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  • br Conclusions br Conflict of interest br Introduction

    2019-05-16


    Conclusions
    Conflict of interest
    Introduction Radiofrequency (RF) catheter ablation is an established method of therapy for symptomatic supraventricular tachycardia (SVT). It has gained widespread acceptance for the treatment of accessory pathways in pediatric SVTs [1]. Accessory pathways are distributed unevenly along the right and left atrioventricular valve annuli. The left-sided accessory pathways are most common and may be accessed by using the transseptal approach or the retrograde aortic approach, or less commonly, from within the coronary sinus. Each approach has proven to be successful, but has a unique set of risks [2].
    Materials and methods
    Results Between January 2010 and September 2014, 59 children underwent accessory pathway ablation, of which 25 (42.4%) had their left-sided accessory pathways accessed via the retrograde aortic approach. The other 34 patients underwent right-sided accessory pathway ablation. The mean age of the patients during the intervention was 11.09±3.71 years (quartiles: 7.96, 12.25, 14.0 years). Our youngest patient was a 17-kg, 105-cm, 4-year-old boy. Seventeen patients (68%) were male, and 8 (32%), female. The mean body weight and height were 49.56±24.92kg (quartiles 35.5, 46.8, 54.5kg) and 148.48±18.34cm (quartiles 135.5, 149.0, 161.0cm), respectively. The mean procedure time was 71.54±21.05min (quartiles 60.0, 70.0, 80.0min); the fluoroscopy time was 31.42±19.57min (quartiles 18.73, 26.0, 39.15min). The RF VE-821 was delivered with 41.38±15.33W (quartiles 34.75, 47.0, 50.0W) at 52.38±5.45°C (quartiles 47.0, 51.50, 57.75°C) for a total of 5.16±3.14min (quartiles 3.0, 4.2, 6.4min). The procedural details are given in Table 1. Sixteen patients (64%) presented with manifest preexcitation on ECG; the remaining 9 patients had only retrograde conduction from the accessory pathway (concealed pathway). Clinical tachycardia was induced in 15 patients (60%), either spontaneously or with atrial/ventricular stimulation. In 3 patients, atrial fibrillation was induced during programmed stimulation along with the reentrant SVT. One of these patients had corrected transposition of the great arteries. The location of the accessory pathway was left lateral in 16 patients, posteroseptal in 5, left anterolateral in 2, and left posterolateral and left posterior in the remaining 2 (Fig. 1). Our youngest patient had Wolff–Parkinson–White (WPW) syndrome with a left lateral location. The accessory pathway was successfully ablated in this patient, without complications. No recurrence was observed during 12 months of follow-up (Fig. 2). The acute success rate in our study group was 96% (24/25 patients). In the patient with WPW syndrome, ablation of the site with earliest ventricular activation, which was located on the left lateral wall, could not eliminate preexcitation even at a temperature of 50°C, which was attained with 50W of energy. Clinical tachycardia could not be induced with programmed stimulations. Instead, atrial flutter with ventricular rate of 177/min was induced. The flutter converted to reentrant tachycardia with atrial overdrive pacing and ended with burst atrial stimulations. Repeated trials of tachycardia induction were unsuccessful. The ablation attempt was unsuccessful for this patient. The patients were followed-up for a mean of 16.68±18.01 months (quartiles: 6, 6, 19.5 months). There were 2 recurrences. The left lateral concealed accessory pathway was successfully ablated in a 14-year-old boy; however, SVT recurred the day following ablation, and oils was treated with 300mg/m2/day propafenone. The patient is still on this medication, without symptoms. Preexcitation returned 19 months after the ablation of a manifest accessory pathway in another patient. The patient was asymptomatic and was followed-up with no medication for 54 months. He presented with SVT (heart rate 203/min), which appeared to be ectopic atrial tachycardia on surface ECG. This patient was receiving methylphenidate for attention deficit syndrome and hyperactivity disorder since 2 months before the presentation. The tachycardia converted to sinus rhythm spontaneously. Methylphenidate was stopped, and propafenone administration was started. EPS and ablation are planned for this patient.