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The day after the new little ice age… (or the chronic outcome of pediatric slow pathway cryoablation)

  • Massimo Stefano Silvetti
    Correspondence
    Address reprint requests and correspondence: Dr Massimo Stefano Silvetti, Cardiac Arrhythmias/Syncope Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital and Research Institute, Via Torre di Palidoro 1, 00050 Palidoro-Fiumicino, Rome, Italy.
    Affiliations
    Paediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital and Research Institute, Rome, Italy
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Published:October 22, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.10.018
      Since 2005,
      • Drago F.
      • De Santis A.
      • Grutter G.
      • et al.
      Transvenous cryothermal catheter ablation of re-entry circuit located near the atrioventricular junction in pediatric patients: efficacy, safety and midterm follow-up.
      slow pathway (SP) cryoablation has become the method of choice for atrioventricular nodal reentry tachycardia (AVNRT) transcatheter ablation in many pediatric electrophysiological centers on the basis of its efficacy and safety profile. Many authors have investigated the outcome of pediatric AVNRT cryoablation, and several factors have been modified: technique improvements, ablation protocols,
      • Drago F.
      • Silvetti M.S.
      • De Santis A.
      • et al.
      Lengthier cryoablation and a bonus cryoapplication is associated with improved efficacy for cryothermal catheter ablation of supraventricular tachycardias in children.
      • Drago F.
      • Russo M.S.
      • Silvetti M.S.
      • et al.
      Time to effect during cryomapping: a parameter related to the long-term success of accessory pathways cryoablation in children.
      • Drago F.
      • Russo M.S.
      • Silvetti M.S.
      • et al.
      Cryoablation of typical atrioventricular nodal reentrant tachycardia in children: six years’ experience and follow-up in a single center.
      • Czosek R.J.
      • Anderson J.
      • Marino B.S.
      • et al.
      Linear lesion cryoablation for the treatment of atrioventricular nodal reentry tachycardia in pediatrics and young adults.
      • Silver E.S.
      • Silva J.N.
      • Ceresnak S.R.
      • et al.
      Cryoablation with an 8-mm tip catheter for pediatric atrioventricular nodal reentrant tachycardia is safe and efficacious with a low incidence of recurrence.
      • Drago F.
      • Placidi S.
      • Righi D.
      • et al.
      Cryoablation of AVNRT in children: early intervention leads to better outcome.
      and the evaluation of electrical signals and myocardium substrate.
      • Drago F.
      • Battipaglia I.
      • Russo M.S.
      • et al.
      Voltage gradient mapping and electrophysiologically guided cryoablation in children with AVNRT.
      According to the Multicenter Pediatric and Congenital EP Quality Initiative registry, acute and chronic results are now comparable to radiofrequency in pediatric patients.
      • Dubin A.M.
      • Jorgensen N.W.
      • Radbill A.E.
      • et al.
      What have we learned in the last 20 years? A comparison of a modern era pediatric and congenital catheter ablation registry to previous pediatric ablation registries.
      Major pediatric studies on AVNRT cryoablation published in 2010–2021
      • Czosek R.J.
      • Anderson J.
      • Marino B.S.
      • et al.
      Linear lesion cryoablation for the treatment of atrioventricular nodal reentry tachycardia in pediatrics and young adults.
      • Silver E.S.
      • Silva J.N.
      • Ceresnak S.R.
      • et al.
      Cryoablation with an 8-mm tip catheter for pediatric atrioventricular nodal reentrant tachycardia is safe and efficacious with a low incidence of recurrence.
      • Drago F.
      • Placidi S.
      • Righi D.
      • et al.
      Cryoablation of AVNRT in children: early intervention leads to better outcome.
      • Drago F.
      • Battipaglia I.
      • Russo M.S.
      • et al.
      Voltage gradient mapping and electrophysiologically guided cryoablation in children with AVNRT.
      ,
      • Russo M.S.
      • Drago F.
      • Silvetti M.S.
      • et al.
      Comparison of cryoablation with 3D mapping versus conventional mapping for the treatment of atrioventricular re-entrant tachycardia and right-sided paraseptal accessory pathways.
      • Drago F.
      • Russo M.S.
      • Battipaglia I.
      • et al.
      The need for a lengthier cryolesion can predict a worse outcome in 3D cryoablation of AV nodal slow pathway in children.
      • LaPage M.J.
      • Saul J.P.
      • Reed J.H.
      Long-term outcomes for cryoablation of pediatric patients with atrioventricular nodal reentrant tachycardia.
      • Das S.
      • Law I.H.
      • Von Bergen N.H.
      • et al.
      Cryoablation therapy for atrioventricular nodal reentrant tachycardia in children: a multicenter experience of efficacy.
      • Scaglione M.
      • Ebrille E.
      • Caponi D.
      • et al.
      Single center experience of fluoroless AVNRT ablation guided by electroanatomic reconstruction in children and adolescents.
      • Cokkinakis C.
      • Avramidis D.
      • Alexopoulos C.
      • et al.
      Cryoablation of atrioventricular nodal reentrant tachycardia in children and adolescents: improved long-term outcomes with increasing experience.
      • Malloy L.
      • Law I.H.
      • Von Bergen N.H.
      Voltage mapping for slow-pathway visualization and ablation of atrioventricular nodal reentry tachycardia in pediatric and young adult patients.
      • Reddy C.D.
      • Ceresnak S.R.
      • Motonaga K.S.
      • et al.
      Bridge to success: a better method of cryoablation for atrioventricular nodal reentrant tachycardia in children.
      • Oster M.E.
      • Yang Z.
      • Stewart-Huey K.
      • et al.
      Radiofrequency ablation versus cryoablation for atrioventricular nodal re-entrant tachycardia in children: a value comparison.
      • Karacan M.
      • Çelik N.
      • Akdeniz C.
      • et al.
      Long-term outcomes following cryoablation of atrioventricular nodal reentrant tachycardia in children.
      including 1927 patients, aged 13 years, showed an acute success of 96% with 8% recurrence rate (range 0%–23%) over 2-year follow-up. The variation in recurrence risk is related to different catheter tips and protocols (number, duration, and extension of cryolesions) but is roughly comparable to published recurrence risk for radiofrequency ablation (0%–16%).
      • Backhoff D.
      • Klehs S.
      • Muller M.J.
      • et al.
      Long-term follow-up after catheter ablation of atrioventricular nodal reentrant tachycardia in children.
      ,
      • Kubuš P.
      • Vít P.
      • Gebauer R.A.
      • et al.
      Long-term results of paediatric radiofrequency catheter ablation: a population-based study.
      Considering such recurrence rates, the cryoablation optimal end point is still a matter of debate. The role of residual SP conduction is controversial, and the study by Zook et al,
      • Zook N.
      • DeBruler K.
      • Ceresnak S.
      • et al.
      Identifying an appropriate end point for cryoablation in children with atrioventricular nodal reentry tachycardia: is residual slow pathway conduction associated with recurrence?.
      presented in this issue of Heart Rhythm Journal, adds valuable data to the dispute. The authors investigated the role of cryoablation procedural end points and found a low recurrence rate (5%) with no difference between patients with complete loss of SP and those with SP modification (residual SP conduction). Most patients were tested with isoproterenol after ablation, although the protocol was not standardized. Therefore, residual SP conduction in children does not increase the risk of recurrences.
      • Dasgupta S.
      • Kelleman M.
      • Whitehill R.
      • et al.
      Recurrent single echo beats after cryoablation of atrioventricular nodal reentrant tachycardia: the pediatric population.
      Most probably, in order to reduce recurrences, a sole standard electrophysiological approach may limit the interpretation of results. Other factors should be investigated. Substrates and age-related changes in the histology of atrioventricular node
      • Waki K.
      • Kim J.S.
      • Becker A.E.
      Morphology of the human atrioventricular node is age dependent: a feature of potential clinical significance.
      and in the geometry of Koch’s triangle may play a substantial role in children
      • Backhoff D.
      • Klehs S.
      • Muller M.J.
      • et al.
      Long-term follow-up after catheter ablation of atrioventricular nodal reentrant tachycardia in children.
      along with anatomical variants.
      • Chaumont C.
      • Mirolo A.
      • Savouré A.
      • et al.
      Very long-term outcomes after catheter ablation of atrioventricular nodal reentrant tachycardia: how does cryoenergy differ from radiofrequency?.
      Patients’ age seems to be an important predictive factor of long-term success,
      • Drago F.
      • Placidi S.
      • Righi D.
      • et al.
      Cryoablation of AVNRT in children: early intervention leads to better outcome.
      as breadth and depth of the SP may significantly differ. Drago et al
      • Drago F.
      • Calvieri C.
      • Russo M.S.
      • et al.
      Low-voltage bridge strategy to guide cryoablation of typical and atypical atrioventricular nodal re-entry tachycardia in children: mid-term outcomes in a large cohort of patients.
      suggested that substrate’s type and complexity rather than the ablation technology could be the main factors affecting outcomes. The innovative use of 3-dimensional voltage gradient mapping as a mean to visualize the SP disclosed a new and promising research field about the substrate role. Cryoablation of the low-voltage bridge (LVB) seems to increase the acute success, diminishing the recurrence rate. In the 4 studies (263 patients) targeting the LVB, the acute success rate was 99.5% whereas the recurrence rate was nearly 2.5% at 1-year follow-up.
      • Drago F.
      • Battipaglia I.
      • Russo M.S.
      • et al.
      Voltage gradient mapping and electrophysiologically guided cryoablation in children with AVNRT.
      ,
      • Malloy L.
      • Law I.H.
      • Von Bergen N.H.
      Voltage mapping for slow-pathway visualization and ablation of atrioventricular nodal reentry tachycardia in pediatric and young adult patients.
      ,
      • Reddy C.D.
      • Ceresnak S.R.
      • Motonaga K.S.
      • et al.
      Bridge to success: a better method of cryoablation for atrioventricular nodal reentrant tachycardia in children.
      ,
      • Drago F.
      • Calvieri C.
      • Russo M.S.
      • et al.
      Low-voltage bridge strategy to guide cryoablation of typical and atypical atrioventricular nodal re-entry tachycardia in children: mid-term outcomes in a large cohort of patients.
      In addition, Zook et al
      • Zook N.
      • DeBruler K.
      • Ceresnak S.
      • et al.
      Identifying an appropriate end point for cryoablation in children with atrioventricular nodal reentry tachycardia: is residual slow pathway conduction associated with recurrence?.
      found a difference in recurrences between standard electroanatomic (11%) and LVB (4%) mapping procedures, although not significant. With the LVB approach, AVNRT recurrences were found to be strictly dependent on the type and complexity of the arrhythmogenic substrate. As a matter of fact, the number of LVBs and the presence of both typical and atypical AVNRT were found to be strongly associated with a higher recurrence rate.
      • Drago F.
      • Calvieri C.
      • Russo M.S.
      • et al.
      Low-voltage bridge strategy to guide cryoablation of typical and atypical atrioventricular nodal re-entry tachycardia in children: mid-term outcomes in a large cohort of patients.
      Moreover, the possible role of the leftward inferior extension of the atrioventricular node as an antegrade conduction pathway should be kept in mind.
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