Catheter ablation

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Catheter ablation
Herzkatheterlabor.jpg
ICD-9-CM 37.34
MeSH D017115

Catheter ablation is a procedure that uses radio-frequency energy or other sources to terminate or modify a faulty electrical pathway from sections of the heart of those who are prone to developing cardiac arrhythmias such as atrial fibrillation, atrial flutter and Wolff-Parkinson-White syndrome. If not controlled, such arrhythmias increase the risk of ventricular fibrillation and sudden cardiac arrest. The ablation procedure can be classified by energy source: radiofrequency ablation and cryoablation.

Contents

Medical uses

Catheter ablation may be recommended for a recurrent or persistent arrhythmia resulting in symptoms or other dysfunction. Atrial fibrillation frequently results from bursts of tachycardia that originate in muscle bundles extending from the atrium to the pulmonary veins. [1] Pulmonary vein isolation by transcatheter ablation can restore sinus rhythm. [1]

Effectiveness

Catheter ablation of most arrhythmias has a high success rate. Success rates for WPW syndrome have been as high as 95% [2] For Supraventricular tachycardia (SVT), single procedure success is 91% to 96% (95% Confidence Interval) and multiple procedure success is 92% to 97% (95% Confidence Interval). [3] For atrial flutter, single procedure success is 88% to 95% (95% Confidence Interval) and multiple procedure success is 95% to 99% (95% Confidence Interval). [3] For automatic atrial tachycardias, the success rates are 70–90%.[ citation needed ] The potential complications include bleeding, blood clots, pericardial tamponade, and heart block, but these risks are very low, ranging from 2.6 to 3.2%.

For non-paroxysmal atrial fibrillation, a 2016 systematic review compared catheter ablation to heart rhythm drugs. After 12 months, participants receiving catheter ablation were more likely to be free of atrial fibrillation, and less likely to need cardioversion. However, the evidence quality ranged from moderate to very low [4] A 2006 study, including both paroxysmal and non-paroxysmal atrial fibrillation, found that the success rates are 28% for single procedures. Often, several procedures are needed to raise the success rate to a 70–80% range. [5] One reason for this may be that once the heart has undergone atrial remodeling as in the case of chronic atrial fibrillation patients, largely 50 and older, it is much more difficult to correct the 'bad' electrical pathways. Young people with AF with paroxysmal, or intermittent, AF therefore have an increased chance of success with an ablation since their heart has not undergone atrial remodeling yet.[ citation needed ] Several experienced teams of electrophysiologists in US heart centers claim they can achieve up to a 75% success rate.[ citation needed ]

Pulmonary vein isolation has been found to be more effective than optimized antiarrhythmic drug therapy for improving quality of life at 12 months after treatment. [6]

Catheter ablation has been found to improve mental health outcomes in individuals with symptomatic atrial fibrillation. [7]

A 2018 study showed efficacy of cardiac ablation for treatment of Premature Ventricular Contraction as 94.1%. [8]

Technique

Catheter ablation is usually performed by an electrophysiologist (a specially trained cardiologist) in a cath lab.[ citation needed ]

Catheter ablation procedure involves advancing several flexible catheters into the patient's blood vessels, usually either in the femoral vein, internal jugular vein, or subclavian vein. The catheters are then advanced towards the heart. The catheters have electrodes at the tips that can measure the electrical signals from the heart. These electrodes create a map of the abnormal pathways causing arrhythmias. Then, the electrophysiologist uses the map to identify areas from which abnormal heart rhythms originate. [9]

Once the abnormal areas are located, catheters are used to deliver energy via local heating or freezing to ablate (destroy) the abnormal tissue that is causing the arrhythmia. The energy is applied cautiously to avoid damaging healthy heart tissue. [9] Originally, a DC impulse was used to create lesions in the intra-cardiac conduction system. [10] However, due to a high incidence of complications, widespread use was never achieved.

In contrast to the thermal methods (extreme heat or cold) electroporation is being used and evaluated as a means of killing very small areas of heart muscle. The cardiac catheter delivers trains of high-voltage ultra-rapid electrical pulses that form irreversible pores in cell membranes, resulting in cell death of cardiac muscle, while not killing adjacent tissues (esophagus and phrenic nerve). [11] It is thought to allow better selectivity than the previous thermal techniques, which used heat or cold to kill larger volumes of muscle. [12]

One type of catheter ablation is pulmonary vein isolation, where the ablation is done in the left atrium in the area where the 4 pulmonary veins connect. [13] [14] Radiofrequency ablation for atrial fibrillation can be unipolar (one electrode) or bipolar (two electrodes). [15] Although bipolar can be more successful, it is technically more difficult, resulting in unipolar being used more often. [15] But bipolar is more effective in preventing recurrent atrial arrhythmias. [16]

During the procedure, the patient's heart rhythm is monitored continuously. The electrophysiologist can observe changes to the patient's cardiac electrical activity to determine the success of the ablation. If the cardiac rhythm shows no abnormal signals or arrhythmias, the catheters are withdrawn from the heart and the incision is closed.

Recovery or rehabilitation

After catheter ablation the patients are moved to a cardiac recovery unit, intensive care unit, or cardiovascular intensive care unit where they are not allowed to move for 4–6 hours. Minimizing movement helps prevent bleeding from the site of catheter insertion. Some people have to stay overnight for observation, some need to stay much longer and others are able to go home on the same day. This all depends on the problem, the length of the operation and whether or not general anaesthetic was used.[ citation needed ]

Recurrence of atrial fibrillation within three months of an ablation is seen in most patients, but many of those patients become free of atrial fibrillation in the long term. [17] For this reason the first three months after an ablation are described as the "blanking period," during which no further intervention is to be attempted. [17] Recurrence during the nine months following the blanking period, occurs in 25% to 40% of patients, the variability greatly affected by obesity and the severity of atrial fibrillation before the ablation. [17]

Complications

Some potential complications associated with the procedure include: [18]

Patients may also experience a return of the arrhythmia after the procedure, requiring them to undergo further treatment. However, in general this procedure is considered a safe, effective, and minimally invasive method to treat arrhythmias. Studies have shown that the overall complication rate of cardiac ablation procedures is about 6%.[ medical citation needed ]

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a sub-specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Wolff–Parkinson–White syndrome</span> Medical condition

Wolff–Parkinson–White syndrome (WPWS) is a disorder due to a specific type of problem with the electrical system of the heart involving an accessory pathway able to conduct electrical current between the atria and the ventricles, thus bypassing the atrioventricular node. About 60% of people with the electrical problem developed symptoms, which may include an abnormally fast heartbeat, palpitations, shortness of breath, lightheadedness, or syncope. Rarely, cardiac arrest may occur. The most common type of irregular heartbeat that occurs is known as paroxysmal supraventricular tachycardia.

<span class="mw-page-title-main">Pulmonary vein</span> Veins that transfer oxygenated blood from the lungs to the heart

The pulmonary veins are the veins that transfer oxygenated blood from the lungs to the heart. The largest pulmonary veins are the four main pulmonary veins, two from each lung that drain into the left atrium of the heart. The pulmonary veins are part of the pulmonary circulation.

<span class="mw-page-title-main">Supraventricular tachycardia</span> Abnormally fast heart rhythm

Supraventricular tachycardia (SVT) is an umbrella term for fast heart rhythms arising from the upper part of the heart. This is in contrast to the other group of fast heart rhythms – ventricular tachycardia, which start within the lower chambers of the heart. There are four main types of SVT: atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), and Wolff–Parkinson–White syndrome. The symptoms of SVT include palpitations, feeling of faintness, sweating, shortness of breath, and/or chest pain.

<span class="mw-page-title-main">AV nodal reentrant tachycardia</span> Medical condition

AV-nodal reentrant tachycardia (AVNRT) is a type of abnormal fast heart rhythm. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men. The main symptom is palpitations. Treatment may be with specific physical maneuvers, medications, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.

<span class="mw-page-title-main">Paroxysmal supraventricular tachycardia</span> Medical condition

Paroxysmal supraventricular tachycardia (PSVT) is a type of supraventricular tachycardia, named for its intermittent episodes of abrupt onset and termination. Often people have no symptoms. Otherwise symptoms may include palpitations, feeling lightheaded, sweating, shortness of breath, and chest pain.

<span class="mw-page-title-main">Radiofrequency ablation</span> Surgical procedure

Radiofrequency ablation (RFA), also called fulguration, is a medical procedure in which part of the electrical conduction system of the heart, tumor or other dysfunctional tissue is ablated using the heat generated from medium frequency alternating current. RFA is generally conducted in the outpatient setting, using either local anesthetics or twilight anesthesia. When it is delivered via catheter, it is called radiofrequency catheter ablation.

Tachycardia-induced cardiomyopathy (TIC) is a disease where prolonged tachycardia or arrhythmia causes an impairment of the myocardium, which can result in heart failure. People with TIC may have symptoms associated with heart failure and/or symptoms related to the tachycardia or arrhythmia. Though atrial fibrillation is the most common cause of TIC, several tachycardias and arrhythmias have been associated with the disease.

The mini-maze procedures are cardiac surgery procedures intended to cure atrial fibrillation (AF), a common disturbance of heart rhythm. They are procedures derived from the original maze procedure developed by James Cox, MD.

Clinical cardiac electrophysiology, is a branch of the medical specialty of cardiology concerned with the study and treatment of rhythm disorders of the heart. Cardiologists with expertise in this area are usually referred to as electrophysiologists. Electrophysiologists are trained in the mechanism, function, and performance of the electrical activities of the heart. Electrophysiologists work closely with other cardiologists and cardiac surgeons to assist or guide therapy for heart rhythm disturbances (arrhythmias). They are trained to perform interventional and surgical procedures to treat cardiac arrhythmia.

<span class="mw-page-title-main">Michel Haïssaguerre</span>

Michel Haïssaguerre is a French cardiologist and electrophysiologist. His investigations have been the basis for development of new markers and therapies for atrial and ventricular fibrillation.

The Sensei X robotic catheter is a medical robot designed to enhance a physician’s ability to perform complex operations using a small flexible tube called a catheter. As open surgical procedures that require large incisions have given way to minimally invasive surgeries in which the surgeon gains access to the target organs through small incisions using specialized surgical tools. One important tool used in many of these procedures is a catheter used to deliver many of things a surgeon needs to do his work, to impact target tissue and deliver a variety of medicines or disinfecting agents to treat disease or infection.

<span class="mw-page-title-main">Atrial fibrillation</span> Irregular beating of the atria of the heart

Atrial fibrillation is an abnormal heart rhythm (arrhythmia) characterized by rapid and irregular beating of the atrial chambers of the heart. It often begins as short periods of abnormal beating, which become longer or continuous over time. It may also start as other forms of arrhythmia such as atrial flutter that then transform into AF.

<span class="mw-page-title-main">Electrophysiology study</span> Medical test to record electrical activity within the heart

A cardiac electrophysiology study is a minimally invasive procedure using catheters introduced through a vein or artery to record electrical activity from within the heart. This electrical activity is recorded when the heart is in a normal rhythm to assess the conduction system of the heart and to look for additional electrical connections, and during any abnormal heart rhythms that can be induced. EP studies are used to investigate the cause, location of origin, and best treatment for various abnormal heart rhythms, and are often followed by a catheter ablation during the same procedure.

<span class="mw-page-title-main">Arrhythmia</span> Group of medical conditions characterized by irregular heartbeat

Arrhythmias, also known as cardiac arrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults – is called tachycardia, and a resting heart rate that is too slow – below 60 beats per minute – is called bradycardia. Some types of arrhythmias have no symptoms. Symptoms, when present, may include palpitations or feeling a pause between heartbeats. In more serious cases, there may be lightheadedness, passing out, shortness of breath, chest pain, or decreased level of consciousness. While most cases of arrhythmia are not serious, some predispose a person to complications such as stroke or heart failure. Others may result in sudden death.

<span class="mw-page-title-main">Topera Medical</span>

Topera, Inc. is a cardiac arrhythmia mapping company for targeting catheter ablation company launched in San Diego, California and specializes in mapping electrical signals of the heart. Topera's headquarters are located in Palo Alto, California. The company uses 3D analysis and mapping to detect the sources of atrial fibrillation, atrial flutter, and atrial tachycardia and ventricular tachycardia to identify targets for catheter ablation.

<span class="mw-page-title-main">Yaariv Khaykin</span> Canadian cardiologist

Yaariv Khaykin is a Canadian cardiologist and a clinical researcher in the area of electrophysiology. He is the director of the Newmarket Electrophysiology Research Group at the Southlake Regional Health Centre. He has published research into complex ablation and pioneered cardiac ablation methods.

Robotic magnetic navigation (RMN) uses robotic technology to direct magnetic fields which control the movement of magnetic-tipped endovascular catheters into and through the chambers of the heart during cardiac catheterization procedures.

Ganglionated plexi (GP) comprise the intrinsic cardiac autonomic nervous system composed of autonomic ganglia of the heart atrium and ventricles. The GP are embedded in the epicardial fat pads, consisting of only a few neurons or as many as 400 neurons. GP are spatially close to the pulmonary veins, such that pulmonary vein isolation necessarily affects the GP. GP has been shown to be a contributor to atrial fibrillation (AFib), such that ablation of the GP has been a strategy for treatment of AFib. Pulsed field ablation has shown to be an AFib ablation strategy which effectively destroys the GP. GP ablation alone has been shown to eliminate AFib in approximately three-quarter of AFib patients.

Pulsed field ablation (PFI) is a non-thermal method of biological ablation utilizing high-amplitude pulsed electric fields to create irreversible electroporation in tissues. It is used most widely to treat tumors (cancer) or cardiac arrhythmias.

References

  1. 1 2 McGarry TJ, Narayan SM (2012). "The anatomical basis of pulmonary vein reconnection after ablation for atrial fibrillation: wounds that never felt a scar?". Journal of the American College of Cardiology . 50 (10): 939–941. doi:10.1016/j.jacc.2011.11.032. PMC   3393092 . PMID   22381430.
  2. ↑ Thakur RK, Klein GJ, Yee R (September 1994). "Radiofrequency catheter ablation in patients with Wolff-Parkinson-White syndrome". CMAJ. 151 (6): 771–776. PMC   1337132 . PMID   8087753.
  3. 1 2 Spector P, Reynolds MR, Calkins H, Sondhi M, Xu Y, Martin A, et al. (September 2009). "Meta-analysis of ablation of atrial flutter and supraventricular tachycardia". The American Journal of Cardiology. 104 (5): 671–677. doi:10.1016/j.amjcard.2009.04.040. PMID   19699343.
  4. ↑ Nyong J, Amit G, Adler AJ, Owolabi OO, Perel P, Prieto-Merino D, et al. (November 2016). "Efficacy and safety of ablation for people with non-paroxysmal atrial fibrillation". The Cochrane Database of Systematic Reviews. 2016 (11): CD012088. doi:10.1002/14651858.cd012088.pub2. PMC   6464287 . PMID   27871122.
  5. ↑ Cheema A, Vasamreddy CR, Dalal D, Marine JE, Dong J, Henrikson CA, et al. (April 2006). "Long-term single procedure efficacy of catheter ablation of atrial fibrillation". Journal of Interventional Cardiac Electrophysiology. 15 (3): 145–155. doi:10.1007/s10840-006-9005-9. PMID   17019636. S2CID   7846706.
  6. ↑ Blomström-Lundqvist C, Gizurarson S, Schwieler J, Jensen SM, Bergfeldt L, Kennebäck G, et al. (March 2019). "Effect of Catheter Ablation vs Antiarrhythmic Medication on Quality of Life in Patients With Atrial Fibrillation: The CAPTAF Randomized Clinical Trial". JAMA. 321 (11): 1059–1068. doi:10.1001/jama.2019.0335. PMC   6439911 . PMID   30874754.
  7. ↑ Al-Kaisey AM, Parameswaran R, Bryant C, Anderson RD, Hawson J, Chieng D, et al. (September 2023). "Atrial Fibrillation Catheter Ablation vs Medical Therapy and Psychological Distress: A Randomized Clinical Trial". JAMA. 330 (10): 925–933. doi:10.1001/jama.2023.14685. PMC   10498333 . PMID   37698564.
  8. ↑ Wang JS, Shen YG, Yin RP, Thapa S, Peng YP, Ji KT, et al. (August 2018). "The safety of catheter ablation for premature ventricular contractions in patients without structural heart disease". BMC Cardiovascular Disorders. 18 (1): 177. doi: 10.1186/s12872-018-0913-2 . PMC   6119274 . PMID   30170545.
  9. 1 2 Cuculich PS, Schill MR, Kashani R, Mutic S, Lang A, Cooper D, et al. (December 2017). "Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia". The New England Journal of Medicine. 377 (24): 2325–2336. doi:10.1056/NEJMoa1613773. PMC   5764179 . PMID   29236642.
  10. ↑ Beazell JW, Adomian GE, Furmanski M, Tan KS (December 1982). "Experimental production of complete heart block by electrocoagulation in the closed chest dog". American Heart Journal. 104 (6): 1328–1334. doi:10.1016/0002-8703(82)90163-6. PMID   7148651.
  11. ↑ Schaack D, Schmidt B, Chun J (2023). "Pulsed Field Ablation for Atrial Fibrillation". Arrhythmia & Electrophysiology Review. 12: e11. doi:10.15420/aer.2022.45. PMC   10326665 . PMID   37427302.
  12. ↑ Tabaja C, Younis A, Hussein AA, Taigen TL, Nakagawa H, Saliba WI, et al. (September 2023). "Catheter-Based Electroporation: A Novel Technique for Catheter Ablation of Cardiac Arrhythmias". JACC. Clinical Electrophysiology. 9 (9): 2008–2023. doi:10.1016/j.jacep.2023.03.014. PMID   37354168.
  13. ↑ Keane D, Ruskin J (Fall 2002). "Pulmonary vein isolation for atrial fibrillation". Reviews in Cardiovascular Medicine. 3 (4): 167–175. PMID   12556750 . Retrieved 22 August 2022.
  14. ↑ "Pulmonary vein isolation". Mayo Clinic. Retrieved 22 August 2022.
  15. 1 2 Soucek F, Starek Z (2018). "Use of Bipolar Radiofrequency Catheter Ablation in the Treatment of Cardiac Arrhythmias". Current Cardiology Reviews . 14 (3): 185–191. doi:10.2174/1573403X14666180524100608. PMC   6131405 . PMID   29792146.
  16. ↑ Pearman CM, Poon SS, Gupta D (2017). "Minimally Invasive Epicardial Surgical Ablation Alone Versus Hybrid Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis". Arrhythmia & Electrophysiology Review. 6 (4): 202–209. doi:10.15420/aer/2017.29.2. PMC   5739900 . PMID   29326836.
  17. 1 2 3 Calkins H, Hindricks G, Yamane T (2018). "2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation". Europace . 20 (1): e1–e160. doi:10.1093/europace/eux274. PMC   5834122 . PMID   29016840.
  18. ↑ Wyman RM, Safian RD, Portway V, Skillman JJ, McKay RG, Baim DS (December 1988). "Current complications of diagnostic and therapeutic cardiac catheterization". Journal of the American College of Cardiology. 12 (6): 1400–1406. doi: 10.1016/S0735-1097(88)80002-0 . PMID   2973480. S2CID   3110166.
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