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New frontiers of supraventricular tachycardia and atrial flutter evaluation and catheter ablation
(2012)
Radiofrequency catheter ablation (RFCA) has revolutionized treatment for tachyarrhythmias and has become first-line therapy for some tachycardias. Although developed in the 1980s and widely applied in the 1990s, the technique is still in development. Transesophageal atrial pacing (TAP) can used for initiation and termination of supraventricular tachycardia (SVT).
Methods: The paroxysmal SVT include a wide spectrum of disorders including, in descending order of frequency, atrial flutter, atrioventricular (AV) nodal reentry, Wolff-Parkinson-White syndrome, and atrial tachycardia. While not life-threatening in most cases, they may cause important symptoms, such as palpitations, chest discomfort, breathlessness, anxiety, and syncope, which significantly impair quality of life. Medical therapy has variable efficacy, and most patients are not rendered free of symptoms. Research over the past several decades has revealed fundamental mechanisms involved in the initiation and maintenance of all of these arrhythmias. Knowledge of mechanisms has in turn led to highly effective surgical and catheter-based treatments. The supraventricular arrhythmias and their treatment are described in this report. SVT initiation was analysed with programmed TAP in 49 patients with palpitations (age 47 ± 17 years, 24 females, 25 males).
Results: In comparison to antiarrhythmic drug therapy the radiofrequency catheter ablation in patients suffering from atrial flutter, atrioventricular nodal reentry, atrioventricular reentry and atrial tachycardia is the better choice in most cases. TAP SVT initiation was possible in 23 patients before RFCA. Atrial cycle length of SVT was 320 ± 59 ms. We initiated AV nodal reentrant tachycardia (AVNRT, n=15), atrial tachycardia (AT, n=6) and AV reentrant tachycardia with Kent pathway conduction (AVRT, n=2) before RFCA.
Conclusions: Radiofrequency catheter ablation is a successful and safe method to cure most patients with paroxysmal supraventricular tachycardias. TAP allowed initiation and termination of SVT especially in outpatients.
Cardiac resynchronization therapy (CRT) with hemodynamic optimized biventricular pacing is an established therapy for heart failure patients with sinus rhythm, reduced left ventricular ejection fraction and wide QRS complex. The aim of the study was to evaluate electrical right and left cardiac atrioventricular delay and left atrial delay in CRT responder and non-responder with sinus rhythm.
Methods: Heart failure patients with New York Heart Association class 3.0 ± 0.3, sinus rhythm and 27.7 ± 6.1% left ventricular ejection fraction were measured by surface ECG and transesophageal bipolar left atrial and left ventricular ECG before implantation of CRT devices. Electrical right cardiac atrioventricular delay was measured between onset of P wave and onset of QRS complex in the surface ECG, left cardiac atrioventricular delay between onset of left atrial signal and onset of left ventricular signal in the transesophageal ECG and left atrial delay between onset and offset of left atrial signal in the transesophageal ECG.
Results: Electrical atrioventricular and left atrial delay were 196.9 ± 38.7 ms right and 194.5 ± 44.9 ms left cardiac atrioventricular delay, and 47.7 ± 13.9 ms left atrial delay. There were positive correlation between right and left cardiac atrioventricular delay (r = 0.803 P < 0.001) and negative correlation between left atrial delay and left ventricular ejection fraction (r = −0.694 P = 0.026) with 67% CRT responder.
Conclusions: Transesophageal electrical left cardiac atrioventricular delay and left atrial delay may be useful preoperative atrial desynchronization parameters to improve CRT optimization.
Background: Cardiac resynchronization therapy (CRT) is an established therapy for heart failure (HF) patients (P) with reduced left ventricular (LV) ejection fraction and electrical interventricular desynchronization, but not all P improved clinically. The aim of the study was to evaluate electrical interventricular delay (IVD) to LV delay (LVD) ratio in atrial fibrillation (AF) CRT responder (R) and non-responder (NR).
Methods: AF P (n = 18, age 60.6 ± 11.4 years, 1 female, 17 males) with HF New York Heart Association (NYHA) class 3.0 ± 0.2, 25.3 ± 5.9 % LV ejection fraction and 157.8 ± 24.4 ms QRS duration (QRSD) were measured by surface ECG and focused transesophageal bipolar LV ECG before implantation of CRT pacemaker (n = 2) or CRT defibrillator (n = 16). IVD was measured between onset of QRS in the surface ECG and onset of LV signal in the LV ECG. LVD was measured between onset and offset of LV signal in the LV ECG.
Results: Electrical ventricular desynchronization in AF CRT P were 61.9 ± 26.9ms IVD, 80.6 ± 24.3ms LVD, 0.85 ± 0.41 IVD-LVD-ratio (Figure), 3.12 ± 1.89 QRSD-IVD-ratio and 2.07 ± 0.47 QRSD-LVD-ratio. There were 72.2 % AF CRT R (n = 13) with 64.2 ± 24.6ms IVD and 77.8 ± 21.6ms LVD with Pearson correlation to 0.89 ± 0.39 IVD-LVD-ratio (r = 0.87, P < 0.01; r = -0.69, P < 0.01), 2.82 ± 1.32 QRSD-IVD-ratio (r = -0.76, P < 0.01; r = 0.67, P = 0.011) and 2.13 ± 0.46 QRSD-LVD-ratio (r = 0.57, P = 0.041; r = -0.85, P < 0.01). There were 27.8% AF CRT NR (n = 5) with 56.0 ± 34.5ms IVD and 87.8 ± 31.9ms LVD without correlation to 0.74 ± 0.48 IVD-LVD-ratio, 3.88 ± 2.98 QRSD-IVD-ratio and 1.90 ± 0.48 QRSD-LVD-ratio. During 15.3 ± 13.1 month CRT follow-up, the AF CRT R NYHA class improved from 3.0 ± 0.2 to 2.2 ± 0.3 (P < 0.001). During 18.8 ± 20.7 month CRT follow-up, the AF CRT NR NYHA class not improved from 3 to 3.3 ± 0.97.
Background: Cardiac resynchronization therapy (CRT) with biventricular (BV) pacing is an established therapy for heart failure (HF) patients (P) with sinus rhythm, reduced left ventricular (LV) ejection fraction (EF) and electrical ventricular desynchronization. The aim of the study was to evaluate electrical interventricular delay (IVD) and left ventricular delay (LVD) in right ventricular (RV) pacemaker pacing before upgrading to CRT BV pacing.
Methods: HF P (n=11, age 69.0 ± 7.9 years, 1 female, 10 males) with DDD pacemaker (n=10), DDD defibrillator (n=1), RV pacing, New York Heart Association (NYHA) class 3.0 ± 0.2 and 24.5 ± 4.9 % LVEF were measured by surface ECG and transesophageal bipolar LV ECG before upgrading to CRT defibrillator (n=8) and CRT pacemaker (n=3). IVD was measured between onset of QRS in the surface ECG and onset of LV signal in the transesophageal ECG. LVD was measured between onset and offset of LV signal in the transesophageal ECG. CRT atrioventricular (AV) and BV pacing delay were optimized by impedance cardiography.
Results: Interventricular and intraventricular desynchronization in RV pacemaker pacing were 228.2 ± 44.8 ms QRS duration, 86.5 ± 32.8ms IVD, 94.4 ± 23.8ms LVD, 2.6 ± 0.8 QRS-IVD-ratio with correlation between IVD and QRS-IVD-ratio (r=-0.668 P=0.0248) and 2.3 ± 0.7 QRS-LVD-ratio. The LVEF-IVD-ratio was 0.3 ± 0.1 with correlation between IVD and LVEF-IVD-ratio (r=-0.8063 P=0.00272) and with correlation between QRS duration and LVEF-IVD-ratio (r=-0.7251 P=0.01157). Optimal sensing and pacing AV delay were 128.3 ± 24.8 ms AV delay after atrial sensing (n=6) and 173.3 ± 40.4 ms AV delay after atrial pacing (n=3). Optimal BV pacing delay was -4.3 ± 11.3 ms between LV and RV pacing (n=7). During 30.4 ± 29.6 month CRT follow-up, the NYHA class improved from 3.1 ± 0.2 to 2.2 ± 0.3.
Conclusions: Transesophageal electrical IVD and LVD in RV pacemaker pacing may be additional useful ventricular desynchronization parameters to improve P selection for upgrading RV pacemaker pacing to CRT BV pacing.
Hintergrund: Das elektrische interventrikuläre Delay (IVD) ist bei Patienten (P) mit Herzinsuffizienz (HF), reduzierter linksventrikulärer (LV) Funktion und verbreitertem QRS Komplex von Bedeutung für den Erfolg der kardialen Resynchronisationstherapie (CRT). Die transösophageale LV Elektrokardiographie (EKG) ermöglicht die Bestimmung des elektrischen IVD und linksventrikulären Delays (LVD). Das Ziel der Studie besteht in der Untersuchung des transösophagealen elektrischen IVD, LVD und deren Verhältnis zur QRS Dauer bei rechtsventrikulärer (RV) Stimulation vor Aufrüstung auf eine biventrikuläre (BV) Stimulation.
Methoden: Bei 11 HF P (Alter 69,0 ± 7,9 Jahre; 10 Männer und 1 Frau) mit DDD Schrittmacher (n=10), DDD Defibrillator (n=1) und RV Stimulation, New York Heart Association (NYHA) Klasse 3,0 ± 0,2, LV Ejektionsfraktion 24,5 ± 4,9 % und QRS-Dauer 228,2 ± 44,8 ms wurden das elektrische IVD als Intervall zwischen Beginn des QRS-Komplexes im Oberflächen EKG und Beginn des LV Signals im transösophagealen LV EKG und das elektrische LVD als Intervall zwischen Beginn und Ende des LV Signals im transösophagealen LV EKG präoperativ vor Aufrüstung auf CRT Defibrillator (n=8) und CRT Schrittmacher (n=3) bestimmt. Der Anstieg des arteriellen Pulse Pressure (PP) wurde zwischen RV Stimulation und transösophagealer LV Stimulation mit unterschiedlichem AV-Delay (n=5) vor Aufrüstung von RV auf BV Stimulation getestet.
Ergebnisse: Bei RV Stimulation betrugen IVD 86,54 ± 32,80 ms, LVD 94,45 ± 23,80 ms, QRS-IVD-Verhältnis 2,63 ± 0,81 mit negativer Korrelation zwischen IVD und QRS-IVD-Verhältnis (r=-0,668 P=0,0248) (Fig.) und QRS-LVD-Verhältnis 2,33 ± 0,73. Vorhofsynchrone ventrikuläre Stimulation führte zu 63,6 ± 27,7 mmHg PP bei RV Stimulation und 80,6 ± 38,5 mmHg PP bei LV Stimulation und der PP erhöhte sich bei LV Stimulation mit optimalem AV Delay um 17 ± 11,2 mmHg gegenüber RV Stimulation (P<0,001). Nach Aufrüstung von RV Stimulation auf BV Stimulation verbesserten sich die NYHA Klasse von 3,1 ± 0,2 auf 2,2 ± 0,3 während 30,4 ± 29,6 Monaten CRT.
Schlussfolgerungen: Das transösophageale LV EKG ermöglicht die Bestimmung des elektrischen IVD und LVD bei RV Stimulation zur Evaluierung der interventrikulären und linksventrikulären elektrischen Desynchronisation. IVD, LVD und deren Verhältnis zur QRS Dauer können möglicherweise zur Vorhersage einer CRT Response vor Aufrüstung von RV auf BV Stimulation genutzt werden.