PEDIATRIC AND ADULT CONGENITAL ARRHYTHMIAS MANAGEMENT: TECHNIQUES AND CHALLENGES (Invited Lecture)
Srikant Das, M.D., University of Arkansas for Medical Sciences, Little Rock, AR, USA
1. Unusual accessory pathways: pathways with Mahaim characteristics can be atriofascicular, atrioventricular, nodofascicular and nodoventricular, depending on their variable proximal and distal insertions. a. Mahaim fiber related tachycardia:
Wide QRS tachycardia in young having no structural heart disease.
Typically decremental and conducting only anterograde.
Anatomically Mahaim fiber is located at the lateral tricuspid annulus in most instances.
Mahaim potential good predictor of a successful ablation site
"Mahaim" automatic tachycardia (MAT), during RF ablation have been considered as a marker of successful ablation.
b. Non-arrhythmic pre-excitation-induced cardiomyopathy: asynchronous ventricular activation over the accessory pathway, especially right-sided, induces septal wall motion abnormalities, ventricular remodeling and ventricular dysfunction. The reversible nature of LV dysfunction after loss of ventricular pre-excitation supports the causal relationship between LV dysfunction and ventricular pre-excitation. We describe the 1st known case of recovery of ventricular function leading to explant of Berlin BiVAD support.
2. Trans-septal or trans-baffle puncture techniques:
SafeSept™ transseptal guidewire (SSTG) use in children
Radio frequency energy for perforation
Intracardiac echocardiographic guidance
3. Catheter ablation of hemodynamically unstable patients
Ventricular assist device/ECMO
IMPELLA circulatory pump
Local anesthesia and/or sedation only
4. Ablation of para-Hisian substrates by IVC approach, ablation in the non-coronary cusp is not an initial or a preferred approach for pediatric patients.
5. Complex congenital postoperative anatomy:
Integration of MRI and electro anatomic mapping
6. Subcutaneous ICD implant in children: Our center’s experience