ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE

Radiofrequency catheter ablation in patients with Wolff-Parkinson-White syndrome

Ranjan K. Thakur, MD, FRCPC; George J. Klein, MD, FRCPC; Raymond Yee, MD, FRCPC
Objective: To report on the experience with radiofrequency catheter ablation of accessory atrioventricular pathways in patients with Wolff-Parkinson-White syndrome in terms of the duration of fluoroscopy exposure to the patient and the operator and the effect of accessorypathway location and operator experience on the success rate. Design: Retrospective review. Setting: Tertiary care university hospital. Patients: Two hundred consecutive patients with Wolff-Parkinson-White syndrome who underwent radiofrequency catheter ablation between September 1990 and June 1992. Interventions: Electrophysiologic study and radiofrequency catheter ablation. Main outcome measures: Success rate, duration of fluoroscopy, complications and longterm follow-up. Results: Of the 224 accessory pathways in the 200 patients 135 were left free wall, 47 posteroseptal, 32 right free wall and 10 anteroseptal. The overall success rate increased from 53% in the first 3 months of the study period to 96% in the last 3 months. The success rate depended on the location of the accessory pathway. The duration of fluoroscopic exposure decreased from 50 (standard deviation [SD] 21) minutes in the first 3 months to 40 (SD 15) minutes in the last 3 months (p < 0.05). Complications occurred in 3.5% of the patients; they included hemopericardium, cerebral embolism, perforation of the right atrial wall, air embolism in a coronary artery and hematoma at the arterial perforation site. None of the complications resulted in death. Conclusions: With experience, radiofrequency catheter ablation of accessory pathways can have an overall success rate of more than 95% and a complication rate of less than 4%. Such rates make this procedure suitable for first-line therapy for patients with Wolff-ParkinsonWhite syndrome.

Objectif: Resumer l'experience d'ablation par catheter 'a hautes frequences de voies auriculoventriculaires accessoires chez des patients atteints du syndrome de Wolff-Parkinson-White en ce qui conceme la duree de l'exposition du patient et de l'operateur a la fluoroscopie et l'effet de l'emplacement de la voie accessoire et de l'experience de l'operateur sur le taux de reussite. Conception : Etude retrospective. Contexte : Hopital universitaire de soins tertiaires. Patients: Deux cents patients consecutifs atteints du syndrome de Wolff-Parkinson-White qui ont subi une ablation par catheter a hautes frequences entre septembre 1990 et juin 1992. Interventions : Etude electrophysiologique et ablation par catheter 'a hautes fr6quences. Mesures de resultats: Taux de reussite, duree de la fluoroscopie, complications et suivi de
longue duree. Resultats: Parmi les 224 voies accessoires chez les 200 patients, on comptait 135 parois liFrom the Department of Medicine, University of Western Ontario, London, Ont.

Dr. Klein is a Distinguished Research Professor of the Heart and Stroke Foundation.

Reprint requests to: Dr. Ranjan K. Thakur, Arrhythmia Service, Thoracic and Cardiovascular Institute, 110-405 W Greenlawn, Lansing, MI 48910; fax (517) 483-7583
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CAN MED ASSOC J 1994; 151 (6) 771

bres gauches, 47 voies posteroseptales, 32 parois libres droites et 10 voies anteroseptales. Le taux de reussite global est passe de 53 % au cours des 3 premiers mois de la periode d'etude a 96 % au cours des 3 demiers mois. Le taux de reussite dependait de l'emplacement de la voie accessoire. La duree de l'exposition 'a la fluoroscopie est tombee de 50 (ecart type [ET] 21) minutes au cours des 3 premiers mois a 40 (ET 15) minutes au cours des 3 demiers mois (p < 0,05). I1 y a eu, chez 3,5 % des patients, des complications, dont les suivantes: hemopericarde, embolie cerebrale, perforation de la paroi auriculaire droite, embolie gazeuse dans une artere coronaire et hematome au point de perforation de l'artere. Aucune des complications n'a ete mortelle. Conclusions: Avec l'experience, l'ablation des voies accessoires par catheter 'a hautes frequences peut presenter un taux de reussite global de plus de 95 % et un taux de complication inferieur 'a 4 %. Ces taux rendent cette intervention appropriee pour le traitement de premiere ligne des patients atteints du syndrome de Wolff-Parkinson-White.

olff-Parkinson-White syndrome is characterized electrocardiographically by a short P-R interval and a delta wave, which cause slurring of the initial part of the QRS complex. The anatomic substrate causing these abnormalities is an accessory atrioventricular (AV) pathway, which may be located anywhere around the AV ring. Patients with accessory pathways usually present with recurrent paroxysmal tachycardia that may, in rare cases, lead to sudden cardiac death.1 Until recently, treatment of Wolff-Parkinson-White syndrome comprised antiarrhythmic drug therapy or surgical interruption of the accessory pathway.9'0 Catheter ablation of accessory pathways initially involved the use of high-energy, direct-current shocks under general anesthesia. This method was reasonably efficacious but was abandoned because of complications related to barotrauma.''-" Catheter ablation using radiofrequency energy was subsequently introduced to overcome these problems.' 20 With this technique success rates of 89% to 99% have been reported.'8-20 However, there has been no consistent report of the duration of fluoroscopy exposure to the patient and the operator or the effect of accessorypathway location and operator experience on the success rate. We describe our experience with this relatively new technique in 200 consecutive patients.
W

fasting state, with midazolam and fentanyl for sedation as required. Young children (generally less than 14 years old) were placed under general anesthesia. Three multipolar electrode catheters were introduced through the right femoral vein and positioned high in the right atrium, the His-bundle recording region and the right ventricular apex. Another multipolar catheter was introduced through the left subclavian vein and positioned in the coronary sinus. Programmed stimulation consisted of incremental atrial and ventricular

were studied in the

pacing to the point of AV and ventriculoatrial (VA)

block respectively and extrastimulus testing with the use of at least single extrastimuli at two drive cycle lengths (the pacing rate for the first 8 beats, followed by a premature beat). The goals of the study were to demonstrate the participation of the accessory pathways in the arrhythmias and to locate the pathways. Programmed stimulation was repeated 30 minutes after ablation to test for continued presence of the pathways.

Catheter ablation
Catheter ablation immediately followed the diagnostic study. The catheter in the His-bundle recording position was removed and replaced by a no. 7 French quadripolar deflectable catheter with a 4-mm tip for mapping and ablation. The AV ring was mapped in the area of interest identified during the baseline study, and electrograms were sought with both atrial and ventricular potentials ("ring electrograms"). For optimal ablation, electrodes were positioned at sites showing the earliest ventricular activation during anterograde pre-excitation or the earliest atrial activation during retrograde pre-excitation, or both. The bipolar electrogram between the distal and the second electrodes (filtered at 40 to 400 Hz) and the unipolar electrogram from the distal tip (filtered at 0.5 to 400 Hz) were recorded with five surface leads and selected intracardiac leads. Mapping of the AV ring was facilitated by the standard catheters that served as anatomic landmarks at the His bundle and in the coronary sinus. One or more of the following criteria determined the site of anterograde pre-excitation: (a) the presence of atrial and ventricular electrograms (each showing a rapid
LE 15 SEPTEMBRE 1994

Methods
The radiofrequency ablation program was begun at the University Hospital, London, Ont., in September 1990. The first 200 hundred patients with accessory pathways and symptomatic arrhythmias who underwent radiofrequency catheter ablation between September 1990 and June 1992 are reported in this study. Indications for ablation included drug refractoriness or patient preference. Patients were considered refractory to medical therapy if they failed to respond to at least two antiarrhythmic drugs of different classes. Informed consent was obtained in writing and orally from all patients.

Diagnostic study
The diagnostic techniques and criteria used in our laboratory have been described previously.2' Patients
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intrinsic deflection) on the same recording, (b) the presence of an electrogram (sharp deflection) compatible with an accessory-pathway potential located between the atrial and ventricular electrograms, (c) the recording of the intrinsic deflection of the ventricular electrogram before the onset of the delta wave on the surface electrogram and (d) a QS pattern on the unipolar ventricular electrogram, with the rapid intrinsic deflection preceding the onset of the delta wave. One or more of the following criteria were used to determine the site of ablation during ventricular pacing or reciprocating tachycardia: (a) the presence of a "ring electrogram," as previously defined, (b) the presence of an accessory-pathway potential between the ventricular and atrial electrograms and (c) the site of the earliest recorded atrial activation. The mitral anulus was mapped from either the atrial or the ventricular side. A transseptal approach was used to map the atrial aspect of the mitral anulus (Fig. 1). Transseptal puncture was done using a Brockenbrough catheter with a needle under guidance in the 600 left an-

terior oblique view. After transseptal puncture a no. 8 French 60-cm Mullins sheath was placed in the left atrium, and the ablation catheter was advanced through the sheath to the mitral anulus for mapping. For mapping of the mitral anulus from the ventricular side the catheter was inserted through the femoral artery. The aortic valve was crossed and the catheter moved under the mitral valve, between the leaflet and the posterolateral endocardial surface. A bolus of heparin of 5000 to 10 000 units was given after the catheter was placed in the left atrium or the left ventricle, and subsequent boluses of intravenous heparin were given to maintain adequate anticoagulation. For right-sided accessory pathways, mapping of the tricuspid anulus was performed by means of advancing a catheter through the right femoral vein or, less frequently, the right internal jugular vein. Mapping and ablation were performed from the atrial side of the AV ring. A Radionics RFG-3C radiofrequency generator (Radionics Inc., Burlington, Mass.) was used to deliver energy at 25 to 35 watts for 20 to 60 seconds. The radiofrequency current was discontinued if an end point was not reached within 5 to 10 seconds or if an increase in impedance was noted.

Follow-up
Patients were monitored electrocardiographically for 24 hours after ablation. An electrocardiogram (ECG) was obtained after ablation and before discharge from hospital. Patients were followed clinically through their family physician or referring physician, and a 12-lead ECG was obtained at 3 months. Ambulatory monitoring was performed in patients following ablation if they complained of palpitations or tachycardia, with repeat electrophysiologic testing as indicated.

Data analysis
The end points assessed were success rates, duration of fluoroscopy and number of radiofrequency applications. Successful ablation was defined as immediate loss of conduction through the accessory pathway and no late return of pre-excitation or recurrence of tachycardia during longterm follow-up (Figs. 2 and 3). To assess the effect of experience on success rates, results from the first 3 months of the study period were compared with those from the last 3 months. Continuous variables were expressed as mean and standard deviation (SD). Procedural variables were compared with the use of Student's t-test for unpaired data. A p value of less than 0.05 was considered significant.
Fig. 1: Fluoroscopic images, showing catheter placement during radiofrequency ablation of an accessory pathway on the left side of the heart. The catheter (arrowheads) was introduced through the fossa ovalis in the interatrial septum to map the mitral ring. Top: right anterior oblique view. Bottom: left anterior oblique view.
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Results

Patients and pathways

The patients' demographic characteristics and numCAN MED ASSOC J 1994; 151 (6)
773

ber of accessory pathways are given in Table 1. The 224 pathways around the AV ring were divided into four general areas: left free wall (135), posteroseptal (47), right free wall (32) and anteroseptal (10). In 150 (75.0%) of the 200 patients the pathways demonstrated bidirectional conduction, in 45 (22.5%) they showed only retrograde conduction (concealed pathways), and in 5 (2.5%) they demonstrated only anterograde conduction. Five patients had associated congenital heart disease. Two had Ebstein's anomaly and two atypical Ebstein's anomaly, all with right free-wall accessory pathways. The fifth patient had corrected transposition of the great vessels and had three left free-wall accessory pathways.

The mean number of radiofrequency applications differed significantly between successful ablations and unsuccessful ablations (6.2 [SD 4.8] v. 15.0 [SD 7.4] respectively; p < 0.01).

Complications
Complications related to the procedure occurred in patients (3.5%). In one patient hemopericardium developed, which was managed expectantly without furseven

Ablation
The 200 patients underwent 215 ablation sessions. In 14 patients (5 with left lateral pathways, 5 with posteroseptal pathways and 4 with right free-wall pathways) the first ablation session was unsuccessful; the second session was successful in 10 (71%). One patient with a posteroseptal and a right free-wall accessory pathway underwent three unsuccessful ablation attempts followed by surgery. Success was related to the location of the accessory pathways and to experience (Table 2). The overall success rate was 52% in the first 3 months of the study period, as compared with 96% in the last 3 months. The duration of fluoroscopy and thus the amount of radiation exposure decreased significantly with experience. The mean duration for the entire group, including the time during the baseline study, was 46 (SD 22) minutes. During the first 3 months of the ablation program it was 50 (SD 21) minutes, in 23 patients, whereas during the last 3 months it was 40 (SD 15) minutes, in 46 patients (p < 0.05).

ther sequelae. An 8-year-old boy had cerebral embolism the day after successful ablation; he had received adequate anticoagulation after transseptal puncture for ablation of his posteroseptal accessory pathway. Magnetic resonance imaging confirmed an embolic lesion in the pretectal area of the midbrain involving the right superior cerebellar peduncle. He was given heparin immediately and subsequently treated with warfarin. His symptoms resolved completely within 5 days. In two patients perforation of the right free wall occurred, without the need for intervention. A large hematoma developed in one patient at an arterial puncture site and resolved within a few days without vascular compromise. Two patients were noted to have transient elevation of the ST segment after transseptal puncture; this resolved spontaneously within 10 minutes and was felt to be related to air embolism in a coronary artery.

Discussion
Closed-chest radiofrequency catheter ablation of arrhythmogenic substrate in a dog model was originally described by Huang and associates,"4 in 1987. The technique is conceptually simple. A catheter electrode is positioned at the ablation site, guided by flouroscopy and by the appearance of the electrogram recorded from the

VI
~~~ V

VI
L~~~AV

ALv

Abw
RV

RV

I. ' l

MPL.

Fig. 2: Example of mapping and ablation during sinus rhythm. Left: surface electrocardiographic recordings from leads 1, 2 and V1 and from intracardiac electrograms. Filtered, bipolar electrogram recording from the electrode on the tip of the ablation catheter (Abl) is shown along with unipolar recording from the same electrode (AbUp). Recordings from the right ventricular apex (RV) and the proximal coronary sinus (CSp) are also shown. Delta waves and short P-R intervals are evident on the surface leads. The tip ablation electrode (Abl) shows atrial (A) and ventricular (V) electrograms separated by a sharp deflection (arrow), which denotes the accessory pathway potential. Right: outcome of ablation at this site. The channel marked LV represents the radiofrequency current flow. Electrical noise is generated with the onset of current delivery through the ablation electrodes, and therefore ablation channels are not shown. The QRS complex is normal (lost delta wave), as is the P-R interval, after the onset of the radiofrequency current.
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LE 15 SEPTEMBRE 1994

catheter tip. Radiofrequency energy is then applied through the catheter tip, creating a small lesion (less than 0.5 cm in diameter) at the catheter-tissue interface.22 The lesion results from thermal injury due to resistive heating.22 The accessory pathway in Wolff-Parkinson-White syndrome is an ideal target because the position of the ablation catheter on the AV ring can be guided flouoroscopically and the accessory pathway can be identified by the appearance of the electrogram recorded from the catheter tip. The results of this study confirm the efficacy of radiofrequency catheter ablation as reported elsewhere.'"20 After an initial learning experience (reported from patient 1 in this series), a success rate of more than 90% can be expected by a group performing a reasonable volume of these procedures (more than 50 per year).23 The technique requires angiographic skills to manoeuvre the catheters to the desired site and electrophysiologic skills

to identify the appropriate target site by electrogram

characteristics. There are no clinical or electrophysiologic factors that contraindicate radiofrequency catheter ablation in a symptomatic patient. The only variable that has some relation to success appears to be location of the accessory pathway. In most series, as in our experience, posteroseptal pathways are the most difficult to ablate.1213"8-20 In general, ablation failure may be related to lack of precise localization of the pathway or poor catheter-tissue contact. These problems are particularly acute for posteroseptal pathways because of the complex anatomy in this region.2F2' The complication rate of 3.5% in our series is consistent with rates in other large series."8-20 Although infrequent, some complications may be catastrophic. Many are related to operator error and inexperience. Cardiac perforation occurred early in our experience. Air embolism with left-sided procedures occurred because of our failure early on to appreciate that the entry site of the ablation catheter did not provide a perfect seal when suction was applied through a side port. The occurrence of embolism after the procedure is infrequent but disturbing. This occurred in one patient, even jhough adequate anticoagulation with heparin was achieved after the ablation catheter entered the left side of the heart. PresumTable 1: Demographic characteristics and incidence of accessory atrioventricular pathways in patients with Wolff-ParkinsonWhite syndrome

CSd

.l I

.I

I,

I--_1-500'--,

Fig. 3: Representative example of mapping and ablation during ventricular pacing. Recordings from surface leads 2 and V,, ablation electrode Abi and proximal (CSp) and distal (CSd) coronary sinus electrodes are shown. During ventricular pacing, 1:1 ventriculoatrial (VA) conduction occurs through a left free-wall accessory pathway (atrial deflection in CSd electrode is earlier than in CSp electrode), with a short VA interval in the CS electrodes. After the onset of the radiofrequency current (*) the VA interval in the CS electrodes is markedly prolonged and has a different activation pattern (atrial deflection in CSp electrode is earlier than in CSd electrode), showing retrograde conduction over the AV node rather than the accessory pathway.

Characteristic No. of patients Mean age (and SD*), yr Sex, no. (and %) of patients
Male Female No. of accessory pathways No. (and %) of patients with 1 pathway 2 pathways 3 pathways
*SD = standard deviation.

Value
200 34 (18)

130 (65) 70 (35)

224 180 (90) 16 (8) 4 (2)

Table 2: Rates of success with radiofrequency catheter ablation of accessory pathways from September 1990 to June 1992

Period; no. (and %) of procedures

First 3 months
Location

Last 3 months

Overall
________
__

of pathway Left free wall Posteroseptal Right free wall

Total 15
7 1 0

Successful
10 (67) 2 (29) 0
-

Total
29

Successful
28 (97) 10 (100) 6 (86) 1 (100)

10 7
1

Anteroseptal
All
SEPTEMBER 15, 1994

23

12

(52)

47

45

(96)

Total 135 47 32 10 224

Successful 120 (89) 31 (66) 25 (78) 10 (100) 186 (83)

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ably a small clot formed at the ablation site that subsequently became an embolus. The long-term risk of radiation exposure to the physicians and patients has been estimated.29 The risk of a fatal malignant disease for patients has been estimated to be 0.7 per 1000 patients per hour of fluoroscopy exposure; compared with the lifetime expected incidence of 200 per 1000 patients30 this risk is not significant. The amount of radiation our catheter operator was exposed to was small and well below the recommended occupational level with fluoroscopic times similar to ours. The excellent efficacy, low complication rate and convenience of radiofrequency catheter ablation allows it to be offered as initial therapy for symptomatic arrhythmias. It can be offered as a reasonable alternative to long-term pharmacologic therapy and is clearly easier and more cost-effective than surgery.20>3' Catheter ablation will probably become a one-day care procedure as further experience is gained.
This study was supported by the Heart and Stroke Foundation of Ontario.

References
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Surg 1983; 36: 584-595 29. Calkins H, Niklason L, Sousa J et al: Radiation exposure during radiofrequency catheter ablation of accessory atrioventricular connections. Circulation 1991; 84: 2376-2382 30. National Research Council: Health Effects of Exposure to Low Levels of Ionizing Radiation, National Academy Press, Washington, 1990 31. Recommendations on Limits for Exposure to Ionizing Radiation, National Council on Radiation Protection and Measurements, Bethesda, 1987 32. DeBuitleir M, Sousa J, Calkins H et al: Dramatic reduction in medical care costs associated with radiofrequency catheter ablation of accessory pathways. [abstract] J Am Coll Cardiol 1991; 17: 109A 33. DeBuitleir M, Bove EL, Schmaltz S et al: Cost of catheter versus surgical ablation in the Wolff-Parkinson-White syndrome. Am J Cardiol 1990; 66: 189-192 34. Kalbfleisch SJ, El-Atassi R, Calkins H et al: Safety, feasibility, and cost of outpatient radiofrequency catheter ablation of accessory atrioventricular connections. J Am Coil Cardiol 1993; 21: 567-570
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