Cryosurgical treatment of atrioventricular node reentrant tachycardia

Paroxysmal supraventricular tachycardia most commonly arises from reentry within the atrioventricular (AV) node. Although ablation of the His bundle has gained popularity for treating patients with AV node reentrant tachycardia refractory to medical therapy, undesirable sequelae include complete heart block and the necessity for a permanent pacemaker. To obviate this limitation, we have developed a discrete cryosurgical procedure that interrupts the reentrant circuit responsible for AV node reentrant tachycardia without blocking AV conduction. After first characterizing the salutary effects of this approach in experimental animals, we performed this procedure in eight patients with AV node reentrant tachycardia. Preoperative, intraoperative, and postoperative electrophysiologic studies were performed in each patient. Under conditions of normothermic cardiopulmonary bypass and during atrial pacing at a constant rate with continuous monitoring of AV conduction, nine separate 3 mm cryolesions (-60 degrees C for 2 min) were placed at predetermined sites around the triangle of Koch in the lower right atrial septum. Postoperatively, each patient had a single AV node conduction curve. No patient had AV node reentrant tachycardia induced or has experienced AV node reentrant tachycardia clinically during a follow-up of up to 5 years. The cryosurgical procedure had no detrimental effects on the AH or HV interval or on the paced cycle length at which AV node Wenckebach occurred. Based on these results, this curative operation offers promise for patients with AV node reentrant tachycardia that is refractory to medical treatment.