532

Radiofrequency Catheter Ablation of Accessory Pathways:

A Contemporary Review
MICHEL HAISSAGUERRE, M.D., FIORENZO GAITA, M.D.,
FRANK I. MARCUS, M.D.,* and JACQUES CLEMENTY, M.D.
From the Hopital Cardiologique du Haut-Leveque, Bordeaux-Pessac, France,
and the *University of Arizona College of Medicine, Tucson, Arizona ' '

RF Catheter Ablation of APs. Catheter ablation techniques are now advocated as the
first line of therapy for arrhythmias caused by accessory pathways (APs). The most common
energy source is radiofrequency current, but technical characteristics vary. Several parameters
can be used to determine the optimal target site: AP potential, AV time, atrial or ventricular
insertion site, or unipolar morphology. Specific considerations are needed depending on AP
location. Despite the different approaches descrihed, there is no significant difference in the
reported success rate, which is over 90%. However, the number of radiofrequency applications
needed to achieve ablation appears to differ significantly, witb median values from 3 to 8
reported. A combination of criteria related to botb timing and direction of the activation wave-
front or use of subthreshold stimulation could improve the accuracy of mapping. In patients
with "resistant" APs, different changes in ablation technique must be considered during the
procedure to achieve elimination of AP conduction. The incidence of complications in multi-
center reports is close to 4%, with a recurrence rate of 8%. The long-term safety of catheter
ablation requires further study. (J Cardiovasc Electrophysiol, Vol. 5, pp. 532-552, June J994)

radiofrequency catheter ablation, accessory pathways

Introduction tion. The entire AV ring was mapped using the

Curative treatment for patients with tachycar-
dia related to an accessory pathway (AP)'-2 was
initially done by surgery and more recently by
catheter ablation.^ '^ The first intentional catheter
fulguration of an AP was performed by Weber
and Schmitz^^ in 1983. In 1984, Morady and
Scheinman^ described a technique suitable for
ablation of posteroseptal APs in which DC shocks
were delivered at the site of an anatomical land-
mark—the coronary sinus ostium.^*"''^ Improve-
ment of AP catheter ablation was accomplished
in 1986 by the ability to map along the different
sites of the AV rings using endocardial (particu-
larly ventricular) electrograms,'"'^''^ thus making
it possible to ablate consistently APs in any loca-
venous approach for the tricuspid annulus. The
tuitral annulus was mapped through a patent fora-
men ovale, transseptal puncture,'^ or by retrograde
transaortic catbeterization.''*'^'' The same technique
of mapping the AV ring continues to be used to
select the target site for ablation.
Catheter ablation techniques are now advocated
as the first line of therapy for arrhythmias caused
by APs. Otir experience includes 817 patients: tbe
first 305 were treated with fulgtiration and the last
512 with radiofrequency (RF) energy. Although
several energy sources have been used for ablation,
this article will deal only with ablation of APs using
RF energy'**"*^ by detailing the techniques, efficacy,
complications, and risk of arrhythmia recurrence
based on the hterature as well as our experience.

Presented in part at the 15th Annual Scientific Sessions of the

North American Society of Pacing and Electrophysiology, May
Technical Consideration of Ablation
11-14, 1994, Nashville, Tennessee. with RF Energy
Address for correspondence: Michel Haissaguerre, M.D.. Hopital
Cardiulogique du Haut-Leveque, Avenue de Magellan. 33604 (1) Energy Source
Bordeaux-Pessac, France. Fax: 33-56-55-65-09.

Manuscript received 27 December 1991; Accepted for publication The diffuse nature of tissue injury with DC
6 April 1994. energy, the high rate of serious complications, and

the limited operator control of the energy deliv-
ered have been the major reasons for the devel-
opment of an alternative ablation energy source."*
Furthermore, there is a near perfect match between
the anatomical size of the AP {0.5 to 7 mm |mean
] 3]4h4sj jy,j jj^yt created by RF lesions. RF energy
used for ablation is an alternating current with a
frequency of 4(K) to UXX) kHz. Tbe primary cause
of tissue injury is heat generated at the electrode-
tissue interface witb a threshold of about 50°C to
produce tissue injury. The following factors play
an important role in lesion fomiation: the power
and total energy delivered, tbe area of the catheter
electrode-tissue contact, the electrode-tissue imped-
ance, and the type of electrodes used. The most
commonly used RF ablation catheter is a 7-Frencb.
sieerable catheter with a platinum tip electrode 4
mm in length. Monitoring of impedance, current,
and voltage during the application of RF energy
is essential. It is anticipated tbat electrode tip tem-
perature will be a suitable substitute for current
a]id voltage. A sudden increase in impedance is an
indication that a coagulum has formed on the
catheter tip. RF generators with a feedback loop
that maintains the tip electrode at a fixed prese-
lected temperature below the boiling point are
preferable for generating a lesion without the con-
cem of coagulum formation. Temperature mea-
surement has tbe litnitation that it may not reflect
tbe temperature at the electrode-tissue interface
unless tbe tip themiistor is in direct contact with
the myocardium.
(2) Technical Characteristics
The sources of RF energy are commercially
available generators. Most commonly, the power
used is between 20 and 40 watts, or, if the energy
being delivered is displayed in volts, 30 to 55 V.
The total duration of energy delivery varies from
30 to 120 seconds when tbe desired result is
seen, or 10 to 30 seconds when tbere is no change
in the electrical signals. In view of some success
noted after delivery of RF energy for 11 to 24 sec-
onds, we extended the duration of energy delivery
to 20 to 30 seconds, even when there was no appar-
ent effect, except when ablating anteroseptal or
mid-septal APs. Under these circumstances, con-
tinuing to apply current may pose a risk to the AV
conduction system. This also applies to ablations
in the coronary sinus or coronary veins to mini-
mize the risk of (Perforation.
Energy delivery must be stopped immediately
if an impedance rise occurs, the catheter is dis-
Haissaguerre. et al. RF Catheter Ablation of APs 533
placed, or there is any indication of complications.
In general, the ECG is monitored continuously
while tbe catheter position on the Huoroscopic
screen is periodically checked during energy deliv-
ery. Tbe ablating catheter must have a stable posi-
tion during either sinus rhythm, ventricular pac-
ing, or tachycardia.
We do not systematically perfbmi "safety" pulses
after an appiirently successful ablation. However,
safety pulses are probably useful if there is difficulty
in achieving a stable catheter position, sucb as in
right lateral sites, or when AP conduction bas not
been eliminated soon (< 7 sec) after tbe on.set of
energy. Either a longer duration or an increased
power of tbe successfiil pulse is more efficient than
the use of a "bonus" pulse.''^
(3) Postahlation Management
Heparin is usually given during and after the
procedure. In our laboratory, we only administer
beparin immediately after tbe procedure because
we are more concerned with the risk of hemo-
pericardium during the procedure than that of
thromboembolism. Using tbis approach, we have
bad a very low incidence of complications; in
particular, we have not recorded tamponade and
have only a 0.8% incidence of minor cerebral
embolic phenomenon. We use a bolus of 1 mg
per kg body weigbt for left-sided ablations and
half this dose for right-sided ablations, then 20
to 40 mg/day subcutaneous enoxaparin for 5 days.
For left-sided APs, other investigators also give
aspirin (250 mg) for a few weeks after tbe pro-
cedure. Postablation routine ecbocardiograpby is
performed in most centers.
Techniques to Determine the Optimal
Ablation Site
An initial electrophysiologic study is required
to identify tbe mechanism of the clinical tachy-
cardia and to ascertain that tbe AP is part of the
circuit. Catheter ablation has been greatly facili-
tated by the introduction of stccrablc catheters.
Ablation of APs may be accomplished by ablat-
ing from eitber the atrium or tbe ventricle. These
"atrial or ventricular" approaches have been advo-
cated, in part, on the basis of tbe presumed fragility
of rigbt and left APs at tlieir proximal atrial or dis-
tal ventricuUir insertions, respectively. In fact, both
approaches can be equally successful provided the
ablating catheter is in close proximity to the AP.
Both anatomical and technical considerations deter-
534 Journal of Cardiovascular Electrophysiology Vol. 5. No. 6, June 1994

mine the direction of the catheters on one or the
other side of the annuius. Generally, transseptal or
retrograde aortic approaches for left-sided APs
yield an atrial or ventricular catheter position,
respectively.''' On the right side of the heart, most
APs can be ablated from the atrium by catheters
introduced from the inferior vena cava, but some
APs, particularly posterior or posteroseptal, are
sometimes best ablated with the catheter inserted
from the superior vena cava. The latter access
makes it possible to ctirve the catheter tip and insert
it beneath the leaflet to reach the ventricular side
of the tricuspid annulus. Therefore, the AA'^ elec-
trogram ratio obtained from catheters placed near
the AV ring does not play a significant role in pre-
dicting a successful outcome. Ratio values vary-
ing from 0.05 to 6 have heen found at successful
ablation sites.
Several parameters can be used to determine the
optimal target site.
scope of the recorder as the catheter position is
changed. Long AV intervals (^ 50 msec from
peak to peak) iire nearly always predictive of abla-
tion failures, except in some posteroseptal APs
(10% in our experience) or in patients who pre-
viously had ineffective surgical or catheter abla-
tion procedures. However, short AV intervals may
be recorded at some unsuccessful sites, particu-
larly in right anteroseptal or lateral APs because
the AV interval measures the relative timing of
two wavefronts and the first atrial signal is inde-
pendent of AP activation (Fig. 1). In some stud-
ies, the AV interval has not been found to be
significantly shorter at successful versus unsuc-
cessful RF ablation sites,'-'** and cannot be used
by itself (without considering timing of ventricu-
lar potentials) as an independent predictive pa-
raiueter for successful outcome. Other workers^'''*''
found that this parameter is the most powerful pre-
dictor of successful sites.

(1) AV Interval (2) Localizing the Atrial Insertion Site by the

The shortest AV conduction time during pre-
excitation is widely used for initial identification
of the approximate site of AP insertion.'-'•'^•^^•''^
This can be ascertained by observing the oscillo-
VA Interval
This criterion, defined as the shortest VA time,
is considered hy some to be an important marker
for successful ahlation. Based on this parameter.

A*^

Z>Z>Z>Z>Z>

Figure I. Example of ultrashort AV time at an unsuccessful ahlation site in a patient with right lateral AP. Atrial pacing pro-
duces block hetween atriai (A) and ventricular (V) potentials, making it possible to differentiate both components. An expla-
nation for virtual AV time (< 5 msec) and ablation failure /.t schematically shown at the bottom. The distal catheter bipole is
located neither at the atrial nor ventricular AP insertion site but gives an ultrashort local AV time due to the relative timing
of atrial and ventricular wavefronts. A similar result would occur with a straight course ofAP but an oblique catheter posi-
tion. An opposite direction (from right to left) of atrial activation would give a long A V time at the same recording site.

Swaitz et al.^' reported excellent results with the
delivery of a median of three RF applications. In
our experience'^'- and that of Calkias et al..'^ a
retrograde continuous electrical activity is frequent,
making the determination of the optimal site impre-
cise. In a study by Smeet.s et al.-*'' using high den-
sity intraoperative computerized mapping, tlie atrial
insertion site could cover a broad zone measuring
2 cm. This is in ctintrast to histologic studies'*''-'^
showing AP width.is riuiging from 1 to 3 mm. More
accurate identifieation of the atrial insertion site
for ieft-sided APs has been proposed using atrial
electrogram polarity reversal.-*" The AP insertion
is m<xleled as a discrete point souree from which
activation spreads directly anteriorly or posteriorly
along the mitral annulus. A recording bipole placed
parallel to the mitral annulus will record a nega-
tive electrogram posterior to the AP insertion
site, then a fractionated and isoelectric elecu-ogram
at the site of the AP atrial insertion. The polarity
reversal will be completed with further anterior
movement of the catheter. Similai' infomiation could
be expected using unipolar retrograde atrial elec-
trograms.'"
(3) Localizitig the Ventricular Insertion Site by
the V-Delta Interval
This criterion is defined as the time from the
ventricular electrogram to the onset of the delta
wave.'^ It is expressed as the V-de!ta interval. The
maximum peak of the bipolar electrogram (rather
than its onset) is preferred for estimating activa-
tion" because there is a better correlation of the
maximal peak with the ItK-al activation time, and
because it is a powerful independent predictor of
successful sites.'-'^ This reliahle criterion has
two pitfalls that may decrease its accuracy: {!) the
exact onset of delta wave is difficult to identify
and probably not repnxlucible at subsequent man-
ual measurements. Computerized detenriination
and memory of the favorable electiogram tor com-
parison with the subsequent ones would be desir-
able for online preablation mapping; iuid (2) in tbe
presence of polyphasic signals, it is difficult to
determine the true local activation timing using
large recording electrtxies, such as the 4-mm tip
electrode that is commonly used. Tbe itK-al acti-
vation time can only be reliably defined by using
either tbe unipohir intiinsic deflection'^" or closely
spaced hipolar electrograms (which require spe-
cially designed catheters'"). The degree of pre-
maturity of ventricular electrograms depends on
AP location'- and varies from patient to patient.
Haissaguerre. et at. RF Catheter Ablation of APs 535
Its value for an individual patient cannot be pre-
dicted. The earliest timings are observed in right
lateral and anteroseptal APs (-18 ± II msec), or
in rigbt posteroseptal APs (-13 ± 9 msec). The
ventricular potentials relative to delta wave onset
are not as early in left posteroseptal (-2 ± 5 msec)
and left lateral APs (0 ± 5 msec) (Fig. 2).
Pacing the ventricular aspect of the annulus (pace
mapping) can be used to reproduce QRS com-
plexes similar or idenfical to fully preexcited QRS
complexes recorded in the 12-lead ECG. This tech-
nique can be used as an additional criterion for
identifying the ventricular insertion site with an
estimated resolution power of 5
(4) Vnfiltered Distal Unipolar Recordings
We consider the use of untilteivd unipolar record-
ing extremely reliable in the selection of AP abla-
tion sites, thereby minimizing the number of unnec-
essary RF pulses. First, it prcivides recordings from
the distal electixxle of the ablation catheter, wbich
then serves to deliver ablative energy, whereas a bipo-
lar reconding might show an apparent optimal pat-
tern provided by the contribution of the proximal
electrode. Second, the use of the intrinsic deflection
gives more precise local activation timing thiui bi^xv
lar recordings, due in part to the wide interelcc-
trode distance of available bipolar catheters. The
intrinsic deHecfion can disclose a Ux'al late ventric-
ular activation despite an appiirently early bipolar
(maximum peak) electrognun. Third, the morphol-
ogy of the "unfiltered" (().().i to 5(X) Hz) ventricular
wave gives direct infomiation on the proximity of
the catheter to the origin of the ventricular activa-
tion.'^••'-•*^ Tbe presence of a clear initial [xisitive
deflection in the unipolar ventricular waveform indi-
cates tbat there is intervening myocardial tissue
between the recording eleetrtxie and the origin of
ventricular excitation.'^ The higher the r wave, the
farther the origin of ventricular excitation and, there-
fore, the less successful the ablation site. A purely
negative ventricular pattem (i.e., a QS wave) indi-
cates proximity of the ventricular activation origin
(Fig. 2). Even in the pre.sence of apparently early
bipokir ventricukir deflections, ablation may still bave
a high probability of failure if it is not associated
with QS unipoliU" morphology. The use of a 4-nini
tip electrode can decrease the resolution of unipolar
recordings and thus its predictive accuracy. An rS
pattem may be observed at successful sites in 7% to
14% of patients,'- particularly in left lateral APs. This
suggests tbat the lesions created are wide enougb
to include the AP ventricular insertion, or that they
536 Journal of Cardiovascular Electrophysiology Vol. 5. No. 6, June 1994

involve either tbe atrial insertion or tbe pathway itself.
In neiu^ly all these cases, we found a probable AP
potential preceding tbe occurrence of the intrinsic
deflection. Therefore, the apparent discrepancy in the
local recording of tbe AP potential and initial r
ventricular wave clearly indicates an oblique
course of the AP, a situation observed in 16% (range
10% to 20%) of left lateral APs.
(5) Recording the AP Potential
Direct recording of AP potentials was initially
used to localize the site for effective abla-
tion 10.24,33.34.54 [n QU,- experience, their amplitudes
are very low—mostly between 0.03 and 0.07 mV—
requiring bigb gain amplification to evidence them.
However, in anteroseptal APs, AP potentials mea-
suring 0.1 to 0.2 mV can be recorded (Fig. 3).
Although tbe AP potential may be the mo.st pre-
cise marker of tbe patbway location, tbe recorded
potentials often cannot be identified with certainty
as originating direcUy from tbe AP. Thus, the result
of some published cases sbowing a wide or slow
deflection well separated from other electrical activ-
ity is unexpected for a rapidly conducting struc-
ture, and others have a higher amplitude tban the
local atrial or ventricular potentials, which is sur-
prising for a tiny pathway. To validate an AP pcHen-
tial requires that it be excluded from bolh the atrial
and ventricuiar activation (Fig. 3). AUhough we
think that it is relatively easy to separate the AP
from tbe atrial potential, it is extremely difficult to
dissociate it from ventricular activation. Further-
more, it is necessary to study tbis site under both
anterograde and retrograde conduction to demon-
strate block at the alrial-Kent and Kent-ventricle
interface, which frequently alters the pattem of the
AP potential. Finally. Kuck et al.'*' showed that
in most patients the site of AP block in antero-
grade and retrograde conductions appears consis-

LL

Figure 2. E.xamples of bipolar and unipolar eleetrograms at .succes.sful ablation .site for right anteroseptal (RAS). right lat-
eral (RL). lefi posteroseptal (LPS), and left lateral (LL) AP. Morphology of electrograms is similar despite the various AP
locations, showing a short AV time, a sharp and tiny AP potential (arrows) between atrial and ventricular potentials, and a
QS pattem of the unipolar ventricular potential. Ventricular potentials occur notably before delta wave onset in right APs
whereas they are .synchronous to delta wave onset in left APs. AP potentials luive a low amplitude (mean 0.05 mV for bipolar
potentials) and are seen well in bipolar electrograms, whereas they only show a tiny notch preceding the QS ventricular
wave in unipolar electrograms.
 Haissaguerre. et al. RF Catheter Ablation of APs 537

BLOCK A-AP BLOCK

Figure 3. Demonstration of an AP potential (arrows) by exclusion of both atrial and ventricular activation. (Lefi panel)
Atrial pacing produces a progressive separation of atrial and AP potential. (Right panel) Block occurs between AP and ven-
tricular potential due to mechanical pressure of the catheter. Note the sharpness and amplitude (0.2 mV) of AP potential
(.similar to His-bundle potential) and its unipotar diphasic morphology. Recording ofthis type of AP potential is particularly
frequent in anteroseptal APs.

tently at the same interface (atrial or ventricular).
Tbis implies that tbis potential could be separated
from the atrial or ventricular activity in only a
minority of patients. Therefore, the AP potential
is usually referred to as "possible" or "probable,""
and it is not surprising that the use of this crite-
rion by itself bas a relatively low predictive value
for successful ablation in some studies." •*''
In order to circumvent the problem of ascrib-
ing a nonatrial potential to the AP or the ventric-
ular activation, we studied another means of val-
idation based on tbe properties of unipolar
recordings. Spach et al. demonstrated that unipo-
lar polyphasic waveforms result from the super-
position of potentials from different strands excited
asynchronous!y, whereas a single (healthy) myocar-
dial component must give an unipbasic waveform.
Therefore, wben we compare simultaneous bipo-
lar and unipolar recordings, we assume that tbe
first nonatrial potential (shown by atrial stimula-
tion) is of ventricular origin if its timing is included
within the unipohy uniphasic ventricular waveform
:md that it is the AP potential if its timing occurred
before the intrinsic deflection of a QS type ven-
tricular waveform (Figs. 2 and 3). Although the
AP potential is best seen in bipolar recordings, it
appears in the unipolar recording as either a notch
or a diphasic or negative deflection with a differ-
ent slope preceding the intrinsic deflection. In an
ongoing prospective study, this criterion was found
to be an excellent marker for successful ablation
using a median of one pulse witb a positive pre-
dictive value of 82% in left lateral APs.
(6) Nonelectrophysiologic Parameters
Effects of suhthreshold stimulation as a pretest for
.succes.sfUl ablation
The use of subtbresbold stimulation^*^ has
recently been introduced to identify the site of suc-
cessful ablation. Tbis may be piulicuhu'ly useful
for evaluation of concealed APs during recipro-
cating tachyciirdia. Its high positive predictive value
would prevent tbe delivery of multiple unneeded
pulses. Further developments of this technique may
prove important for improving the safety and
efficacy of ablation for APs.
Reproducible mechaniciU inhibition of superficial
APs can be used to locate the site of successful
ablation. This method was appiied in some of
our patients with anteroseptal or mid-septal APs.
538 Journal of Cardiovascular Electrophysiology Vol. 5. No. 6. June 1994

Based on this finding, an energy as low as 10 to
15 watts successfully abolished preexcitation with-
out injuring the nonnal AV conduction system, in
spite of the recording of a large His-bundle poten-
tial at the same site (Fig. 4).
Optimal catheter-tissue interface
It should be emphasized that catheter stability
and a good tissue contact at the target site are of
paramount importance for successful ablation.
Catheter stability can be better assessed by stable
electrograms than by the degree of catheter excur-
sion on fluoroscopy. In addition, the presence of a
high ST segment elevation (> 2 mV) on unipolar
waveforms'^ indicates excessive catheter contacl
with the myocardium, which frequently results in
an impedance rise and subsequent complications.^''
In summary, the ablation site for manifest APs
can be approached by tinding the shortest AV inter-

Figure 4. Twelve-lead ECG (left panel), view at ablation site (bottom right panel), and recording at postablation site (top
right panel) in a 23-year-old patient with a dilated cardiomyopathy (left ventricular ejection fraction 24%). The negative pat-
tem in leads V! and V2 of delta wave pattem is .suggestive of para-Hisian septal AP. View at ahlation .site is in very close
proximity to the His bundle (upper catheter). After a transient "mechanical" block of the AP due to catheter pressure. RF
energy (15 watts) was delivered for 20 seconds, abolishing preexcitation within 3 seconds and yielding a transient right bun-
dle branch block. A 0.08-mV His-bundle potential was present at the postablation site (top).
 Haissaguerre, et ai RF Catheter Ablation of APs 539

val. Then the earliest ventricular potential relative
to delta wave onset must be looked for, ideally
confirming the latter by the use of unipolar
intrinsic detlection. A ventricular potential syn-
chronous with delta wave onset is acceptable for
a target site in left-sided preexcitations, while
earlier values are sought to locate the optimal abla-
tion site for right-sided preexcitations. The pres-
ence of a deflection preceding the main ventricu-
lar potential suggestive of an AP potential is an
additional favorable criterion.
terion for bipolar AP potential is accomplished by
a comparison with both morphology and timing of
unipolar recordings, dramatically enhancing the
probability of success of an RF application. In par-
ticular, it allows for the ablation of a left lateral AP
using a median of 1 pulse. Additional predictive
accuracy could be expected using tlie effects <.)f sub-
threshold stimulation on AP conduction in addition
to the shortest retrograde VA time for ablating con-
cealed APs.

(7) Evaluation of Different Electrogram Criteria for
AP Ablation
Despite difFerent approaches there is no significant
difference in the reported success rate (which is
over 90%). suggesting that no mapping technique
is clearly superior to any other. Indeed, success rates
obtained using either ventricular activation map-
ping, atrial mapping, or recording AP potentials are
similar. However, the number of RF pulses needed
to achieve ablation appears to differ significantly
(Table I). TTiis is due to a different interpretation
and lack of resolution of conventional electrograms
and the difficulty in determining the exact onset of
the delta wave. Minimizing the number of unneeded
RF pulses requires using criteria that have a higher
positive predictive value. Estimation of the timing
and direction of the activation wavefront as pro-
vided by unfiltered unipohir electrogram morphol-
ogy or by atrial electrogram polarity reversal could
improve the accuracy of mapping. In our experi-
ence, ablation must not be attempted when a
significant (> 0.1 mV) r wave is seen in the unipo-
lar ventricular wave recordings. Furthermore, we
lirmly believe that a more stringent and specific cri-
Specific Considerations
(I) Left Lateral APs
The anteroposterior. right anterior oblique, or,
ideally. 60° left anterior oblique views are used for
mapping. A catheter is inserted in the coronary
sinus for localization of the AP atrial insertion using
the shortest retrograde VA time, and for use as a
radiographic reference. The site of the eiirliest ven-
tricular activation can be determined if large ven-
tricular electrograms are recorded. In addition, this
catheter serves other functions: (1) Since the coro-
nary sinus is an epicardial structure, it can show
earlier electrograms than those recorded from the
endocardium, suggesting an epicardial course of
the AP; and (2) If several RF pulses are delivered,
the ablated sites can be referenced to the coronary
sinus electrodes to prevent delivery of energy to
similar sites. Some workers use a single catheter
for mapping and ablation.-" In some centers, the
ablation catheter is introduced using the transsep-
tal technique, but most prefer the retrograde aor-
tic approach to avoid the potential complications
of transseptal catheterization. However, both tech-

TABLE I
Literature Review
Mean (m) or Mean
AP Location Median (M) Fluoroscopy Recurrences
No. of No. of
Author Patients APs I,I, PS AS RL No. of Pulses Time (min) Success
105 111 9(M) 53 3 89
430 453 6(M) 8 95
Jackman^' t66 t77 106 43 13 15 3(M) 9 99
Catkins" 250 267 161 49 to 47 6<M) 47 7 94
Miles'" 28 30 10 (m) 4 86
Lesh'" 100 109 45 36 7 21 8(M) 66 to 89
X. Chen"' 57 60 40 13 7 6(M) 80
Silka^ too 107 48 37 4 IS 6(M) 87
Ualher" 75 84 44 8 2 9 5-t4(m) 33-63 0 71-90
Natate'' 80 82 82 6(m) 34-42 4 92.5
S.A. 142 166 IO(m) 50-67 10 96
Swartz*' 114 122 76 24 10 12 3! -63
See reference for details. Note that some reports are preliminary and do not reflect current results.
540 Journal of Cardiovascular Electrophysiology Vol. 5, No. 6, June 1994

niques are complementary.'•*"'^-5' In the transsep-
tal approach, the ablation catheter must be held
during ablation to ensure contact with the atrial
side of the mitral annulus, whereas a catheter intro-
duced retrogradely is usually positioned underneath
the valve and has better stabihty and tissue con-
tact. Unipolar ST segment elevation can suggest
that the catheter pressure is too great, and the
catheter should then be withdrawn slightly.
(2) Right Anteroseptal APs
Radiographic anteroposterior or 30'^ right ante-
rior oblique views are used for mapping. These
pathways can be approached from underneath the
tricuspid valve as suggested by Jackman et al..-^
but this approach may be associated with a higher
risk of inducing right bundle branch block (BBB).
TTie ablation catheter can also be intrtxluced through
a femoral vein and placed parallel to the His-
bundle catheter. A superior "atrial" approach is
more frequently used."'^'^ A subclavian or jugular
catheter is directed toward the atrial side of the tri-
cuspid valve, usually 5 to 10 mm anterior to and
above the His-bundle catheter. The anterior posi-
tion, well seen in oblique views, often requires that
the catheter be twisted firmly in a clockwi.se direc-
tion throughout RF delivery. Although a tiny
His-bundle potential is frequently seen, a significant
(> O.I mV) His-bundle potential must not be pres-
ent at the ablation site. A catheter positioned at the
His-bundle area would guiu'd against encroachment
of the ablation catheter on this region throughout
RF delivery. As a rule, the ventricular potentials
should precede the delta wave onset by a mean
of 18 ± 10 msec, i.e., occurring within the P wave
(Fig. 5). As in right lateral APs. the earliest onset
of delta wave is recorded in the V, through V3
leads rather than in standard leads I, II, or III.
The major problem and challenge is to ablate
APs while preserving AV conduction. In the
ablation registries, complete AV block occurred
mainly during ablation of right anteroseptal APs.
This risk should be reduced with increased oper-
ator experience. Indeed, previous surgicaP" and
fulguration procedures." both causing large abla-
tive lesions, showed a very low incidence of AV
block due to the fact that these APs have an ante-

4
!l i 1 : nil

Figure 5. Right anteroseptal AP. (Left panel) Bipolar and unipolar electrograms at succes.iful ablation site for right
anteroseptal AP. Arrows indicate the local ventricular activation timing. (Top right panel) ECG showing the di.sappearame
of preexcitation at the first .second of RF delivery. Radiogram (right bottom panel) shows the ablation catheter {arrow} 5 mm
above the His-bundle catheter.
 , et al. RF Catht'ter Ablatiim of APs 541

rior rather than septal Uxation. We had only one
patient in 25 who developed AV block during
anteroseptal ablation using fulguration (at the atrial
side of the annulus). Therefore, AV block should
be exceptional when focal lesions are caused by
RF energy. In our opinion, AV conduction can be
always preserved by: (1) Minimi/ing the number
of RH pulses by using the maximum predictive cri-
teria. If there is some doubt as to which target sites
to choose, apply the Hrst pulse at the most ante-
rior site; (2) Checking for Ihe absence of a
signiticant His-bundle potential by induction of
narrow QRS complexes; (3) Applying RF energy
for < 10 seconds if the pathway has not been
changed; and (4) Stopping RF delivery immedi-
ately in the event of a sustained junctionai rhythm,
which is a constant marker heralding the occur-
rence of AV block.
APs. extremely short or even virtual simultaneous
AV times and very early ventricular potentials are to
be sought. These pathways may be diftictilt to ablate
due to catheter instability and poor tissue contact.
Higher energy outputs are usually necessary to
achieve the same temperature as for left-sided APs."'
Better catheter designs, such as those with long
distal ctirves or the use of long sheaths, may be help-
tul to minimize this instability and improve tissue
contact. Some workers recommend Ihe use of a
catheter introduced in the right coronary iutciy' to
serve as a reference. However, this does not solve
the problem of endociuxlial catheter instability, and
there is a risk of coronmy spasm t>r of endothelial
abrasion that could be potentially athercjgenic. The
site of the pathway can be easily recognized during
catheter mapping and marked on the tluoroscopy
screen, or a h;ilo-shaped electrode can be inserted
and laid around the ring to locate the AP.

(3) Right iMteral APs

(4) "Mahaim Fibers"
Both oblique radiographic views are suitable for
mapping. Subclavian or feinoml vein appmaches can In our experience of 16 patients, we observed
be used as shown in Figure 6. As with anteroseptal three types of decremental conducting APs. One

Wr jtflWv
LAD 60°
AAA.
F 6

VWAAA

ABLi

Figure 6. Right lateral AP. (Left panel) Twelve-lead ECG during maximal preexcitation induced by atrial stimulation. (Mid-
dle panel) Two annular bipolar electrograms were recorded: I from a femoral catheter positioned above the leaflet, and 2
from a .subclavian catheter positioned underneath the leaflet. Earlier ventricular potential is noted in electrogram /. which
was the successful ablation site. (Right panel) A 60" LAO view shows the position of catheters I and 2.
 542 Journal of Cardiovascular Electrophysiology Vol. 5, No. 6, June 1994
had a true Mahaim nodoventricuiar AP, two had a
short (para-annular) atrioventricular AP, and 13
had a long atrioventricular AP. Therefore, most
of these APs with anterograde decrementai con-
duction properties are long pathways with a right
lateral proximal insertion that can include AV node
type cells and a distal fascicular/right ventricular
insertion.*2-6s These APs may be "ectopic nodal
AV pathways." Although these pathways are not
thought of as having retrograde conduction, in one
case we found*"^ that conduction can occur from
the ventricle through the AP but may be blocked
at its proximal insertion. Different approaches for
ablation^^^i can be used: (1) VetUricular insertion
mapping guided by the earliest ventricular poten-
tial relative to preexcitation onset; (2) Atrial inser-
tion mapping by use of the shortest atrial stimulus
to delta wave interval. The approximate location
of the pathway can also be found by delivering
late atrial extrastimuli during antidromic tachy-
cardia and identifying the paratricuspid pacing site
that results in the greatest advance in the timing
of the next ventricular complex; and (3) Direct
recording of AP potentials either at the atrial or
ventricular insenion or along the pathway. When
we used the tirst technique of earliest V-delta time,
we found that most patients had both an arboriza-
tion of the distal insertion and a myocardial gap
between tfiis insertion and the right bundle branch
system, suggesting a ventricular (not fascicular)
distal insertion. The distal AP insertion was ablated
in 13 patients with only one case of right BBB.^"
The Ideal .site for ablation is the mid-part of the
pathway because it is a very narrow and insu-
lated bundle-t>pe structure. A spike originates from
this bundle, but its recording is often difficult due
to the instability of the catheter. In 6 of 13 cases,
we observed a mechanical block of the AP at
this site, a phenomenon also reported by the Ham-
burg group."
(5) Posteroseptal APs
Ablation of posteroseptal APs-'-^''-^"-^^ " may be
difficult because of the complex three-dimensional
anatomy of the posterior space. The effective abla-
tion sites can be tbe tricuspid annulus, the margin
of the coronary sinus ostium, the coronary sinus
itself, a venous branch, or the mitral annulus. In
some patients, RF pulses must be applied to both
sides of the septum to achieve complete elimina-
tion of anterograde and retrograde AP conduction.
Changes in the preexcitation pattem. either spon-
taneous (Fig. 7) or induced by pacing, is a rea-
sonable indication that there is a wide insertion
of AP fibers that will require a greater number of
maximum applications of RF energy with regard
to both time and amount of energy delivered.
Right versus left posteroseptal APs are con-
ventionally defined by their ventricular insertion
site, which gives, respectively, a predominant
positive or negative maximally preexcited QRS
complex in the V, lead. This simple differentia-
tion is con-oborated by the effects of functional
BBB on the VA interval during orthodromic re-
ciprocating tachycardia." In patients with promi-
nent positive preexcitation in V,, the occurrence
of right BBB prolonged the VA interval in only
I of 18 patients, whereas it was prolonged by
left BBB in 14 of 19 patients (74%). In patients
with prominent negative preexcitation in V,, the
occurrence of left BBB during tachycardia
increased the VA interval in 1 of 12 patients (8%),
and right BBB increased the VA interval in 2
of 11 patients. In all cases, attempts to map and
ablate from a right-sided approach should be
made either by the endocardial septum or in the
proximal coronary sinus. It is important to remem-
ber that the left AP ventricular potentials are not
as early as those from the right side. When the
favorable site based on anterograde and retro-
grade parameters is more than 15 mm inside the
coronary sinus, left septal mapping is recom-
mended. A 60" left anterior oblique view was
found optimal for AP ablation with a right-sided
approach, because it showed the maximal ampli-
tude of catheter movements. Furthermore, the
respective positions of the septum, tricuspid annu-
lus, and mitral annulus are clearly differentiated,
and the ablation sites of right or left APs are usu-
ally directed toward the left or right side of the
fluoroscopic screen, respectively.
In our experience, all posteroseptal APs with
prominent negative preexcited complexes in V,
were ablated from the right side (i.e., right endo-
cardium [88%]) or proximal coronary sinus [12%]).
Right posteroseptal APs with a negative delta wave
polarity in V, require fewer RF applications than
those with an isoelectric or positive initial vector
(4 ± 3 vs 8 ± 6; P < 0.05). Posteroseptal APs with
prominent positive preexcited complexes in V,
were ablated at the right endocardium, the proxi-
mal coronary sinus, or the left endocardium in
55%, 27%, and 18% of cases, respectively. The
high prevalence of APs related to the coronary
sinus appears to us to be clearly related to a bias
in the referral of patients who underwent prior
unsuccessful ablation attempts; a similar preva-
 Haissaguerre. et al. RF Catheter Ablation of APs 543

Figure 7. Spontaneous chan^ie.s (white und hUtck .stars) in rif-lit posteroseptal preexcitation. Whereas hipolar electrograms at
the posteroseptal [PS) .site are similar, morphology of unipolar electrograms shows a clear difference with either an rS pat-
tem (black star) or a QS pattem (white star).

lence was reported also by othcrs.^-'^'* In patients (6) Mid-Septat APs

with left posteroseptal APs. some ECG parame-
ters have a valuable though imperfect predictive
accuracy for the side of approach.^*' Our results are
summarized in Table 2. The association of a neg-
ative delta wave steeper than 45" in lead II and a
positive complex in aVR yielded a 75% predic-
tive value for a coromu7 sinus approach.
Mid-septal APs are described as APs located in
the zone between the His bundle and the coronary
sinus. Applying this detinition,^^-^'^ most APs have
been ablated just above the coronary sinus; there-
fore, the approach is not different from that for the
conventional posteroseptal APs. However, taie mid-
septal APs are those that are adjacent to the His

TABLE 2
I'rediLiive Value of Maximal Preexcitalion Pattem tor Successful Approach of Postcroseplal APs

Tvpt" of Apprnat h ECC

Paramt'tiT Sensitivity Specificity PPV
for Sucfi'.ssful Abliition
Posteroseptal Accessory Pathways with a QRS Predominantly Positive in Lead V,* (whatever the delta wave) tn = 51)
Righl endocardial Delia wave <45Mn VI 72% 70%
Right endocardial QRS predominantly negative in aVR 58% 77% 74%
Ij^tt cndocardial or coronary sinus Delta wave ^45° in VI 72% 61% 64%
t-efi endocardial or coronary sinus QRS predominantly positive in aVR 77% 68% 73%

All Posteroseptal Accessory Pathways (n = 92)

Coronary sinus or venous branch Negative delta wave (>45'') in lead II 76% 71% 54%
Coronary sinus or venous branch Negative delta wave (>45*') in 11 and rSR' 67% 75%
pattern in aVR
* This criterion is applicable regardless of the polarity of the delta wave in the first 40 msec in V,, PPV = positive predictive
value.
544 Journal of Cardiovascular Electrophysiology
bundle (para-Hisian) or immediately posterior to
the His bundle, close to the AV node (paranodal).
This differentiation is of clinical importance
since ablation of the APs that are close to the AV
conducting system clearly involves the risk of devel-
oping AV block. We have encountered five para-
nodal APs and four para-Hisian APs. The para-
Hisian AP had an anteroseptal-type preexcitation
pattem (positive delta wave in leads I, II, and aVF)
but a QS pattern in V, and V^. These criteria
yielded an 80% predictive value for a para-
Hisian AP. Despite a local His-bundle potential
measuring 0.15 to 0.4 mV, all were ablated with-
out creating AV block using low energy (10 to
15 watts).
(7) Permanent Junctional Reciprocating
Tachycardia
This tachycardia is associated with APs hav-
ing retrograde decremental conduction properties.
Although typically described in the posteroseptal
location, other AP locations have been recognized.**"
Our experience includes 27 patients with the fol-
Figure 8. Ablation sites in three cases of permanent junctional reciprocating tachycardia: two posteroseptal (PS) and one
rifiht lateral (RL). Bipolar atrial electrograms during tachycardia are either fragmented (first panel) or dual (second and
third panels). Simultaneous unipolar electrograms show a QS pattern (arrows).
Vol. 5. No. 6, June 1994
lowing locations: posteroseptal 22 (81%), mid-sep-
tal 3 (11%), right lateral 1 (4%), and left lateral I
(4%). Guided by the shortest VA time and a QS
pattern of the unipolar atrial wave during tachy-
cardia, ablation was performed in all mid- or
posteroseptal cases through a right-sided approach:
right endocardial septum in 16 and by the proxi-
mal coronary sinus in 9 (including 1 in the mid-
dle cardiac vein). In six of the latter cases, map-
ping the left endocardial septum showed less
favorable electrograms than within the coronary
sinus. Six of the 9 patients ablated through the
coronary sinus had an initially negative P wave in
lead I during tachycardia versus 6 of the other 16
septal APs. This criterion yields a predictive value
of 50% for this approach. The electrogram at the
successful sites (Fig. 8) showed earlier activatit)ti
than the coronary sinus reference (subclavian
catheter) in 22 of 27 patients and was synchronous
in 5. A new finding was the observation of frac-
tionated dual or multiple atrial electrograms (Fig.
8) at the successful site in 23 of 27 patients (85%),
whereas this pattem was absent or less marked in
most cases either at the contiguous sites in tachy-
 Haissaguerre. et al. RF Catheter Ablation of A!*s 545

cardia or at the same site in sinus rhythm. The
duration of this local atrial electrogram was 52 ±
15 msec. The complex electrogram was presumed
to be related either Io the complexity of the AP-
atrial interface or the presence of an AP poten-
tial.
Mana}{cnient of "Resistant" APs
When electrograms are not favorable, a vari-
ety of different catheters from superior or
femoral approaches must be tried. In some patients,
ablation is unsuccessful in spite of appiucnt favor-
able electrogratns, catheter stability, and adeqtiate
temperature delivery"*' at target sites. Under tbese
circumstances, the following suggestions may be
helpful.
(/) ChanginR the Site of Ablation to the Side of the
Annulus Opposite to That Where Initial RF Pulses
Were Applied
In right-sided APs, a new catheter introduced
from a superior vein may allow the catheter to be
positioned beneath the tricuspid leaflet. In pos-
teroseptal APs. we select sites showing a high AA'
ratio instead of initially low ratios or vice versa.
In left-sided APs (particularly posterior ones) that
could not be ablated from beneath the Icaliet, the
catheter is advanced reUogradcly into ihc Icit atrium
and then progressively withdrawn to ablate the
atrial side of the mitral annulus using the same
anterograde parameters. Otherwise, a transseptal
approach must be considered.
(2) Changing the Mapping Criterion
Switchitig from the earliest anterograde to the
earliest retrograde activation site is useful in pos-
teroseptal or left lateral APs. wbere an oblique
course has been encountered relatively fre-
quently. In 5 of our 14 posteroseptal APs (36%)
ablated in the proximal coronary sinus or afFerent
branches, the local retrograde VA time was veiy
short despite a relatively long AV time during pre-
excitation (Fig. 9). It should be emphasized tbat
the mere positioning of the ablation catheter at the
atria! or ventricular side of the annulus (as reflected

OUT

Fijiure **. "Resistant" lefi posteroseptal AP with a steep QS wave in lead U and an rSR pattem in aVR strongly sugge.%ting an
epicardial A P. Middle pane! shows a relatively long AV time (62 msec) during pree.uitation. but a QS pattern in the unipolar
electrogram (arrow) al an ablation site inside the cotonaiy .sinu.s. The .shortest VA tune during reciprocating tachycardia
(ORT, right panel) is recorded at this same site. Ablation using 15 watts of energy was succes.sful (bottom panel).
 546 Journal of Cardiovascular Electrophysiolog;^ Vol. 5, No. 6. June 1994

by high or low AA^ electrogram ratio) is to be dis-
tinguished from mapping of the atrial or ventric-
i- insenion of the AR
(3) Seeking an AP Potential
Tbis applies to posteroseptal APs and also to
presumed wide APs for which the use of short
pulses, although at appropriate sites, would not
create significant confluent lesions for effective
ablation.

This may be self evident but is a criterion that

must be used particularly when previous multiple
RF applications guided by atrial or ventricular
insertion mapping were unsuccessful. AP poten-
tial is frequently present at a very low amplitude
between atrial and ventricular potentials that are
separated more than usual (Fig. 10). suggesting
that previous ablations have altered a part of the
AP insertions.
(5) Excluding Structural Abnormalities
Some posteroseptal APs can be associated with
a coronary sinus diverticulum or aneurysm. In
these cases, the AP is usually found at the neek
of the diverticulum. The presence of the minor
forms of these structural abnonnalities can be visu-
alized only by direct angiography as shown by
Kuck et al.'5

(4) Using a Longer Duration of RF Pulse (6) Epicardial Located APs

Limiting unsuccessful pulse duration to 10 In 5% of our left lateral APs, the AP could not
seconds may miss a successful (possibly deep) be ablated endocardially. and ablation inside the
site that would require longer energy delivery. mid-distal coronary sinus was successful in 11 of

CS RPS

Figure 10. Examples of successful ablation sites for "resistant" AP: two left lateral APs were ablated on the mitral annulus
(MiT) and two posteroseptal APs were ablated either in the coronary .sinus (CS) or on the right endocardial septum (RPS).
All successful sites .show bipolar wide and fragmented ventricular electrograms requiring an unipolar recording to determine
the local activation timing. In the unipolar recordings (U). the onset of intrinsic defiection (.small arrow) has a QS pattern. A
probable AP potential (arrow) preceding the ventricular activation is present in bipolar electrograms (arrow) with a very low
amplitude and unusual shape.
 Hai.ssagiierre. et at. RF Catheter Ablation of APs 547

13 patients."- In 7 of the 11 patients, the coronary
sinus electrograms were more favorable than the
endtx:ardia] ones, while they were compiirable in
the other 4 patients. Ablation was required in the
proximal coronary sinus or the middle cardiac vein
in 12% and 27% of our right and left posterosep-
tal APs, respectively. The energy used in the coro-
nary sinus was only 8 to 20 watts (Fig. 9).
(7) Using Bipolar Transseptal RF Pulses
This technique has been proptised to ablate pos-
teroseptal APs^'' that could not be ablated by unipo-
lar pulses applied on either side of the septum.
(8) Sequential Applications ofRF Energy or Other
Sources of More Penetrating Energy
This can be used as the last resort to cover a
wider area or to attain deeper tissue injury. The
sequential ablation is supported by the fact that
"successful" sites could show less favorable elec-
trograms than "unsuccessful" sites.""' In these sit-
uations, we believe that previous applications guided
by the shortest times have altered a part of the AP
insertions, leaving some fibers with longer con-
duction times that ean be ablated with additional
applications. Furthermore, we have four observa-
tions suggesting that scar tissue due to transiently
successful ablation of APs limited heat transmis-
sion and effectiveness of subsequent RF pulses.
One observation is shown in Figure 11. Tliese {nine)
inadequacies of RF ablation applied through the
usual catheters can be circumvented by either the
use of stronger energies**^**"^ (see below) or possi-
bly by the use of RF energy through new types
of eleetrodes.^-^'
Results
Table 1 summarizes the results nt RF ablation
in different studies, including the mean or
median number of applications delivered, the
fluoroscopy time, the total recurrence rate, and the
success rate.
Since 1990, 512 patients were referred to our
center for RF ablation of APs. Sixty-seven were
children below 17 years (13 ± 8). Fifty-nine (12%0
had previously had an unsuccessful attempt at
catheter ablation of APs. Twenty-five had multi-
ple APs (2 APs: n = 22; 3 APs: n = 3). Success-
ful ablation was achieved in 502 patients (98%).

PSAP

Figure U. He.ustani posteroseptal AP. The patient underwent three ablation sessions. The first was un.successful. During the
second session, the application of RF energy at a site showing the AP potential produced an immediate disappearance of pre-
excitation: however. AP conduction recurred I month tater. During the third .session, multiple RF applications at the previ-
oustx succe.fsfut site ("SITE" aiut arrow on ttie radiogram) or at other right, coronary sinu.t, or teft .sites were un.succe.i.sfut.
A 160-J DC shock at the previously successful site definitively eliminated AP conduction.
548 Journal of Cardiovascular Electrophysiology Vot. 5. No. 6, June 1994

The remaining 10 patients (2%) failed repeated RF
ablation procedures; of these, 7 had po.steroseptal
APs, 2 had left lateral APs, and 1 had right Iat-
eraJ AP. DC fulguration successfully ablated tive
of the APs that could not be ablated with RF
energy, markedly depressed AP conduction in a
sixth, but failed in the other four patients. Table 3
summarizes our results. The results are divided
into categories of success and failure; the failures
are subdivided into those that were secondary to
AP recurrence and refusal for reablation, and those
that failed repeated ablation attempts.
With a mean follow-up period of 14 ± 11
months, recurrences occurred in 8% of all APs:
42% of recurrences occurred at day 1, 12% at day
2 or 3, and 46% after day 7. The recurrence rate
was higher in overt APs (12%) than in concealed
APs (3%). In addition, the recurrence rate was
significantly higher in patients with right antero.sef>-
tal or right lateral APs (16% to 19%) compared to
those with posteroseptal (9%) or left lateral (5%)
APs. In 15 patients, AP conduction recurred at day
1 to 3, then spontaneously disappeared until dis-
charge. However, recurrence was observed in 11
of these 15 patients (73%). Ail but five patients
with recurrences underwent a second/third suc-
cessful ablation procedure.
Complications
The incidence of complications in multicenter
reports was 3.8% in 787 patients cited by Schein-
man.'^'' and 4.4% in a total of 2222 patients cited
by Hindricks and Haverkamp**" reporting from the
European registry MERFS. Complications reported
in MERFS were"**: arrhythmias 0.81%, perfora-
tion/tamponade 0.72%, AV block 0.63%, pericar-
dial effusion 0.54%, pulmonary or cerebral
embolism 0.58%, vascular thrombosis 0.36%, and
other 0.76%. The incidence of severe complica-
tions including complete AV block, embolic events,
and cardiac tamponade was 2.3%. Whether car-
diac tamponade was due to either mechanical \iex-
foration or RF-induced perforation was not
specified. This complication may be reduced by
using lower power and avoiding unwiirranted pres-
sure contact as reflected by high ST elevation on
unipohir waveforms. Embolic events occurred in
0.6% of patients. It is not clear whether heparin
anticoagulation during the procedure prevents
emboiic events. Anticoagulation with heparin after
the procedure is recommended for both right-
and left-sided ablation. Maintenance with aspirin
is also recommended for left-sided ablation.
Although the relationship of embolic events with
an impedance rise is not proven, it is desirable to
avoid this impedance change. In the future, this
should be accomplished by the use of devices
equipped with temperature or impedance moni-
toring and automatic energy control.
No major complications including death, lam-
ponade, or AV block occurred in our series. Side
effects related to the introduction or manipulation
of catheters occurred in a total of 11 patients (2%):
peripheral vascular damage 7. pneumothorax 2,
sepsis 1, and permanent mechanically induced left
BBB 1. Complications related to RF applications
occurred in 11 patients (2%): right BBB 3,
mural thrombus in the coronary sinus 2, and dis-
tal right coronary artery spasm during RF deliv-

TABLE 3
Results of AP Catheter Ablation in our Experience of 512 Patients

No. of Median Duration (min) Long-Term Follow-Up

AP APs Number of Ablation Recurrences
Location (n) RF Pulses Procedure* Fluorcscopy* Recurrences Success Failures (nonablaled)
Overt RAS 32 4 54 ± 38 14± 12 b {]'-y'4 ) .11 1
Overt R LAT 32 6 118 ± 157 50 ± 74 5 (16'/f J 30 1 1
Concealed RAS
or R LAT 9 6 54 ± 32 I9± 15 I (11%) 9
Mahaim Fibers 16 5 59 ± 51 19± 14 1 (6%) 16
Overt RPS 59 3 59 ± 58 24 ±23 5(8%) 56 3
Oven LPS 61 4 79 ± 69 38 ±29 6(10%) 58 3
Concealed PS 18 4 57 ± 38 21 ± 11 0 17 1
PJRT 27 3 62 ± 32 25 ± 8 4(15%) 26 1
Overt L LAT 193 2 51 ± 42 19 * 12 10(5%) 189 2 2
Concealed L LAT 93 4 45 ± 30 I7± 8 2(3%) 93
540 3 58 ± 49 23 ±21 40 (8%) 525 10 5
(97%) (1.8%) (1.2%)
*Duration of only the Iherapeutic componeni of the procedure.

cry in the proximal coronary sinus 1. A transient
unilaleral impairment of vision was observed in
5 patients at day 2, 2. 3, 5, and 12. respectively,
presumably due to microemboli. Despite the fact
that we do not use heparin during the procedure,
this incidence is similar to that reported in groups
using full heparinization. On the other hand,
heparinization not performed during the prtKedure
could explain the absence of tamponade in our
series.
indications
RF energy catheter ablation is the procedure
of choice for AP ablation. It is highly efFective in
eliminating AP conduction and has a low rate of
serious complications. Therefoit. It should be con-
sidered for patients witb drug refractory, AP-medi-
ated tachyciirdiiLs and even for symptomatic patients
who do not wish to take aniiarrhythyniic dmgs for
an indefinite period. In addition, all the antiar-
rhythmic drugs are not without morbidity and a
finite mortality, and some are quite expensive. In
asymptomatic patients wiih Wolf^-Piirkinson-White
syndrome, the decision lo ablate APs musl be indi-
vidualized. It may be based in part on the occu-
pation of the patient and personal preference of the
patient guided by the patient's physician.
Ablation in young children warrants special con-
sideration. In experimental animals, RF lesions
induced at the atrial and ventricular tissue border-
ing the AV annuli api->car to grow as tbe animals
aged.'** Also, the significant radiation exposure is
associated with an increased lifetime risk of devel-
oping genetic disorders or malignancy. Given these
uncertainties, we believe that catbeter ablation tech-
niques should be reserved for children with drug
refractory or life-threatening tachycardias.
Conclusions
RF catheter ablation is widely and success-
fully used to treat a variety of arrhythmias.
Future research to decrea.se the time involved for
ablation must include improved catheter design to
ensure stable electrode-tissue contact, particularly
for right-sided APs. In addition, better RF energy
delivery systems with temperature control would
be useful. Although inapping has become more
precise, there is still room for improvement to
rapidly identify the best site of ablation. More pow-
erful yet controllable energy scources, such as
microwave or ultrasound, should be useful to reacb
lesions that are not readily accessible to RF eneigy.
Hals.saguerre, el al. RV Calhctcr Ablation of APs 549
Long-term follow-up of patients who have had
catheter ablation is needed to assess its term safety
and efficacy.
Acknowk'd^mctu: We wish lo ihank Jo^lle Biissihey for secrolaria!
assistance.
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1. Wellens HJJ. Brugada P: Value of programmed stimu-
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