[Left-sided His bundle ablation after failure of right-sided approach: technique and initial results]

Although interruption of atrioventricular conduction has been widely used over the last decade in patients with supraventricular arrhythmias and rapid conduction resistant to antiarrhythmic therapy, the incidence of atrioventricular block obtained by delivering the energy at the tricuspid ring ranges from 45 to 92%. Failure of this technique is usually related to the inhability to record endocavitary electrogrammes compatible with probable success by the right-sided approach. The authors report four cases of interruption of atrioventricular conduction in 4 men (average age 61.5 +/- 10 years) by the retrograde arterial catheterisation after one or more (1 to 3) failures by the right-sided approach. After arterial puncture, the ablation catheter is positioned against the interventricular septum below the aortic cusps to record the His bundle electrogram. His bundle ablation was obtained after an average of 2 radio frequency energy applications (range 1 to 3). At the time of effective application, the average amplitude of the endocavitary electrogram was as follows: auriculogram 0.09 mV (range 0.05 to 0.2 mV), His bundle electrogram 0.19 mV (0.15-0.22 mV), ventriculogram 1.36 mV (1.0 to 1.7 mV). No complications were observed. After an average follow-up of 4 months, the 4 patients were still in complete atrioventricular block. This preliminary series shows that left-sided interruption of atrioventricular conduction is effective and safe. It may be proposed after failure of a right-sided attempt.