Different Approaches for Catheter Ablation of Para-Hisian Accessory Pathways: Implications for Mapping and Ablation
Ming Liang1, Zulu Wang2, Yanchun Liang1
1From the Department of Cardiology, The General Hospital of Shenyang Military Region, Shenyang, China.
Insights
The inferior vena cava approach (IVC-A) is effective for ablating para-Hisian accessory pathways (APs). Ventriculoatrial fusion during mapping helps predict successful catheter ablation sites for these challenging cases.
Area of Science:
- Electrophysiology
- Cardiology
- Medical Devices
Background:
- Para-Hisian accessory pathways (APs) ablation is technically challenging due to proximity to vital cardiac conduction tissues.
- Existing ablation approaches include inferior vena cava (IVC-A), noncoronary cusp (NCC-A), and superior vena cava (SVC-A).
- Optimal timing and approach selection for para-Hisian APs remain unclear.
Purpose of the Study:
- To evaluate the efficacy and safety of different catheter ablation approaches for para-Hisian APs.
- To determine the preferred approach for mapping and ablating para-Hisian APs.
- To identify predictors of successful ablation in para-Hisian AP cases.
Main Methods:
- Retrospective analysis of 55 patients with para-Hisian APs undergoing catheter ablation.
- Categorization of patients based on successful ablation approach: IVC-A, NCC-A, or SVC-A.
- Analysis of clinical characteristics, surface ECG, intracardiac electrograms, and ablation outcomes.
Main Results:
- Catheter ablation using IVC-A was successful in 87% (48/55) of patients with para-Hisian APs.
- NCC-A and SVC-A were required less frequently (7% and 6%, respectively).
- Significant ventriculoatrial (VA) potential fusion during retrograde AP conduction was observed in 45/48 patients treated with IVC-A, aiding in successful ablation.
Conclusions:
- The IVC-A is a safe and effective primary approach for ablating most para-Hisian APs.
- Ablation via the NCC is not recommended as an initial strategy.
- The degree of local VA fusion during retrograde AP conduction is a key predictor for successful para-Hisian AP ablation site identification.
Background:
Catheter ablation of para-Hisian accessory pathways (APs) can be challenging because of adjacent conduction tissue. Some different approaches for ablation, including the inferior vena cava approach (IVC-A), the noncoronary cusp approach (NCC-A), or the superior vena cava approach (SVC-A), have been reported. However, when should para-Hisian APs be mapped and ablated by the IVC-A, NCC-A, or SVC-A is not well established.
Methods And Results:
This study included 55 consecutive patients (mean age, 53±11 years, 36 males) with para-Hisian APs. On the basis of the approach resulting in successful ablation, patients were divided into IVC-A, NCC-A, and SVC-A groups. The clinical characteristics, surface ECG, intracardiac electrogram findings, and response to ablation were analyzed. Para-Hisian APs were eliminated by IVC-A in 48 of the 55 (87%) patients. The rates of para-Hisian APs requiring NCC-A (4/55 patients, 7%) and SVC-A (3/55 patients, 6%) were relatively low. During mapping at the para-Hisian region, the local ventricular and atrial potentials were well fused during retrograde AP conduction in 45 of the 48 patients in IVC-A group, 0 of the 4 patients in NCC-A group, and 1 of the 3 patients in SVC-A group, respectively. There was no significant difference in the preexcitation characteristics among the 3 groups.
Conclusion:
Most para-Hisian APs can be safely and effectively ablated by IVC-A, and ablation in the NCC is not an initial or a preferred approach. The degree of local ventriculoatrial fusion in the para-Hisian region during retrograde AP conduction can differentiate or predict the successful ablation site.
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