Epicardial/Endocardial Sinus Node Ablation After Failed Endocardial Ablation for the Treatment of Inappropriate Sinus Tachycardia

Introduction Success of endocardial sinus node (SN) ablation for refractory inappropriate sinus tachycardia (IST) is limited by the epicardial location of the SN and potential damage to the phrenic nerve (PN). An epicardial approach may overcome these limitations. Methods and Results IST patients wh...

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Published in:Journal of cardiovascular electrophysiology 2014-03, Vol.25 (3), p.236-241
Main Authors: JACOBSON, JASON T., KRAUS, ALEXANDRIA, LEE, RICHARD, GOLDBERGER, JEFFREY J.
Format: Article
Language:English
Subjects:
Adult
Body Surface Potential Mapping - methods
catheter ablation
Catheter Ablation - methods
Cryosurgery - methods
Endocardium - pathology
Endocardium - surgery
epicardial ablation
Female
Humans
inappropriate sinus tachycardia
mapping
Pericardium - pathology
Pericardium - surgery
phrenic nerve
Retrospective Studies
Sinoatrial Node - pathology
Sinoatrial Node - surgery
Tachycardia, Sinus - diagnosis
Tachycardia, Sinus - physiopathology
Tachycardia, Sinus - surgery
Treatment Failure
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Summary:Introduction Success of endocardial sinus node (SN) ablation for refractory inappropriate sinus tachycardia (IST) is limited by the epicardial location of the SN and potential damage to the phrenic nerve (PN). An epicardial approach may overcome these limitations. Methods and Results IST patients who failed endocardial ablation underwent an epicardial approach. Percutaneous pericardial access was obtained with a double wire technique for PN protection (i.e., with a balloon catheter), if needed. Earliest sinus activation was mapped and ablated with remapping for changes in P‐wave morphology or sinus rate. The endpoint was total SN ablation (patients with atrial pacing [AP]); otherwise the target was a >25% decrease in sinus rate and inversion of P‐wave axis. Five patients (all female, age 36 ± 4 years) underwent ablation. Two had prior AP, and 1 elected to have SN ablation and pacemaker during the same procedure. Three had prior endocardial ablation limited by PN proximity. Baseline sinus rate was 119 ± 20 bpm. After 35.2 ± 21.3 lesions (22.4 ± 21.7 epicardial, 12.8 ± 21.3 endocardial), 4 were in junctional rhythm, 1 in atrial rhythm at 90 bpm. This latter patient had symptom recurrence and underwent combined minimally invasive surgical/catheter SN cryoablation. Atrial tachycardia subsequently occurred and was successfully ablated. The only significant complication was pericarditis (3 patients). At last follow‐up (30.4 ± 18.4 months), all had symptom resolution. Two were AP >99%, 1 was AP 54%. Two remain in ectopic atrial rhythm with controlled rates. Conclusions Combined epicardial/endocardial SN ablation is a viable approach for patients with severely symptomatic IST after a failed endocardial attempt.
ISSN:1045-3873
1540-8167
DOI:10.1111/jce.12318