2019 ESC Guidelines for the management of patients with supraventricular tachycardia : The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC): Developed in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC)

2019 ESC Guidelines for themanagement of patients with supraventricular tachycardia

Cyanotic Conditions Patients with cyanotic congenital heart disease have arterial oxygen desaturation resulting from the shunting of systemic venous blood to the arterial circulation. The magnitude of shunting determines the severity of desaturation. Most children with cyanotic heart disease do not survive to adulthood without surgical intervention. In adults, the most common causes of cyanotic congenital heart disease are tetralogy of Fallot61 and Eisenmenger's syndrome. Tetralogy of Fallot Tetralogy of Fallot, the most common cyanotic congenital heart defect after infancy, is characterized by a large ventricular septal defect, an aorta that overrides the left and right ventricles, obstruction of the . . .

https://www.nejm.org/doi/pdf/10.1056/NEJM200001273420407?listPDF=true

Congenital heart disease in adults: First of two parts

PACES/HRS Expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease

Ebstein’s anomaly is a rare congenital heart disorder occurring in 1 per 200 000 live births and accounting for 1% of all cases of congenital heart disease.2–6 This anomaly was described by Wilhelm Ebstein in 1866 in a report titled, “Concerning a very rare case of insufficiency of the tricuspid valve caused by a congenital malformation.” 7,8 The patient was a 19-year-old cyanotic man with dyspnea, palpitations, jugular venous distension, and cardiomegaly. 7,8 At autopsy, Ebstein described an enlarged and fenestrated anterior leaflet of the tricuspid valve. The posterior and septal leaflets were hypoplastic, thickened, and adherent to the right ventricle. There was also a thinned and dilated atrialized portion of the right ventricle, an enlarged right atrium, and a patent foramen

Ebstein’s Anomaly

Jonathan L. Halperin, MD, FACC, FAHA, Chair 

Glenn N. Levine, MD, FACC, FAHA, Chair-Elect 

Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair [¶][1]

Nancy M. Albert, PhD, RN, FAHA[¶][1]

Sana M. Al-Khatib, MD, MHS, FACC, FAHA

Kim K. Birtcher, PharmD, AACC

Biykem Bozkurt, MD, PhD, FACC

2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society

Background In patients with Ebstein's anomaly, localization of accessory pathways (APs) may be impeded by abnormal local electrograms recorded along the atrialized right ventricle and by the presence of multiple APs The impact of these factors on radiofrequency (RF) current catheter ablation of APs has not been evaluated yet Methods and Results Twenty-one patients with Ebstein's anomaly and reentrant atrioventricular tachycardias underwent electrophysiological evaluation and subsequent attempts at RF catheter ablation Thirty-four right-sided APs were found, with 30 located along the atrialized ventricle Local electrograms in this region were normal in 10 patients but fragmented in 11 Fragmented electrograms prevented the clear distinction between atrial and ventricular activation potentials as well as the identification of AP potentials Right coronary artery mapping was performed in 7 patients Abolition of all 26 APs was achieved in the 10 patients with normal local electrograms and in 6 of 11 pati

Radiofrequency Current Catheter Ablation of Accessory Atrioventricular Pathways in Ebstein's Anomaly

Die Hochfrequenzstrom-(HFS)-Ablation stellt in den letzten Jahren ein neues kuratives Therapieverfahren fur ektope atriale Tachykardien (EAT) dar. Wir untersuchten unterschiedliche Mapping-Strategien bei der HFS-Ablation von rechts- und linksseitigen EAT-Foki. Eingeschlossen in die Studie wurden 48 Patienten (35±18 Jahre) mit 52 EAT-Foki. Zur Lokalisation der Foki verwendeten wir das Aktivierungs-Mapping im bipolaren Lokalelektrogramm und die morphologische Beurteilung des unipolaren Lokalelektrogramms (QS-Komplex). Im Falle von mechanischen Blockierungen wurden die stimulierten P-Wellen im Oberflachen-EKG mit den P-Wellen wahrend EAT verglichen.Ergebnisse: Bei 44 Patienten konnten 46 EAT (zehn links- und 36 rechtsseitige) durch HFS-Ablation terminiert werden. Bei den linksseitigen EAT waren 40% in dem Bereich der Pulmonalvenen lokalisiert. Die durchschnittliche Prozedurund Durchleuchtungsdauer unterschied sich nicht zwischen links-(304±131 min bzw. 39±29 min) und rechtsseitiger, (241±101 min bzw. 31±19 min) Lokalisation. Das Intervall zwischen dem Lokalelektrogramm und dem Beginn der P-Welle war bei links- (45±22 ms) im Vergleich zu rechtsseitiger (30±18 ms) Fokuslokalisation signifikant langer. Bei zehn Patienten (20%) kam es wahrend des Mappings zu mechanischen Blockierungen. Die Lokalisation des Ursprungsorts wahrend mechanischer Blockierung gelang mit Hilfe des Vergleichs der P-Welle von EAT und Stimulation in acht Fallen. Bei zwei Patienten kam es innerhalb von 24 Stunden zum erneuten Auftreten der EAT. Wahrend der Nachbeobachtung von vier bis 58 Monaten kam es drei bis acht Monate nach Ablation bei vier Patienten (8%) zu einem Rezidiv der EAT. Schlusfolgerungen: 1. Die HFS-Ablation von EAT ist sowohl fur links- als auch rechtsseitige Ursprungsorte ein effektives und risikoarmes. Therapieverfahren. Die Prozedur- und Durchleuchtungsdauer unterscheiden sich nicht bei rechts- und linksseitiger Lokalisation. 2. Durch haufige Lokalisationen linksseitiger EAT in dem Bereich der Pulmonalvenen zeigt das Aktivierungs-Mapping hier ein fruheres Lokalelektrogramm im Verhaltnis zur P-Welle als bei rechtsseitigen EAT. 3. Es kommt in etwa 20% der HFS-Ablationen von EAT zu mechanischen Blockierungen. Wahrend Blockierung kann der Vergleich der stimulierten P-Welle mit der EAT-P-Welle eine nutzliche Hilfe zur Lokalisation des Ursprungs der EAT darstellen.

Hochfrequenzstromablation von ektopen atrialen Tachykardien

Ectopic atrial tachycardia (EAT) is a rare form of supraventricular tachycardia and often drug-resistant. Radiofrequency catheter (RFC) ablation offers an alternative therapy suggesting a high efficacy rate. Localization of the EAT origin is proposed to be efficacious by various mapping strategies. We analyzed the efficacy of different mapping strategies for localization of right and left sided EAT foci.Methods and Patients: In a cohort of 48 patients (25 female; age 35±18 years) RFC ablation of 40 right and 12 left sided EAT foci was performed. Mapping of the right atrium was achieved with 2 ablation catheters using the “encircling” technique (Figure 1). We looked for an early bipolar local electrogram in relation to the onset of the P-wave and a QS-complex in the unipolar electrogram. The bipolar local electrogram was retrospectively analyzed for a fragmented morphology and duration of more than 50 ms (Figure 3). In case of mechanical block of the EAT during mapping P-wave pace mapping over the mapping catheter was performed (Figure 4).Results: RFC ablation succeeded in 44 patients with 46 EAT foci (Figure 5). Left sided EAT origin was in 40% in the region of the pulmonary veins. Two left sided foci were abladed within the coronary sinus. An anteroseptal location in vicinity to the bundle of His was found in 4 cases (Figure 6). There were no differences between left and right sided origin regarding session duration (304±131 vs 241±101 min) and fluoroscopic time (39±29 vs 31±19 min). The activation time related to the onset of the P-wave was at successful ablation site for left sided origin significantly earlier compared to a right sided origin (45±22 vs 30±18 ms). Fragmentation of the bipolar local electrogram was found before successful RFC application in 86% in the left and in 65% in the right atrium. The unipolar electrogram showed in 87% of all cases a QS-complex before the successful RFC pulse. In 16% a beat to beat change of the unipolar electrogram could be found at successful ablation site (Figure 7). Both criteria had a low specifity and sensitivity. Mechanical block could be induced during mapping in 10 patients (20%). In these cases RFC application at a site with a perfect match of P-wave pace mapping succeeded in 8 patients. In 2 patients the same EAT occurred within the following 24 hours.During a follow-up of 4 to 58 months there were additionally recurrence of EAT in 3 patients (3 to 6 months after ablation). No influence of the AV nodal conduction was observed after ablation of anteroseptal EAT foci. Other acute or chronic complications were not observed.Conclusions: 1. RFC ablation of right and left sided EAT foci is a safe and efficacious treatment. There were no differences regarding session duration and fluoroscopic time between right and left sided foci. 2. Activation mapping showed an earlier activation time for left sided origin compared to right sided. 3. Mechanical block could be induced in 20% of cases. P-wave pace mapping might offer a strategy to localize the focus during mechanical block.

Hochfrequenzstromablation von ektopen atrialen Tachykardien : Unterschiedliche Mapping-Strategien zur Lokalisation rechts- und linsseitiger Ursprungsorte (Nichtmedikamentöse Therapie Supraventrikulärer Arrhythmien)

Predictors for long-term success of slow pathway ablation in recurrent AV nodal reentrant tachycardia without reproducible inducibility

ZusammenfassungDie Hochfrequenzstrom-(HFS)-Ablation stellt in den letzten Jahren ein neues kuratives Therapieverfahren für ektope atriale Tachykardien (EAT) dar. Wir untersuchten unterschiedliche Mapping-Strategien bei der HFS-Ablation von rechts- und linksseitigen EAT-Foki. Eingeschlossen in die Studie wurden 48 Patienten (35±18 Jahre) mit 52 EAT-Foki. Zur Lokalisation der Foki verwendeten wir das Aktivierungs-Mapping im bipolaren Lokalelektrogramm und die morphologische Beurteilung des unipolaren Lokalelektrogramms (QS-Komplex). Im Falle von mechanischen Blockierungen wurden die stimulierten P-Wellen im Oberflächen-EKG mit den P-Wellen während EAT verglichen.Ergebnisse: Bei 44 Patienten konnten 46 EAT (zehn links- und 36 rechtsseitige) durch HFS-Ablation terminiert werden. Bei den linksseitigen EAT waren 40% in dem Bereich der Pulmonalvenen lokalisiert. Die durchschnittliche Prozedurund Durchleuchtungsdauer unterschied sich nicht zwischen links-(304±131 min bzw. 39±29 min) und rechtsseitiger, (241±101 min bzw. 31±19 min) Lokalisation. Das Intervall zwischen dem Lokalelektrogramm und dem Beginn der P-Welle war bei links- (45±22 ms) im Vergleich zu rechtsseitiger (30±18 ms) Fokuslokalisation signifikant länger. Bei zehn Patienten (20%) kam es während des Mappings zu mechanischen Blockierungen. Die Lokalisation des Ursprungsorts während mechanischer Blockierung gelang mit Hilfe des Vergleichs der P-Welle von EAT und Stimulation in acht Fällen. Bei zwei Patienten kam es innerhalb von 24 Stunden zum erneuten Auftreten der EAT.Während der Nachbeobachtung von vier bis 58 Monaten kam es drei bis acht Monate nach Ablation bei vier Patienten (8%) zu einem Rezidiv der EAT.Schlußfolgerungen: 1. Die HFS-Ablation von EAT ist sowohl für links- als auch rechtsseitige Ursprungsorte ein effektives und risikoarmes. Therapieverfahren. Die Prozedur- und Durchleuchtungsdauer unterscheiden sich nicht bei rechts- und linksseitiger Lokalisation. 2. Durch häufige Lokalisationen linksseitiger EAT in dem Bereich der Pulmonalvenen zeigt das Aktivierungs-Mapping hier ein früheres Lokalelektrogramm im Verhältnis zur P-Welle als bei rechtsseitigen EAT. 3. Es kommt in etwa 20% der HFS-Ablationen von EAT zu mechanischen Blockierungen. Während Blockierung kann der Vergleich der stimulierten P-Welle mit der EAT-P-Welle eine nützliche Hilfe zur Lokalisation des Ursprungs der EAT darstellen.AbstractEctopic atrial tachycardia (EAT) is a rare form of supraventricular tachycardia and often drug-resistant. Radiofrequency catheter (RFC) ablation offers an alternative therapy suggesting a high efficacy rate. Localization of the EAT origin is proposed to be efficacious by various mapping strategies. We analyzed the efficacy of different mapping strategies for localization of right and left sided EAT foci.Methods and Patients: In a cohort of 48 patients (25 female; age 35±18 years) RFC ablation of 40 right and 12 left sided EAT foci was performed. Mapping of the right atrium was achieved with 2 ablation catheters using the “encircling” technique (Figure 1). We looked for an early bipolar local electrogram in relation to the onset of the P-wave and a QS-complex in the unipolar electrogram. The bipolar local electrogram was retrospectively analyzed for a fragmented morphology and duration of more than 50 ms (Figure 3). In case of mechanical block of the EAT during mapping P-wave pace mapping over the mapping catheter was performed (Figure 4).Results: RFC ablation succeeded in 44 patients with 46 EAT foci (Figure 5). Left sided EAT origin was in 40% in the region of the pulmonary veins. Two left sided foci were abladed within the coronary sinus. An anteroseptal location in vicinity to the bundle of His was found in 4 cases (Figure 6). There were no differences between left and right sided origin regarding session duration (304±131 vs 241±101 min) and fluoroscopic time (39±29 vs 31±19 min). The activation time related to the onset of the P-wave was at successful ablation site for left sided origin significantly earlier compared to a right sided origin (45±22 vs 30±18 ms). Fragmentation of the bipolar local electrogram was found before successful RFC application in 86% in the left and in 65% in the right atrium. The unipolar electrogram showed in 87% of all cases a QS-complex before the successful RFC pulse. In 16% a beat to beat change of the unipolar electrogram could be found at successful ablation site (Figure 7). Both criteria had a low specifity and sensitivity. Mechanical block could be induced during mapping in 10 patients (20%). In these cases RFC application at a site with a perfect match of P-wave pace mapping succeeded in 8 patients. In 2 patients the same EAT occurred within the following 24 hours.During a follow-up of 4 to 58 months there were additionally recurrence of EAT in 3 patients (3 to 6 months after ablation). No influence of the AV nodal conduction was observed after ablation of anteroseptal EAT foci. Other acute or chronic complications were not observed.Conclusions: 1. RFC ablation of right and left sided EAT foci is a safe and efficacious treatment. There were no differences regarding session duration and fluoroscopic time between right and left sided foci. 2. Activation mapping showed an earlier activation time for left sided origin compared to right sided. 3. Mechanical block could be induced in 20% of cases. P-wave pace mapping might offer a strategy to localize the focus during mechanical block.

Hochfrequenzstromablation von ektopen atrialen Tachykardien: Unterschiedliche Mapping-Strategien zur Lokalisation rechts- und linsseitiger Ursprungsorte

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