Cập nhật HƯỚNG dẫn cắt đốt QUA CATHETER các rối LOẠN NHỊP ở TRẺ EM

Procedural Recommendations Class I  EP lab and postprocedure recovery unit should be suitable for the care of pediatric and CHD pts  Ablation for patients with moderate or complex CHD

HƯỚNG DẪN CẮT ĐỐT QUA CATHETER CÁC RỐI LOẠN NHỊP

Ở TRẺ EM

BS Bùi Thế Dũng

BV Đại học Y Dược – TP HCM

CẬP NHẬT

TÀI LIỆU THAM KHẢO

1 Freidman RA (2002), "NASPE Expert Consensus

Conference: Radiofrequency Catheter Ablation in Children with and without Congenital Heart Disease“

2 Cohen MI (2012), "PACES/HRS Expert Consensus

Statement on Asymptomatic Young Patient With WPW Pattern"

3 Saul JP (2016), "PACES/HRS expert consensus

statement on the use of catheter ablation in children and patients with congenital heart disease“

SAFETY - EFFICACY

 2000 – 2002 (n=2761, 41 centers):

Succes rate of RFCA: 93% SVT, 78% VT

Recurrence at 12 months: 24.6% right septal APs, 15.8% right freewall APs; 9.3% left free wall APs, 4.8% left septal APs; 4.8% AVNRT

 Complications:

1991 – 1995: 4.2%

1996 – 1999: 3%

Complications

 Death and major complications:

congenital heart disease

lower patient weight

greater number of RF applications

Fluoroscopy Exposure

Deterministic effects

(threshold level is 2 Gy)

Stochastic effects (dose independent)

Skin erythema Malignancies: 0.02% – 0.03%

Techniques to Reduce Procedure-Based Radiation

1 As Low as Reasonably Achievable (ALARA)

• Pulsed fluoroscopy

• Lower frame rate

• Adjusting collimators to decrease field view

• Limiting the use of magnification

• “store fluoro” function instead of cineangiography

• Alternating between two views rather than a single imaging view to minimize site exposure

2 Nonfluoroscopic systems

• 3-D imaging systems + TEE or ICE

Anesthesia and Sedation

 Aims: improve patient comfort, reduce movement, and have minimal effect on the arrhythmia substrate

 Personnel:

• Pts > 12 years: nurse anesthetist

• Pts ≤ 12 years: nurse anesthetist + anesthesiologist

 General anesthesia with endotracheal intubation or laryngeal mask: age ≤ 12 years, significant CHD; ventricular dysfunction; pulmonary hypertension; hemodynamic instability; prolonged procedure; the need for complete immobility and patient or parent choice

 Age-appropriate cardiovascular surgical program and back-up at the same institution where the ablation is performed for patients from 12 to 18 years of ages

Safety Recommendations

Class I

 For patients ≤ 12 years of and/or with moderate or complex CHD, the procedure staff should have a pediatric and/or CHD pts anesthesiologist

 Fluoroscopy use should be as low as possible

 Anticoagulation with unfractionated heparin: When the procedure will take place in the left atrium or ventricle, or there is a known or potential right-to-left shunt to prevent systemic embolization (ACT: 250 –

300 s during procedures)

Procedural Recommendations

Class I

 EP lab and postprocedure recovery unit should be suitable for the care of pediatric and CHD pts

 Ablation for patients with moderate or complex CHD

or complex arrhythmias should be performed by an electrophysiologist with the appropriate expertise

 3D mapping system should be available and strongly considered for mapping and ablation of postoperative arrhythmias in patients with moderate or complex CHD

Procedural Recommendations

Class IIa

Irrigated or large electrode-tip RF catheters can be useful for the ablation of postoperative arrhythmias in patients with CHD

Nonfluoroscopic imaging can be useful to reduce radiation exposure

Cryoablation can be useful for slow pathway modification in pediatric patients with AVNRT

Indications for SVT Ablation

Indications for SVT Ablation

Class II a

Recurrent symptoms clearly consistent with PSVT in pts > 15 kg, and one of the following: evidence of AP involvement; inducible SVT

Slow pathway modification in pts > 15 kg with documented SVT, when SVT is not inducible

at EP testing, but evidence for dual AV nodal physiology Cryotherapy should be considered

Indications for SVT Ablation

Class II b

Recurrent symptoms clearly consistent with PSVT in pts < 15 kg, and one of the following: evidence of AP; inducible SVT

Cryotherapy should be considered

Recurrent hypotension or syncope from SVT

in pts < 15 kg

Intermittent symptomatic SVT which is nonsustained (less than 30s) in pts > 15kg

Indications for SVT Ablation

Slow pathway modification when dual AV node physiology is demonstrated after ablation

of a different arrhythmia substrate (such as an

AP when there is no inducible AVNRT

Indications for WPW pattern Ablation

Class I

WPW pattern following cardiac arrest

WPW pattern with syncope when there are predictors of high risk for cardiac arrest (The shortest preexcited RR interval during AF, or during incremental atrial pacing ≤ 250 ms; Multiple accessory pathways)

Indications for WPW pattern Ablation

Class II a

WPW pattern with ventricular dysfunction in pts

> 15 kg, or when medical therapy is either not effective or intolerant in pts < 15 kg

WPW pattern with predictors of high risk for cardiac arrest in pts > 15 kg

WPW pattern with syncope, without predictors of high risk for cardiac arrest in pts > 15 kg

Asymtomatic WPW pattern in pts > 15 kg when the absence of WPW pattern is a prerequisite for participation in personal or professional activities

Indications for WPW pattern Ablation

Class II b

Asymtomatic WPW pattern in pts > 15 kg without high risk for cardiac arrest because of

a patient or family choice

Indications for ablation of ventricular arrhythmias without CHD

Class I

 VPCs or VT caused ventricular dysfunction, when medical therapy is either not effective or intolerant, or

as an alternative to medical therapy in pts > 15 kg

 Recurrent or persistent symptomatic verapamil – sensitive VT, idiopathic outflow tract VT, or VT with hemodynamic compromise, when medical therapy is either not effective or intolerant, or as an alternative

to medical therapy in pts > 15 kg (LOVT-VT was a Class IIa indication in the prior pediatric guidelines)

Indications for ablation of ventricular arrhythmias without CHD

(Class IIa in the prior pediatric guidelines)

Recurrent/frequent polymorphic ventricular arrhythmia when there is a suspected triggering focus, arrhythmia, or substrate that can be

targeted

Indications for ablation of ventricular arrhythmias without CHD

Class III

VT in pts < 15 kg controlled medically, or is well tolerated without ventricular dysfunction

Acc idioventricular rhythm in pts < 15kg

Indications for ablations

in patients with CHD

Class I

Recurrent or persistent AT, SVT related to AP or twin AV nodes in patients with CHD when medical therapy is either not effective or intolerant Ablation is also recommended as an alternative to medical therapy for pts > 15 kg

WPW pattern and high-risk, commonly in Ebstein’s anomaly, in pts > 15 kg

Ablation as adjunctive therapy to an ICD in pts with recurrent monomorphic VT, a VT storm, or multiple appropriate shocks that are not manageable by device reprogramming or drug

Indications for ablations

in patients with CHD

Class II a

• Sustained monomorphic VT causing symptoms

or hypotension, when drug therapy is not effective or intolerant Ablation is an alternative

to medical therapy in pts > 15 kg

• AVNRT when medical therapy is either not effective or intolerant in pts > 15 kg with moderate or complex CHD

Class I Indications for Ablation for

Infants and Patients <15 kg

 Pediatric cardiovascular surgical support should be available in-house during ablation procedures

 Documented SVT, when medical therapy is either not effective or intolerant

 WPW pattern following resuscitated cardiac arrest

 WPW pattern with syncope when there are predictors

of high risk for cardiac arrest

 Idiopathic JET, or congenital JET associated with ventricular dysfunction, when medical therapy is either not effective or intolerant (cryotherapy is preferred)

Class I Indications for Ablation for

Infants and Patients <15 kg

VPC or VT with ventricular dysfunction, when medical therapy is not effective or intolerant

SVT related to accessory AV connections or twin

AV nodes in patients with CHD when medical therapy is either not effective or intolerant

Symptomatic AT occurring outside the early postoperative phase (less than 3 – 6 months) in patients with CHD, when medical therapy is either not effective or intolerant

Patient weight was more important than age

High succes rate and safety if follow guideline