Anatomical Ablation of the Atrioventricular Node

Overview

Journal Arrhythm Electrophysiol Rev

Date 2024 Sep 2

PMID 39221060

Authors

Demosthenes G Katritsis

Konstantinos C Siontis

Sharad Agarwal

Stavros Stavrakis

Eleftherios Giazitzoglou

Hina Amin

Joseph E Marine

Justin T Tretter

Damian Sanchez-Quintana

Robert H Anderson

Hugh Calkins

Affiliations

Soon will be listed here.

Abstract

Background: Atrioventricular (AV) conduction ablation has been achieved by targeting the area of penetration of the conduction axis as defined by recording a His bundle potential. Ablation of the His bundle may reduce the possibility of a robust junctional escape rhythm. It was hypothesised that specific AV nodal ablation is feasible and safe.

Methods: The anatomical position of the AV node in relation to the site of penetration of the conduction axis was identified as described in dissections and histological sections of human hearts. Radiofrequency (RF) ablation was accomplished based on the anatomical criteria.

Results: Specific anatomical ablation of the AV node was attempted in 72 patients. Successful AV nodal ablation was accomplished in 63 patients (87.5%), following 60 minutes (IQR 50-70 minutes) of procedure time, 3.4 minutes (IQR 2.4-5.5 minutes) of fluoroscopy time, and delivery of 4 (IQR 3-6) RF lesions. An escape rhythm was present in 45 patients (71%), and the QRS complex was similar to that before ablation in all 45 patients. Atropine was administered in six patients after the 10-min waiting period and did not result in restoration of conduction. In nine patients, AV conduction could not be interrupted, and AV block was achieved with ablation of the His after delivery of 12 (IQR 8-15) RF lesions. No cases of sudden death were encountered, and all patients had persistent AV block during a median 10.5 months (IQR 5-14 months) of follow-up.

Conclusion: Anatomical ablation of the AV node is feasible and safe, and results in an escape rhythm similar to that before ablation.

References

Katritsis D, Zografos T, Siontis K, Giannopoulos G, Muthalaly R, Liu Q . Endpoints for Successful Slow Pathway Catheter Ablation in Typical and Atypical Atrioventricular Nodal Re-Entrant Tachycardia: A Contemporary, Multicenter Study. JACC Clin Electrophysiol. 2019; 5(1):113-119. DOI: 10.1016/j.jacep.2018.09.012. View

Katritsis D, Josephson M . Electrophysiological Testing for the Investigation of Bradycardias. Arrhythm Electrophysiol Rev. 2017; 6(1):24-28. PMC: 5430927. DOI: 10.15420/aer.2016:34:2. View

Edner M, Caidahl K, Bergfeldt L, Darpo B, Edvardsson N, Rosenqvist M . Prospective study of left ventricular function after radiofrequency ablation of atrioventricular junction in patients with atrial fibrillation. Br Heart J. 1995; 74(3):261-7. PMC: 484016. DOI: 10.1136/hrt.74.3.261. View

Souza O, Gursoy S, Simonis F, STEURER G, Andries E, Brugada P . Right-sided versus left-sided radiofrequency ablation of the His bundle. Pacing Clin Electrophysiol. 1992; 15(10 Pt 1):1454-9. DOI: 10.1111/j.1540-8159.1992.tb02918.x. View

Cabrera J, Anderson R, Macias Y, Nevado-Medina J, Porta-Sanchez A, Rubio J . Variable Arrangement of the Atrioventricular Conduction Axis Within the Triangle of Koch: Implications for Permanent His Bundle Pacing. JACC Clin Electrophysiol. 2020; 6(4):362-377. DOI: 10.1016/j.jacep.2019.12.004. View

Anderson R, Sanchez-Quintana D, Mori S, Cabrera J, Sternick E . Re-evaluation of the structure of the atrioventricular node and its connections with the atrium. Europace. 2020; 22(5):821-830. DOI: 10.1093/europace/euaa031. View

Poquet F, Clementy J, Gencel L, Haissaguerre M . [Survival after His bundle ablation for supraventricular arrhythmia. A 10-years experience in 317 consecutive patients]. Arch Mal Coeur Vaiss. 1995; 88(11):1593-600. View

Vaksmann G, Lacroix D, Klug D . Radiofrequency ablation of the His bundle for malignant atrial flutter after Mustard procedure for transposition of the great arteries. Am J Cardiol. 1996; 77(8):669-70. DOI: 10.1016/s0002-9149(97)89332-0. View

Pandozi C, Botto G, Loricchio M, DAmmando M, Lavalle C, Del Giorno G . High-density mapping of Koch's triangle during sinus rhythm and typical atrioventricular nodal re-entrant tachycardia, integrated with direct recording of atrio-ventricular node structure potential. J Cardiovasc Electrophysiol. 2024; 35(3):379-388. DOI: 10.1111/jce.16168. View

10.

Fenelon G, Goethals M, Brugada P . Two hearts beating as one: radiofrequency ablation of the His bundle in a heterotopic heart transplant patient. Pacing Clin Electrophysiol. 1996; 19(3):374-5. DOI: 10.1111/j.1540-8159.1996.tb03343.x. View

11.

Alison J, Lonergan L, Mohama R, LEATHER R, Kerr C . High success rate of atrioventricular node ablation with radiofrequency energy. J Am Coll Cardiol. 1991; 18(7):1753-8. DOI: 10.1016/0735-1097(91)90516-c. View

12.

Peters R, Wever E, Hauer R, Wittkampf F, Robles De Medina E . Bradycardia dependent QT prolongation and ventricular fibrillation following catheter ablation of the atrioventricular junction with radiofrequency energy. Pacing Clin Electrophysiol. 1994; 17(1):108-12. DOI: 10.1111/j.1540-8159.1994.tb01358.x. View

13.

Buys E, van Hemel N, Kelder J, Ascoop C, van Dessel P, Bakema L . Exercise capacity after His bundle ablation and rate response ventricular pacing for drug refractory chronic atrial fibrillation. Heart. 1997; 77(3):238-41. PMC: 484689. DOI: 10.1136/hrt.77.3.238. View

14.

Wood M, Brown-Mahoney C, Kay G, Ellenbogen K . Clinical outcomes after ablation and pacing therapy for atrial fibrillation : a meta-analysis. Circulation. 2000; 101(10):1138-44. DOI: 10.1161/01.cir.101.10.1138. View

15.

Vijayaraman P, Subzposh F, Naperkowski A . Atrioventricular node ablation and His bundle pacing. Europace. 2017; 19(suppl_4):iv10-iv16. DOI: 10.1093/europace/eux263. View

16.

Darpo B, Walfridsson H, Aunes M, Bergfeldt L, Edvardsson N, Linde C . Incidence of sudden death after radiofrequency ablation of the atrioventricular junction for atrial fibrillation. Am J Cardiol. 1997; 80(9):1174-7. DOI: 10.1016/s0002-9149(97)00635-8. View

17.

Macias Y, Tretter J, Anderson R, Sanchez-Quintana D, Soares Correa F, Farre J . Miniseries 1-Part IV: How frequent are fasciculo-ventricular connections in the normal heart?. Europace. 2022; 24(3):464-472. DOI: 10.1093/europace/euab286. View

18.

Tretter J, Spicer D, Sanchez-Quintana D, Sternick E, Farre J, Anderson R . Miniseries 1-Part III: 'Behind the scenes' in the triangle of Koch. Europace. 2022; 24(3):455-463. DOI: 10.1093/europace/euab285. View

19.

Wang R, Lee H, Hodge D, Cha Y, Friedman P, Rea R . Effect of pacing method on risk of sudden death after atrioventricular node ablation and pacemaker implantation in patients with atrial fibrillation. Heart Rhythm. 2013; 10(5):696-701. DOI: 10.1016/j.hrthm.2013.01.021. View

20.

Natale A, Zimerman L, Tomassoni G, Kearney M, Kent V, Brandon M . Impact on ventricular function and quality of life of transcatheter ablation of the atrioventricular junction in chronic atrial fibrillation with a normal ventricular response. Am J Cardiol. 1996; 78(12):1431-3. DOI: 10.1016/s0002-9149(97)89296-x. View