Mapping and ablation of supraventricular tachycardia in pediatric and congenital heart disease patients

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Abstract

The past two decades have witnessed astounding advances in the efficacy and safety of catheter ablation techniques as definitive therapy of supraventricular tachycardia, with application to an ever widening spectrum of pediatric and congenital heart disease patients. This review covers both general considerations in pediatric ablation and technical pearls specific to a variety of ablation targets. Tools of ablation, indications for ablation, historical outcomes and unique considerations in children and complex congenital heart disease are addressed. This is followed by discussion of ablation of accessory pathways, AV node reentrant tachycardia, focal atrial tachycardia in structurally normal hearts and atrial tachycardia in congenital heart disease.

Introduction

Although over 50 years passed from the earliest description of accessory pathways until the first report of closed-chest ablation of such substrate [1], [2], the following two decades witnessed astounding progress in the success and safety of this now definitive therapy for supraventricular tachycardia [3], [4], [5], [6]. No less remarkable has been the application of ablation therapy to pediatric patients with structurally normal hearts, as well as a wide spectrum of congenital structural heart disease [7], [8], [9], [10], [11], [12]. This has been facilitated by advances in the tools available to the interventional electrophysiologist, an improved understanding of special considerations in children that has informed appropriate indications for ablation, and collaborative reporting of outcomes. Experience has highlighted technical considerations specific to each class of targets: accessory pathways, modification of the atrioventricular (AV) node inputs, focal atrial tachycardias and intra-atrial reentrant tachycardia in structural congenital heart disease. There nonetheless remain areas for quality improvement by further increasing efficacy while honing strategies to decrease acute and long-term complications.

Section snippets

Advances in tools

High-fidelity recording and accurate interpretation of intracardiac electrograms remain the keystone of successful mapping and ablation. Recording of biopotentials ranging from 25 μV to 5 mV with optimized signal-to-noise ratio requires rigorous attention to every detail from physical and electrical organization of the electrophysiology laboratory through signal display on the monitor [13]. Amplification and filtering of the recorded signals must be chosen appropriate to the intracardiac

Accessory pathway

Both surgical and transcatheter ablations were initially applied to accessory pathways, as they represent discrete structural targets which can be directly mapped [78], [79]. Strategies for accessory pathway ablation depend upon several factors, including whether there is manifest preexcitation; location of the pathway, particularly proximity to the AV node; and whether the target represents a typical accessory pathway with rapid, non-decremental conduction or an atypical accessory pathway with

Future directions

There clearly remain areas for improvement. Although acute efficacy is excellent, recurrences continue to be described following ablation of many substrates. There are opportunities for technical advances facilitating delivery of more lasting lesion formation without extending damage to bystander, normal structures; this is particularly true in those patients with atrial myocardium altered by prior surgeries and longstanding pressure and volume load. There may be further decrease in

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