F. Morady et al., REASONS FOR PROLONGED OR FAILED ATTEMPTS AT RADIOFREQUENCY CATHETER ABLATION OF ACCESSORY PATHWAYS, Journal of the American College of Cardiology, 27(3), 1996, pp. 683-689
Objectives. The purpose of this study was to categorize the reasons fo
r a prolonged or failed procedure in a series of patients undergoing c
atheter ablation of an accessory pathway. Background. Radiofrequency a
blation of accessory pathways at times requires a lengthy procedure or
a second ablation session, or both, and no prior studies have systema
tically investigated the reasons for this. Methods. In a consecutive s
eries of 619 patients undergoing catheter ablation of an accessory pat
hway, the mean ablation time +/- SD was 68 +/- 64 min. The subjects of
this study were 14 patients who had an ablation time > 2 SD greater t
han the mean (> 196 min) and 51 patients who required a second ablatio
n session for a successful outcome. The accessory pathway in the 65 pa
tients in this study was located in the right free wall in 19 patients
(29%), septum in 14 (22%) and left free wall in 32 (49%). Results. Th
e primary reasons for a lengthy or failed ablation attempt were 1) ina
bility to position the ablation catheter at the effective target site
(16 patients, 25%); 2) instability of the ablation catheter or inadequ
ate tissue contact at the target site, or both (15 patients, 23%); 3)
mapping error due to an oblique course of the accessory pathway (7 pat
ients, 11%); 4) failure to recognize a posteroseptal accessory pathway
as being left-sided instead of right sided (4 patients, 6%); 5) other
errors in accessory pathway localization (6 patients, 9%); 6) epicard
ial location of the accessory pathway (5 patients, 8%); 7) recurrent a
trial fibrillation (2 patients, 3%); 8) occurrence of a complication (
2 patients, 3%); 9) unusual right-sided accessory pathway that inserte
d in the anterior right ventricle, 2 cm away from the lateral tricuspi
d annulus (1 patient, 1.5%); and 10) unexplained factors (7 patients,
11%). The most common effective strategies employed to achieve a succe
ssful outcome in these patients were 1) substitution of a more experie
nced operator; 2) use of ablation catheters of varying configurations;
3) switching from a retrograde aortic to a transseptal approach; 4) s
witching from an inferior to a superior vena caval approach; 5) use of
a 60-cm guiding sheath; 6) detailed mapping of the atrial or ventricu
lar insertion of the accessory pathway; and 7) searching within the co
ronary sinus for a presumed accessory pathway potential. Conclusions.
A lengthy or failed attempt at catheter ablation of an accessory pathw
ay may be due to a variety of reasons, the most common of which are pr
oblems related to some aspect of catheter manipulation and errors in a
ccessory pathway localization. Knowledge of the most common reasons fo
r a lengthy or ineffective procedure may facilitate successful outcome
of accessory pathway ablation.