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Comparison of the retrograde and transseptal methods for ablation of left free wall accessory pathways.
J Am Coll Cardiol 1993; 22(2):542-9JACC

Abstract

OBJECTIVES

The purpose of this study was to compare success rates, procedure and fluoroscopy times and complications for the transseptal and retrograde aortic approaches in a consecutive series of patients undergoing catheter ablation of left free wall accessory pathways.

BACKGROUND

Radiofrequency catheter ablation of left-sided accessory pathways can be performed either by a retrograde, transaortic approach or by means of a transseptal puncture.

METHODS

A total of 106 patients (mean age 33 years, range 4 to 79) underwent attempted catheter ablation of a single left-sided accessory pathway by either the retrograde or the transseptal approach, or both. In the first 65 patients, the retrograde aortic approach was the preferred initial method. In the most recent 51 patients, we first attempted the transseptal approach whenever a physician trained in the technique was available. Ultimately, 102 (96.2%) of 106 patients had successful ablation.

RESULTS

Of 89 retrograde procedures, 85% resulted in elimination of accessory pathway conduction. Four retrograde procedures performed after failure of the transseptal approach were successful. Of the 13 patients with a failed retrograde procedure, 11 later underwent ablation using the transseptal approach. Twenty-six (85%) of 33 transseptal procedures were successful. All four patients with unsuccessful initial transseptal attempts were successfully treated with the retrograde method during the same session in the electrophysiology laboratory. Ten of 11 transseptal procedures after unsuccessful retrograde procedures were successful. Crossover from the retrograde to the transseptal approach was performed during a separate session in 9 of these 11. There was no difference in total procedure time (220 +/- 12.8 vs. 205 +/- 12.5 min) (mean +/- SEM) or fluoroscopy time (44.1 +/- 4.4 vs. 44.7 +/- 5.1 min) between the retrograde and transseptal methods. Ablation time was longer for the retrograde method (69.2 +/- 10.5 vs. 43.4 +/- 9.3 min) (p < 0.01). Of patients > or = 65 or < or = 16 years old, technical factors requiring crossover to the other technique or complications occurred in 7 (42%) of 17 patients undergoing the retrograde and 1 (11%) of 9 patients undergoing the transseptal approach (p < 0.01). The overall rate of complications was the same for both (6.7% for retrograde and 6.1% for transseptal). The most serious complication involved dissection of the left coronary artery with myocardial infarction during a retrograde procedure.

CONCLUSIONS

The retrograde and transseptal approaches are complementary; if one method fails, the other should be attempted, yielding an overall success rate close to 100%. Because patients undergo heparinization immediately after the arterial system is entered during a retrograde procedure, failure of that approach requires crossover to the transseptal method during a separate session or reversal of heparin; if the transseptal method is tried first, crossover to the retrograde approach can be accomplished easily during the same session. To avoid complications related to access, the transseptal method should be the first used in children, the elderly and those with arterial disease or hypertrophic ventricles.

Authors+Show Affiliations

Department of Medicine, University of California, San Francisco 94143-0214.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article

Language

eng

PubMed ID

8335827

Citation

Lesh, M D., et al. "Comparison of the Retrograde and Transseptal Methods for Ablation of Left Free Wall Accessory Pathways." Journal of the American College of Cardiology, vol. 22, no. 2, 1993, pp. 542-9.
Lesh MD, Van Hare GF, Scheinman MM, et al. Comparison of the retrograde and transseptal methods for ablation of left free wall accessory pathways. J Am Coll Cardiol. 1993;22(2):542-9.
Lesh, M. D., Van Hare, G. F., Scheinman, M. M., Ports, T. A., & Epstein, L. A. (1993). Comparison of the retrograde and transseptal methods for ablation of left free wall accessory pathways. Journal of the American College of Cardiology, 22(2), pp. 542-9.
Lesh MD, et al. Comparison of the Retrograde and Transseptal Methods for Ablation of Left Free Wall Accessory Pathways. J Am Coll Cardiol. 1993;22(2):542-9. PubMed PMID: 8335827.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Comparison of the retrograde and transseptal methods for ablation of left free wall accessory pathways. AU - Lesh,M D, AU - Van Hare,G F, AU - Scheinman,M M, AU - Ports,T A, AU - Epstein,L A, PY - 1993/8/1/pubmed PY - 1993/8/1/medline PY - 1993/8/1/entrez SP - 542 EP - 9 JF - Journal of the American College of Cardiology JO - J. Am. Coll. Cardiol. VL - 22 IS - 2 N2 - OBJECTIVES: The purpose of this study was to compare success rates, procedure and fluoroscopy times and complications for the transseptal and retrograde aortic approaches in a consecutive series of patients undergoing catheter ablation of left free wall accessory pathways. BACKGROUND: Radiofrequency catheter ablation of left-sided accessory pathways can be performed either by a retrograde, transaortic approach or by means of a transseptal puncture. METHODS: A total of 106 patients (mean age 33 years, range 4 to 79) underwent attempted catheter ablation of a single left-sided accessory pathway by either the retrograde or the transseptal approach, or both. In the first 65 patients, the retrograde aortic approach was the preferred initial method. In the most recent 51 patients, we first attempted the transseptal approach whenever a physician trained in the technique was available. Ultimately, 102 (96.2%) of 106 patients had successful ablation. RESULTS: Of 89 retrograde procedures, 85% resulted in elimination of accessory pathway conduction. Four retrograde procedures performed after failure of the transseptal approach were successful. Of the 13 patients with a failed retrograde procedure, 11 later underwent ablation using the transseptal approach. Twenty-six (85%) of 33 transseptal procedures were successful. All four patients with unsuccessful initial transseptal attempts were successfully treated with the retrograde method during the same session in the electrophysiology laboratory. Ten of 11 transseptal procedures after unsuccessful retrograde procedures were successful. Crossover from the retrograde to the transseptal approach was performed during a separate session in 9 of these 11. There was no difference in total procedure time (220 +/- 12.8 vs. 205 +/- 12.5 min) (mean +/- SEM) or fluoroscopy time (44.1 +/- 4.4 vs. 44.7 +/- 5.1 min) between the retrograde and transseptal methods. Ablation time was longer for the retrograde method (69.2 +/- 10.5 vs. 43.4 +/- 9.3 min) (p < 0.01). Of patients > or = 65 or < or = 16 years old, technical factors requiring crossover to the other technique or complications occurred in 7 (42%) of 17 patients undergoing the retrograde and 1 (11%) of 9 patients undergoing the transseptal approach (p < 0.01). The overall rate of complications was the same for both (6.7% for retrograde and 6.1% for transseptal). The most serious complication involved dissection of the left coronary artery with myocardial infarction during a retrograde procedure. CONCLUSIONS: The retrograde and transseptal approaches are complementary; if one method fails, the other should be attempted, yielding an overall success rate close to 100%. Because patients undergo heparinization immediately after the arterial system is entered during a retrograde procedure, failure of that approach requires crossover to the transseptal method during a separate session or reversal of heparin; if the transseptal method is tried first, crossover to the retrograde approach can be accomplished easily during the same session. To avoid complications related to access, the transseptal method should be the first used in children, the elderly and those with arterial disease or hypertrophic ventricles. SN - 0735-1097 UR - https://www.unboundmedicine.com/medline/citation/8335827/Comparison_of_the_retrograde_and_transseptal_methods_for_ablation_of_left_free_wall_accessory_pathways_ L2 - https://linkinghub.elsevier.com/retrieve/pii/0735-1097(93)90062-6 DB - PRIME DP - Unbound Medicine ER -