Abstract
Objective
This study aimed to reveal individual variations in Koch’s triangle using NavX and to evaluate the efficacy of the NavX-guided slow pathway ablation.
Methods
A regional geometry around Koch’s triangle was constructed in 42 consecutive patients with atrioventricular nodal reentrant tachycardia (AVNRT), and a bipolar electrogram map was created with 72 ± 30 sampling points during sinus rhythm to identify sites with Haissaguerre’s slow potentials (SPs) and His bundle electrograms (HBEs) to examine the anatomical and electrical variations. Radiofrequency ablation was performed at the most prominent SP recording site. The acute results and long-term outcome were examined in comparison to another 42 consecutive patients who underwent a conventional fluoroscopy-guided slow pathway ablation in the previous months.
Results
The size of Koch’s triangle and the coronary sinus ostium varied over a wide range of 132 to 490 and 69 to 346 mm2, respectively. HBEs were recorded linearly along the antero-septal right atrium (n = 29) or deviated downward toward the midseptum (n = 13, 31 %). The SPs were always distributed below the lowest HBE recording site. The NavX-guided ablation eliminated AVNRT with a median of 1 radiofrequency pulse, 9.1 ± 4.6 min of fluoroscopy, and 49 ± 14 min of procedure time, all of which were significantly smaller than those in fluoroscopy-guided ablation. No procedure-related complications or long-term recurrence was noted in either group.
Conclusion
Koch’s triangle varies in terms of the size and electrogram distribution, and the NavX-guided slow pathway ablation overcomes the diversity and seems more effective than fluoroscopy-guided ablation.
Similar content being viewed by others
References
Jackman, W. M., Beckman, K. J., McClelland, J. H., Wang, X., Friday, K. J., Roman, C. A., et al. (1992). Treatment of supraventricular tachycardia due to atrioventricular nodal reentry, by radiofrequency catheter ablation of slow-pathway conduction. The New England Journal of Medicine, 327, 313–318.
Haissaguerre, M., Gaita, F., Fischer, B., Commenges, D., Montserrat, P., d’Ivernois, C., et al. (1992). Elimination of atrioventricular nodal reentrant tachycardia using discrete slow potentials to guide application of radiofrequency energy. Circulation, 85, 2162–2175.
Kalbfleisch, S. J., Strickberger, S. A., Williamson, B., Vorperian, V. R., Man, C., Hummel, J. D., et al. (1994). Randomized comparison of anatomic and electrogram mapping approaches to ablation of the slow pathway of atrioventricular node reentrant tachycardia. Journal of the American College of Cardiology, 23, 716–723.
Ooie, T., Tsuchiya, T., Ashikaga, K., Honda, T., & Takahashi, N. (2003). Anterograde slow pathway is not the same as retrograde slow pathway conducted in the reverse direction in patients with uncommon atrioventricular nodal reentrant tachycardia. Journal of Cardiovascular Electrophysiology, 14, 722–727.
Inoue, S., & Becker, A. E. (1998). Koch’s triangle sized up: anatomical landmarks in perspective of catheter ablation procedures. Pacing and Clinical Electrophysiology, 21, 1553–1558.
Ueng, K. C., Chen, S. A., Chiang, C. E., Tai, C. T., Lee, S. H., Chiou, C. W., et al. (1996). Dimension and related anatomical distance of Koch’s triangle in patients with atrioventricular nodal reentrant tachycardia. Journal of Cardiovascular Electrophysiology, 7, 1017–1023.
Yamane, T., Iesaka, Y., Goya, M., Takahashi, A., Fujiwara, H., & Hiraoka, M. (1999). Optimal target site for slow AV nodal pathway ablation: possibility of predetermined focal mapping approach using anatomic reference in the Koch’s triangle. Journal of Cardiovascular Electrophysiology, 10, 529–537.
Cooke, P. A., & Wilber, D. J. (1998). Radiofrequency catheter ablation of atrioventricular nodal reentry tachycardia utilizing nonfluoroscopic electroanatomical mapping. Pacing and Clinical Electrophysiology, 21, 1802–1809.
Bharati, S., & Lev, M. (1989). The morphology of the AV junction and its significance in catheter ablation. Pacing and Clinical Electrophysiology, 12, 879–882.
Inoue, S., & Becker, A. E. (1998). Posterior extensions of the human compact atrioventricular node: a neglected anatomic feature of potential clinical significance. Circulation, 97, 188–193.
Massing, G. K., & James, T. N. (1976). Anatomical configuration of the His bundle and bundle branches in the human heart. Circulation, 53, 609–621.
Engelstein, E. D., Stein, K. M., Markowitz, S. M., & Lerman, B. B. (1996). Posterior fast atrioventricular node pathways: implications for radiofrequency catheter ablation of atrioventricular node reentrant tachycardia. Journal of the American College of Cardiology, 27, 1098–1105.
Kay, G. N., Epstein, A. E., Dailey, S. M., & Plumb, V. J. (1992). Selective radiofrequency ablation of the slow pathway for the treatment of atrioventricular nodal tachycardia. Circulation, 85, 1675–1688.
Calkins, H., Yong, P., Miller, J. M., Olshansky, B., Carlson, M., Saul, J. P., et al. (1999). Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia, and the atrioventricular junction: final results of a prospective, multicenter clinical trial. Circulation, 99, 262–270.
Delise, P., Sitta, N., Bonso, A., Coro’, L., Fantinel, M., Mantovan, R., et al. (2005). Pace mapping of Koch’s triangle reduces risk of atrioventricular block during ablation of atrioventricular nodal reentrant tachycardia. Journal of Cardiovascular Electrophysiology, 16, 30–35.
Tsuchiya, T., Okumura, K., Tabuchi, T., Iwasa, A., Ohgushi, M., Yasue, H., et al. (1999). Atrial ectopy originating from the posteroinferior atrium during radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia. Pacing and Clinical Electrophysiology, 22, 727–737.
Ventura, R., Rostock, T., Klemm, H. U., Lutomsky, B., Demir, C., Weiss, C., et al. (2004). Catheter ablation of common-type atrial flutter guided by three-dimensional right atrial geometry reconstruction and catheter tracking using cutaneous patches: a randomized prospective study. Journal of Cardiovascular Electrophysiology, 15, 1157–1161.
Miyamoto, K., Tsuchiya, T., Yamaguchi, T., Nagamoto, Y., Ando, S., Sadamatsu, K., et al. (2011). A new method of a pulmonary vein map to identify a conduction gap on the pulmonary vein antrum ablation line. Circulation Journal, 75, 2363–2371.
Josephson, M. E. (2008). Clinical cardiac electrophysiology: techniques and interpretations (4th ed., p. 20). Philadelphia: Lippincott Williams & Wilkins.
Yamabe, H., Okumura, K., Tsuchiya, T., Tabuchi, T., Iwasa, A., & Yasue, H. (1998). Slow potential-guided radiofrequency catheter ablation in atrioventricular nodal reentrant tachycardia: characteristics of the potential associated with successful ablation. Pacing and Clinical Electrophysiology, 21, 2631–2640.
Pandozi, C., Ficili, S., Galeazzi, M., Lavalle, C., Russo, M., Pandozi, A., et al. (2011). Propagation of the sinus impulse into the Koch triangle and localization, timing, and origin of the multicomponent potentials recorded in this area. Circulation. Arrhythmia and Electrophysiology, 4, 225–234.
Sumitomo, N., Tateno, S., Nakamura, Y., Ushinohama, H., Taniguchi, K., Ichikawa, R., et al. (2007). Clinical importance of Koch’s triangle size in children: a study using 3-dimensional electroanatomical mapping. Circulation Journal, 71, 1918–1921.
Boulos, M., Hoch, D., Schecter, S., Greenberg, S., & Levine, J. (1998). Age dependence of complete heart block complicating radiofrequency ablation of the atrioventricular nodal slow pathway. The American Journal of Cardiology, 82, 390–391.
Li, Y. G., Gronefeld, G., Bender, B., Machura, C., & Hohnloser, S. H. (2001). Risk of development of delayed atrioventricular block after slow pathway modification in patients with atrioventricular nodal reentrant tachycardia and a pre-existing prolonged PR interval. European Heart Journal, 22, 89–95.
Earley, M. J., Showkathali, R., Alzetani, M., Kistler, P. M., Gupta, D., Abrams, D. J., et al. (2006). Radiofrequency ablation of arrhythmias guided by non-fluoroscopic catheter location: a prospective randomized trial. European Heart Journal, 27, 1223–1229.
Conflict of interest
Dr. Tsuchiya has served as a speaker and consultant for Nihon Kohden and St. Jude Medical.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Yamaguchi, T., Tsuchiya, T., Nagamoto, Y. et al. Anatomical and electrophysiological variations of Koch’s triangle and the impact on the slow pathway ablation in patients with atrioventricular nodal reentrant tachycardia: a study using 3D mapping. J Interv Card Electrophysiol 37, 111–120 (2013). https://doi.org/10.1007/s10840-012-9769-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10840-012-9769-z