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Radiofrequency Catheter Ablation for Cardiac Tachyarrhythmias

Antonis S. Manolis, MD; Paul J. Wang, MD; and N. A. Mark Estes, MD
[+] Article and Author Information

From New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts. Requests for Reprints: Antonis S. Manolis, MD, Division of Cardiology, Tufts/New England Medical Center, Box 868, 750 Washington Street, Boston, MA 02111.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1994;121(6):452-461. doi:10.7326/0003-4819-121-6-199409150-00010
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Purpose: To review the radiofrequency ablation method, describe the technique, and discuss the indications, results, and limitations of its use in patients with cardiac tachyarrhythmias.

Data Sources: Peer-reviewed reports in the literature by clinical investigators who use radiofrequency catheter ablation as identified by a MEDLINE search and our own experience with this intervention in 214 patients with cardiac tachyarrhythmias.

Study Selection: All articles reporting results of radiofrequency ablation for cardiac tachyarrhythmias and articles describing the ablation technique or comparing it with direct-current or surgical methods.

Results of Data Synthesis: Percutaneous catheter ablation of cardiac arrhythmias using high-voltage, direct current was limited by a high complication rate and a need for general anesthesia. This method was recently replaced by a new safe and efficacious technique using low-voltage, high-frequency (radiofrequency) alternating current. Nonsurgical cure of many supraventricular arrhythmias is now feasible with radiofrequency ablation, especially in patients with accessory pathways or atrioventricular nodal reentrant tachycardia. For these arrhythmias, success rates are greater than 90%. The indications for ablation include preexcitation syndromes, atrioventricular nodal reentrant tachycardia, and other selected atrial and ventricular tachyarrhythmias refractory to antiarrhythmic drug therapy. The efficacy and safety profile of this technique has made it feasible for children as well as adults.

Conclusions: Percutaneous radiofrequency catheter ablation has evolved as a safe and effective method for managing and curing the two most common forms of supraventricular tachycardia: those associated with preexcitation syndromes and atrioventricular nodal reentrant tachycardia. Further studies are needed to determine the efficacy of this method or to evaluate alternative transcatheter techniques in patients with atrial tachycardias and, more importantly, in the large population of patients with ischemic ventricular tachycardia.

Figures

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Figure 1.
Top.Bottom.

Mechanism of atrioventricular (AV) nodal reentrant tachycardia. Two pathways constitute the circuit of this tachycardia; the α or slow pathway serves as the anterograde limb, and the β or fast pathway serves as the retrograde limb of the tachycardia circuit. Although both of these pathways were initially thought to be located within the AV node, they are apparently accessible to radiofrequency ablation techniques at locations outside the node. The slow pathway can be ablated successfully with the catheter positioned inferior and posterior to the AV node, whereas the fast pathway is located in an anterior and superior position. (CS = coronary sinus; RA = right atrium; RV = right ventricle; SA = sinoatrial) Mechanism of orthodromic atrioventricular (AV) reciprocating tachycardia observed in patients with the Wolff-Parkinson-White syndrome and in patients with concealed accessory pathways. The impulse travels down the AV node-His-Purkinje system, which constitutes the anterograde limb of the tachycardia, and returns to the atria through the accessory pathway (a left free-wall pathway here), which serves as the retrograde limb of the circuit. The accessory pathway is now accessible to the ablation catheter, which is positioned at the atrial or ventricular aspects of the tricuspid or mitral annuli. Delivery of radiofrequency energy through the catheter interrupts pathway conduction. (CS = coronary sinus; LA = left atrium; LV = left ventricle; SA = sinoatrial).

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Figure 2.
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Radiofrequency ablation of the Wolff-Parkinson-White syndrome. Delivery of radiofrequency current ( ) at the target site as detailed in the text resulted within 5 seconds in permanent loss of preexcitation ( ) in a patient with a posteroseptal accessory pathway. The application of radiofrequency current was continued for 60 seconds and was followed by a second lesion (total number of radiofrequency lesions applied to this patient was 8). Impedance, voltage, current, and power through a 500-KHz Radionics radiofrequency device were monitored continuously during delivery of radiofrequency energy. B. Radiofrequency ablation of incessant orthodromic tachycardia. A 6-year-old girl had incessant supraventricular tachycardia at a rate of 136 beats per minute diagnosed as the permanent form of junctional reciprocating tachycardia by electrophysiologic testing; she had successful radiofrequency ablation in the posteroseptal region near the os of the coronary sinus. Displayed are surface leads II and V . Note the long RP interval of the tachycardia and the negative P wave in the inferior lead II. When the application (starting at the first arrow on the left) of radiofrequency current (fifth lesion) was successful, the permanent form of junctional reciprocating tachycardia terminated ( ) and could no longer be induced with programmed stimulation or isoproterenol infusion. C. Radiofrequency ablation of ventricular tachycardia. A 42-year-old man with no structural heart disease had exercise-related, wide-complex tachycardia (rate, 150 beats/min; morphologic features, left bundle-branch block-like with right axis deviation), which was reproduced and mapped to the right ventricular outflow tract during an electrophysiologic study. During the same session, radiofrequency ablation was successful (single first lesion) in eliminating the focus of the ventricular tachycardia. Displayed are surface leads II and V . Note the termination of the tachycardia and restoration of sinus rhythm with successful ablation of the right ventricular outflow tract focus ( ) (beginning of radiofrequency current application is indicated by the first arrow on the left).

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