New Approach for Atrioventricular Conduction Modulation by Ablation at a Distance From the Atrioventricular Node
2021; Lippincott Williams & Wilkins; Volume: 14; Issue: 4 Linguagem: Inglês
10.1161/circep.120.009550
ISSN1941-3149
AutoresJosé Luis Ibáñez, Alicia Ibáñez-Críado, Teresa Barrio-López, Thomas Brouzet, Eduardo Castellanos, Mercedes Ortiz, Jessica Sánchez-Quiñones, Amaya García-Fernández, Pablo Ramos-Ruiz, Santiago Heras, Raquel Ajo, M. A. Galvany Ferrer, María Carmen Rico, Juan Antonio Quiles, Francisco Sogorb-Garri, Juan Martínez, Jesús Almendral,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 14, No. 4New Approach for Atrioventricular Conduction Modulation by Ablation at a Distance From the Atrioventricular Node Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBNew Approach for Atrioventricular Conduction Modulation by Ablation at a Distance From the Atrioventricular NodeRole in Nonpharmacologic Rate Control of Atrial Tachyarrhythmias José Luis Ibáñez Criado, MD, PhD, Alicia Ibáñez Criado, BS, Teresa Barrio-López, MD, PhD, Thomas Brouzet, BS, Eduardo Castellanos, MD, PhD, Mercedes Ortiz, MD, PhD, Jessica Sánchez-Quiñones, MD, PhD, Amaya Garcia-Fernández, MD, PhD, Pablo Ramos-Ruiz, BS, Santiago Heras, MD, PhD, Raquel Ajo Ferrer, MD, PhD, Maria Ajo Ferrer, BS, Maria Rico, BS, Juan Antonio Quiles, BS, Francisco Sogorb-Garri, MD, PhD, Juan Gabriel Martínez Martínez, BS and Jesús Almendral, MD, PhD José Luis Ibáñez CriadoJosé Luis Ibáñez Criado Correspondence to: José Luis Ibáñez Criado, MD, PhD, Arrythmia Unit, Department of Cardiology, Hospital General Universitario de Alicante, Spain. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0792-6669 Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Alicia Ibáñez CriadoAlicia Ibáñez Criado https://orcid.org/0000-0001-7352-6597 Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Teresa Barrio-LópezTeresa Barrio-López Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain (T.B.-L., E.C., M.O., J.A.). , Thomas BrouzetThomas Brouzet https://orcid.org/0000-0003-1289-3240 Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Eduardo CastellanosEduardo Castellanos https://orcid.org/0000-0002-5081-8252 Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain (T.B.-L., E.C., M.O., J.A.). , Mercedes OrtizMercedes Ortiz Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain (T.B.-L., E.C., M.O., J.A.). , Jessica Sánchez-QuiñonesJessica Sánchez-Quiñones Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Amaya Garcia-FernándezAmaya Garcia-Fernández https://orcid.org/0000-0002-8040-0527 Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Pablo Ramos-RuizPablo Ramos-Ruiz https://orcid.org/0000-0002-3161-0560 Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Santiago HerasSantiago Heras Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Raquel Ajo FerrerRaquel Ajo Ferrer https://orcid.org/0000-0001-9467-9517 Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Maria Ajo FerrerMaria Ajo Ferrer Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Maria RicoMaria Rico Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Juan Antonio QuilesJuan Antonio Quiles Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Francisco Sogorb-GarriFrancisco Sogorb-Garri Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). , Juan Gabriel Martínez MartínezJuan Gabriel Martínez Martínez https://orcid.org/0000-0003-2255-3530 Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL foundation) (J.L.I.C., A.I., T.B., J.S.-Q., A.G.-F., P.R.-R., S.H., R.A.F., M.A.F., M.R., J.A.Q., F.S.-G., J.G.M.M.). and Jesús AlmendralJesús Almendral https://orcid.org/0000-0001-6223-0862 Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain (T.B.-L., E.C., M.O., J.A.). Originally published16 Apr 2021https://doi.org/10.1161/CIRCEP.120.009550Circulation: Arrhythmia and Electrophysiology. 2021;14Therapeutic strategies for atrial fibrillation include rhythm control and rate control. However, the failure rate for the former is substantial, and pharmacological control for the latter is sometimes insufficient. Ablation of atrioventricular nodal (AVN) conduction and pacemaker implantation is a therapy of last resort for rate control.1The modulation of AVN conduction was postulated years ago as a possible alternative but has currently been abandoned because of the unpredictability of the short- and long-term results and a significant rate of high-grade inadvertent atrioventricular block.2,3We recently reported that right atrial septal applications intended to produce interatrial disconnection may produce AVN modulation.4Thus, we prospectively tested the hypothesis that an ablation line around the AVN but at a distance from it produces effective AVN modulation without inadvertent atrioventricular block.From June 2015 to December 2018, 33 patients with a history of symptomatic refractory atrial fibrillation or atypical atrial flutter that were not amenable to rhythm control (see Data Supplement) were recruited in 2 centers. The study was approved by the ethics committees of both institutions. The data of this study are available from the corresponding author upon reasonable request.An irrigated-tip ablation catheter with contact force-sensing technology was used for mapping and ablation.The procedures were performed during sinus rhythm. Electroanatomical activation mapping of the right atrium was performed during ventricular stimulation to identify the right atrial breakthrough (presumably the main atrial insertion of the AVN). A semicircumferential line with a diameter of at least 1.5 cm was empirically drawn around that site. This line (primary ablation line, Figure [A] and [B]) was divided into 3 segments of approximately equal longitude (Figure [A]) for evaluating the ablation effects. Ablation started at the lower segment and continued upward toward the middle and upper segments. Point by point lesions were delivered with a power of 25 W. If the primary ablation line was not successful, additional applications were delivered inside the ablation line (secondary ablation line, Figure [C]), always maintaining a distance of at least 0.5 cm to the right atrial breakthrough site. Conduction intervals and atrioventricular block cycle length were frequently measured, at least after each ablation segment.Download figureDownload PowerPointFigure. Example of electroanatomical map of the right atrial electrical activation during ventricular pacing and the different segments of the ablation line that produced atrioventricular node (AVN) modulation. The green balls represent sites where His bundle activation was recorded. The white area represents the right atrial breakthrough. The red balls represent radiofrequency applications. A, Primary ablation line. The white lines demarcate segments for evaluation of success. B, Primary ablation line in right anterior oblique projection. C, Secondary ablation line depicting location of additional applications and success for each segment. CS indicates coronary sinus; RF, radiofrequency; and TA, tricuspid annulus.Modulation was considered successful if 2 end points were fulfilled: (1) an increase in atrioventricular block cycle length >50 ms, (2) atrioventricular block cycle length exceeding 450 ms.Successful AVN modulation occurred in 29 patients (88%), and no case of persistent high-degree AVN block was observed (transient atrioventricular block in 12%). Modulation occurred during the primary ablation line in 15 patients (45%), in the lower (12%), middle (12%), or upper segment (21%, Figure [A]). The mean distance between the right atrial breakthrough and the His bundle electrogram was 0.62 cm (see Data Supplement). Modulation occurred during the secondary ablation line in 14 patients (42%, Figure [C]). No major procedural complications occurred.During the 1-year follow-up, 3 patients (10%), who initially achieved successful modulation, recurred with rapid ventricular rates.In 24-hour Holter monitoring, maximum and average heart rates were significantly decreased after modulation (median, 150 beats per minute preablation versus 120 during follow-up, P<0.001 for maximum and 108 versus 78, P<0.001 for average heart rate). The left ventricular ejection fraction improved (mean baseline left ventricular ejection fraction 49.8%; 1-year follow-up left ventricular ejection fraction 56.9%; P=0.018) and so did the New York Heart Association functional class (mean baseline 2.5; 1-year follow-up 1.4; P<0.001; see Data Supplement).This study provided information on the feasibility, efficacy, and safety of performing an ablation line around, but at a distance, from the AVN to modulate AVN conduction. AVN modulation occurring at a certain (and variable) distance to the atrioventricular node and at different anatomic areas could be consistent with (1) an impairment in the conduction due to injury to extensions of the atrioventricular node or transitional cells, as anatomic studies show that there are typically 3 atrioventricular nodal extensions but also that on all sides, the compact node has transitional cells interposed between it and the ordinary atrial myocardium atrioventricular block5; (2) person-to-person variability in the size and location of these structures.Thus, the observed changes could be consistent, on the one hand with slow pathway modification (increase in the atrioventricular block cycle length), but on the other hand with fast pathway impairment (increase in PR and AH intervals, Table IV in the Data Supplement), or even with damage to direct minor inputs to the compact node.A comparative study atrioventricular block3 of classic AVN modulation with AVN ablation and pacemaker implantation showed higher efficacy and shorter procedure and fluoroscopy times for the latter but similar long-term results. Thus, a procedure that produces AVN modulation with a high success rate and no risk of atrioventricular block could be appealing to some candidates to AVN ablation, since it does not preclude subsequent AVN ablation if results are unsatisfactory. We think that if our results can be reproduced at a larger scale, AVN modulation could regain clinical interest.Nonstandard Abbreviations and AcronymsAVNatrioventricular nodalAcknowledgmentsWe acknowledge Fernando Sirvent and Ángel Sánchez-Barbie for her contribution to this work. We thank Jesús Soriano for editing the images used in this article.Sources of FundingNone.Supplemental MaterialsData Supplement Tables I–IVData Supplement Figures I–VIIDisclosures None.FootnotesFor Sources of Funding and Disclosures, see page 459.The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCEP.120.009550.Correspondence to: José Luis Ibáñez Criado, MD, PhD, Arrythmia Unit, Department of Cardiology, Hospital General Universitario de Alicante, Spain. Email [email protected]comReferences1. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, et al.; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society.Circulation. 2014; 130:2071–2104. doi: 10.1161/CIR.0000000000000040LinkGoogle Scholar2. Williamson BD, Man KC, Daoud E, Niebauer M, Strickberger SA, Morady F. Radiofrequency catheter modification of atrioventricular conduction to control the ventricular rate during atrial fibrillation.N Engl J Med. 1994; 331:910–917. doi: 10.1056/NEJM199410063311404CrossrefMedlineGoogle Scholar3. Proclemer A, Della Bella P, Tondo C, Facchin D, Carbucicchio C, Riva S, Fioretti P. Radiofrequency ablation of atrioventricular junction and pacemaker implantation versus modulation of atrioventricular conduction in drug refractory atrial fibrillation.Am J Cardiol. 1999; 83:1437–1442. doi: 10.1016/s0002-9149(99)00121-6CrossrefMedlineGoogle Scholar4. Ibáñez JL, Ibáñez A, Barrio T, Ortiz M, Ajo R, Castellanos E, Heras S, Brouzet T, Sánchez J, Ajo M, et al.. Lessons learned in attempting catheter-based interatrial electrical disconnection for nonpharmacologic rate control of atrial fibrillation or flutter.J Interv Card Electrophysiol. 2020; 57:333–343. doi: 10.1007/s10840-018-0448-6CrossrefMedlineGoogle Scholar5. Anderson RH, Ho SY. The morphology of the specialized atrioventricular junctional area: the evolution of understanding.Pacing Clin Electrophysiol. 2002; 25:957–966. doi: 10.1046/j.1460-9592.2002.00957.xCrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 2021Vol 14, Issue 4Article InformationMetrics Download: 269 © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.120.009550PMID: 33858181 Originally publishedApril 16, 2021 Keywordspacemakerablationatrial fibrillationatrioventricular blockatrioventricular nodePDF download SubjectsAtrial FibrillationCatheter Ablation and Implantable Cardioverter-DefibrillatorElectrophysiology
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