Catheter Ablation of Supraventricular Arrhythmias and Atrial Fibrillation ADAM R SHAPIRA MD Advanced Heart Care PA The Heart Hospital Baylor Plano Plano Texas Supraventricular arrhythmias are relatively common often persistent and rarely life threatening cardiac rhythm disturbances that arise from the sinus node atrial tissue or junctional sites between the atria and ventricles The term supraventricular arrhythmia most often is used to refer to supraventricular tachycardias and atrial flutter The term supraventricular tachycardia commonly refers to atrial tachycardia atrioventricular nodal reentrant tachycardia and atrioventricular reciprocating tachycardia an entity that includes Wolff Parkinson White syndrome Atrial fibrillation is a distinct entity classified separately Depending on the arrhythmia catheter ablation is a treatment option at initial diagnosis when symptoms develop or if medical therapy fails Catheter ablation of supraventricular tachycardias atrial flutter and atrial fibrillation offers patients high effectiveness rates durable and often permanent therapeutic end points and low complication rates Catheter ablation effectiveness rates exceed 88 percent for atrioventricular nodal reentrant tachycardia atrioventricular reciprocating tachycardia and atrial flutter are greater than 86 percent for atrial tachycardia and range from 60 to 80 percent for atrial fibrillation Complication rates for supraventricular tachycardias and atrial flutter ablation are 0 to 8 percent The complication rates for atrial fibrillation ablation range from 6 to 10 percent Complications associated with catheter ablation result from radiation exposure vascular access e g hematomas cardiac perforation with tamponade catheter manipulation e g cardiac perforation with tamponade thromboembolic events or ablation energy delivery e g atrioventricular nodal block Am Fam Physician 2009 80 10 1089 1094 1095 Copyright 2009 American Academy of Family Physicians T Patient information A handout on supraventricular tachycardia written by the author of this article is provided on page 1095 This article exempifies the AAFP 2009 Annual Clinical Focus on management of chronic illness S upraventricular arrhythmias a family of cardiac arrhythmias including supraventricular tachycardias and atrial flutter are common often persistent and rarely life threatening They arise from the sinus node atrial tissue or junctional sites between the atria and ventricles and are amenable to medical and catheter based therapies The term supraventricular tachycardia commonly refers to atrial tachycardia atrioventricular nodal reentrant tachycardia AVNRT and atrioventricular reciprocating tachycardia AVRT Atrial fibrillation is a distinct entity classified separately Although antiarrhythmic medications can be used for treatment they often lack effectiveness are associated with multiple adverse effects and are prone to drug drug interactions Thus a principal therapy for many supraventricular arrhythmias is catheterbased ablation Ablation can safely treat if not cure many common dysrhythmias with excellent effectiveness Table 11 26 and without incurring the long term sometimes morbid consequences of antiarrhythmic drug therapy Catheter ablation is first line therapy for many supraventricular arrhythmias including AVNRT symptomatic AVRT atrial flutter and symptomatic or incessant atrial tachycardia 1 Catheter based ablation of a cardiac arrhythmia is performed in an electrophysiology laboratory in conjunction with an electrophysiology study An electrophysiology study involves the percutaneous insertion of catheters into the femoral veins and often the internal jugular vein The catheter tips are positioned at specific locations in the heart Electrical stimulation is delivered to the myocardium via these catheters to characterize cardiac conduction and arrhythmias Once the patient s conduction system has been studied and the rhythm disturbance diagnosed an ablation catheter is used to thermally destroy the pathogenic myocardial tissue underlying the arrhythmia s initiation or maintenance Success and complication rates vary depending on the individual arrhythmia Table 11 26 Introduction of catheters into the heart with or without the delivery of ablative energy uniformly Downloaded from the American Family Physician Web site at www aafp org afp Copyright 2009 American Academy of Family Physicians For the private noncommercial use of one individual user of the Web site All other rights reserved Contact copyrights aafp org for copyright questions and or permission requests SORT KEY RECOMMENDATIONS FOR PRACTICE Evidence rating References Catheter ablation is a relatively safe procedure that provides a high rate of effectiveness for most arrhythmias treated The complication rate is highest for atrial fibrillation C 1 23 Catheter ablation is first line therapy for many supraventricular arrhythmias including atrioventricular nodal reentrant tachycardia symptomatic atrioventricular reciprocating tachycardia atrial flutter and symptomatic or incessant atrial tachycardia C 1 Catheter ablation of atrial fibrillation is an option in symptomatic patients with a normal left atrial size and in whom antiarrhythmic medications have failed C 23 26 Clinical recommendation A consistent good quality patient oriented evidence B inconsistent or limited quality patient oriented evidence C consensus diseaseoriented evidence usual practice expert opinion or case series For information about the SORT evidence rating system go to http www aafp org afpsort xml carries the risk of cardiac perforation and possibly tamponade If detected early and in the absence of systemic anticoagulation iatrogenic cardiac tamponade caused by catheter perforation uncommonly is a life threatening complication however it does require the percutaneous insertion of a temporary subxiphoid pericardial drain if associated with hemodynamic compromise Atrial Tachycardia Sustained atrial tachycardia is a relatively uncommon arrhythmia diagnosed in about 5 to 15 percent of patients referred for supraventricular tachycardia ablation but with increasing age it constitutes a larger percentage of supraventricular tachycardias 27 It is a focal arrhythmia that can arise from anywhere in the right or left atrium For atrial tachycardia ablation success rates are 86 to 100 percent with a recurrence rate of 0 to 8 percent 1 3 Uncommon complications 0 to 8 percent include cardiac perforation phrenic
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