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A practical approach to slow pathway ablation for the treatment of atrioventricular nodal re-entrant tachycardia (AVNRT) is to use a combined anatomic and electrogram technique to identify target sites. The efficacy and safety of radiofrequency (RF) ablation depend on the stability of the ablation catheter during RF energy delivery. Unusual anatomy, abrupt rhythm changes during RF application, and intraprocedural catheter and patient movement can pose significant challenges. Inadvertent AV block remains a concern occurring in approximately 1% of cases.
A 42 year old woman with a narrow complex regular tachycardia that had a pseudo ŕ in V1 during tachycardia but not during sinus rhythm underwent a diagnostic electrophysiological study followed by RF ablation for cure of her AVNRT. The patient’s own anatomy was leveraged not only as a means to localise an ablation target, but most importantly, as a stabilising factor during performance of slow pathway ablation. This highly streamlined approach can be performed safely, successfully, and rapidly entirely from the left femoral vein, through a single sheath, and with only two catheters in appropriately selected supraventricular tachycardia (SVT) patients.
A 12 French long sheath was introduced into the femoral vein and guided fluoroscopically to the base of the right atrium. A 6 French Bard EP-XT catheter was inserted into the coronary sinus (CS). Next, a 6 French EPT Blazer II ablation catheter was directed to the His and then, after confirming the diagnosis of AVNRT, moved to the putative anatomic region of the slow pathway. During three RF applications, the mobility constraints of the “sheath-catheter-catheter” complex led to excellent electrogram and ablation catheter stability by taking advantage of the “collaring” effect of the 12 French sheath which was in turn “anchored” to the diagnostic catheter placed in the CS. No further tachycardia was inducible or has occurred clinically in follow up.