35

Intracardiac tracing showing surface LI and V2 (preexcited) and shortest AV in PCS (in sinus rhythm) denoting the presence of posteroseptal AP. RF ablation was applied via the ablation catheter which recorded shortest AV than that of PCS catheter

slide-36
SLIDE 36

During RF ablation, normolization of the QRS complex and AV prolongation denoting successful ablation.

slide-37
SLIDE 37

Management of AVRT (accessory pathways)

LLAP-RAO-atrial side

slide-38
SLIDE 38

Management of AVRT (accessory pathways)

LLAP-RAO-ventricular side

slide-39
SLIDE 39

Management of Cardiac Arrhythmias

Atrial FLutter

slide-40
SLIDE 40

Mechanism of Atrial Flutter (AFL)

Kalman et al., Circulation. 1996;94:398

Schematic depicting the entire flutter circuit in red rotating counterclockwise around the TA. Blue arrows represent passive activation

  • utside the circuit.

The crista terminalis and the ER act as lines of block preventing activation from "short circuiting" the annulus.

slide-41
SLIDE 41

Diagnosis of Atrial Flutter (AFL)

slide-42
SLIDE 42

Diagnosis of Atrial Flutter (AFL)

Adenosine in AFL

slide-43
SLIDE 43

Mechanism Goals of Therapy Pharmaco- logic Electric- Ablation Pacing Devices Surgery Macro- reentrant circuit (passing through the IVC-CS isthmus)

  • Slow VR
  • Resume

SR

  • Prevent

Recurrence

  • Digitalis
  • Beta

Blockers

  • Ca

antagonists

  • Amiodarone
  • Ia, Ic
  • Amiodarone
  • Ia, Ic
  • Amiodarone
  • AVJ

ablation

  • External

CV

  • Ablation

(IVC-CS block)

PM after AVJ ablation

  • Atrial

defibrillator

  • Antitachy-

cardia pacing-ATP

  • Surgical

division / cryoablation

  • f His

bundle

  • Left atrial

isolation

  • Corridor
  • peration
  • Maze
  • peration

Management of Atrial Flutter (AFL)

slide-44
SLIDE 44

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-45
SLIDE 45

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-46
SLIDE 46

Symptomatic MSx

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-47
SLIDE 47

Symptomatic MSx

ACC/AHA/ESC Practice Guidelines for Management of Patients With Supraventricular Arrhythmias, 2003

slide-48
SLIDE 48

Indications of RF ablation of AFL

  • RF ablation is indicated in all patients

with AFL

  • It is Class I indication in symptomatic patients
  • It is Class IIa indication in first episode pts and

symptomatic non-CTI dependent AFL

slide-49
SLIDE 49

Management of Cardiac Arrhythmias

Atrial Fibrillation

slide-50
SLIDE 50

Pharmacologic Treatment

1-Restroration of sinus rhythm 2-Prevention of recurrence of AF 3-Control of ventricular response of AF 4-Anticoagulation

Non-pharmacologic Treatment

1-Ablation: Linear ablation, Focal ablation, AVN ablation 2-PM Therapy: Multisite atrial pacing, Atrial Defibrillators 3-Electric Cardioversion: ICV, ECV 4-Surgical Ablation: Corridor operation, Maze operation

Therapy of AF

slide-51
SLIDE 51

Mechanism Goals of Therapy Pharmaco- logic Electric- Ablation Pacing Devices Surgery Multiple reentrant wavelets (circuits)

  • Slow VR
  • Resume

SR

  • Prevent

Recurrence

  • Anticoag-

ulation

  • Rx of

Cause

  • Digitalis
  • Beta

Blockers

  • Ca

antagonists

  • Amiodarone
  • Ia, Ic
  • Amiodarone
  • Ia, Ic
  • Amiodarone
  • Heparin
  • Warfarin
  • ASA
  • AVN

modification

  • AVJ

Ablation

  • External CV
  • Internal CV
  • Maze-like

Ablation

  • PV

disconnec- tion PM after AVJ ablation

  • Atrial

defibrillator

  • Antitachy-

pacing-ATP

  • Biatrial

pacing-BAP

  • Atrial

pacing in SSS

  • Surgical

division / cryoablation

  • f His

bundle

  • Left atrial

isolation

  • Corridor
  • peration
  • Maze
  • peration

Management of Atrial Fibrillation (AF)

slide-52
SLIDE 52

Pharmacologic Treatment of AF

AF THERAPY

ANTITHROMBOTIC RX RHYTHM CONTROL RATE CONTROL

OR ? AND

slide-53
SLIDE 53

Target sites for different radiofrequency ablation approaches in treating atrial fibrillation:

1 pulmonary vein ectopic foci, 2 proximal bundle of His, 3 atrial walls for linear ablation

slide-54
SLIDE 54

Maloney et al. In: Interventional electrophysiology; 1997.

  • AVN Ablation:
  • RF catheter positioned at

compact AV node

  • Radiofrequency (RF)

energy applied

  • AVN Modification :

involves a more inferoposterior “shaving” approach

AV Node Ablation: Technique

slide-55
SLIDE 55

Before After

AV Node Ablation: Technique

slide-56
SLIDE 56

Placement of Catheters

slide-57
SLIDE 57

Electrophysiologic guided PV disconnection

Mapping (Lasso) and Ablation Catheters

Placement of Catheters

slide-58
SLIDE 58

Case Study

EP-Guided Pulmonary Vein Ostial Ablation

slide-59
SLIDE 59

An Algorithm for Management of AF

slide-60
SLIDE 60

Pharmacologic Treatment of AF

Fuster V et al. ACC/ AHA/ ESC guidelines. Eur Heart J 2 0 0 1 ;2 2 :1 8 5 2 -1 9 2 3

slide-61
SLIDE 61

Pharmacologic Treatment of AF

Fuster V et al. ACC/ AHA/ ESC guidelines. Eur Heart J 2 0 0 1 ;2 2 :1 8 5 2 -1 9 2 3 AARx for Rhythm Control AARx for Rhythm Control

ECV as needed

slide-62
SLIDE 62

Indication for Surgery or PM ? Indication for Surgery Indication for PM Maze CRT DDDRP SSS HF MVS

Non-Pharmacologic Treatment of AF

NO Yes Yes

Ablate and Pace

slide-63
SLIDE 63

Indication for Surgery or PM ? LA disease PV disease 3D- guided AF Ablation EP- guided AF Ablation Indication for AF Ablation ? LA disease

Non-Pharmacologic Treatment of AF

NO

Ablate and Pace

slide-64
SLIDE 64

Indication for Surgery or PM ? Indication for Surgery Indication for PM Maze CRT DDDRP LA disease PV disease 3D- guided AF Ablation EP- guided AF Ablation SSS HF MVS Indication for AF Ablation ? LA disease

Non-Pharmacologic Treatment of AF

NO Yes Yes

Ablate and Pace

slide-65
SLIDE 65

Thank You

slide-66
SLIDE 66