412

Success Rates in Pediatric WPW Ablation Are Improved with 3-Dimensional Mapping Systems Compared with Fluoroscopy Alone: A Multicenter Study SCOTT R. CERESNAK, M.D.,∗ ANNE M. DUBIN, M.D.,∗ JEFFREY J. KIM, M.D.,† SANTIAGO O. VALDES, M.D.,† STEVEN B. FISHBERGER, M.D.,‡ IRA SHETTY, M.D.,§ FRANK ZIMMERMAN, M.D.,§ RONN E. TANEL, M.D.,¶ MICHAEL R. EPSTEIN, M.D.,∗∗ KARA S. MOTONAGA, M.D.,∗ CHRISTINE A. CAPONE, M.D.,†† LYNN NAPPO, R.N.,†† GREGORY J. GATES, Ph.D.,†† and ROBERT H. PASS, M.D.†† From the ∗ Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University, Palo Alto, California, USA; †Department of Pediatric Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA; ‡Department of Pediatrics, Miami Children’s Hospital, Miami, Florida, USA; §Department of Pediatrics, Advocate Children’s Hospital, Oak Lawn, Illinois, USA; ¶Department of Pediatrics, UCSF School of Medicine, UCSF Benioff Children’s Hospital, San Francisco, California, USA; ∗∗ Department of Pediatrics, Maine Medical Center, Portland, Maine, USA; and ††Department of Pediatrics, Albert Einstein College of Medicine, The Children’s Hospital at Montefiore, Bronx, New York, USA

3-D Mapping Improves Success Rates for WPW Ablation. Introduction: Three-dimensional mapping (3-D) systems are frequently used for ablation of supraventricular tachycardia. Prior studies have demonstrated radiation dosage reduction with 3-D, but there are no data on whether 3-D improves the efficacy of ablation of Wolff-Parkinson-White syndrome (WPW). We sought to determine if 3-D improves the success rate for ablation of WPW in children. Methods: Multicenter retrospective study including patients ࣘ21 years of age with WPW undergoing ablation from 2008 to 2012. Success rates using the 2 techniques (3-D vs. fluoroscopy alone [FLUORO]) were compared. Results: Six hundred and fifty-one cases were included (58% male, mean age 13 ± 4 years, 366 [56%] 3-D). Baseline characteristics including gender, weight, accessory pathway (AP) location, number of APs, and repeat ablation attempts were similar between the 2 groups (3-D and FLUORO) The 3-D group was slightly younger (12.7 ± 4.0 vs. 13.3 ± 4.0 years; P = 0.04) and less likely to undergo ablation utilizing cryoenergy (38 [10%] vs. 56 [20%]; P < 0.01). The 3-D group had a higher acute success rate of ablation (355 [97%] vs. 260 [91%]; P < 0.01). No differences were seen in recurrence (16 [5%] vs. 26 [9%]; P = 0.09) or complication rates (1 [0.3%] vs. 1 [0.4%]; P = 0.86) between the groups. On multivariable analysis, 3-D was shown to significantly improve success at ablation with an odds ratio of 3.1 (95% CI 1.44–6.72; P < 0.01). Conclusions: Use of 3-D significantly improved success rates for ablation of WPW in children. The increase in acute success associated with 3-D suggests it is an important adjunct for catheter ablation of WPW in children. (J Cardiovasc Electrophysiol, Vol. 26, pp. 412-416, April 2015) 3-D mapping, ablation, children, pediatrics, WPW Introduction Three-dimensional mapping systems (3-D) were first introduced in the late 1990s to aid in complex ablation procedures.1,2 Pediatric electrophysiologists historically have used these systems (such as Carto and NavX) to aid in ablation of patients with congenital heart disease (CHD) and intraatrial re-entry tachycardia or ventricular tachycardia with improvement in both acute and chronic ablation No disclosures. Address for correspondence: Scott R. Ceresnak, M.D., Pediatric Cardiology, Pediatric Electrophysiology–Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA. Fax: 650-724-4922; E-mail: [email protected] Manuscript received 15 October 2014; Revised manuscript received 26 December 2014; Accepted for publication 30 December 2014. doi: 10.1111/jce.12623

success rates.3-6 Recently, these systems have been employed for other ablation substrates including AV nodal re-entry tachycardia, concealed accessory pathways (APs), and Wolff-Parkinson-White syndrome (WPW) because of the additional benefit of reducing or eliminating radiation exposure.7,8 There have been multiple studies highlighting the role of these systems to enable ablation of supraventricular tachycardia (SVT) substrates with decreased (or zero) radiation exposure to both patient and staff.7-11 Many of these studies have secondarily demonstrated that acute success rates with ablation using 3-D mapping systems are comparable, with a focus on non-inferiority. While these smaller scale studies have demonstrated a marked decrease in patient radiation exposure, the question of whether 3-D mapping systems can influence the efficacy of ablation of WPW remains unanswered. The objective of our investigation was therefore to determine if the use of 3-D mapping systems improve success rates for ablation of WPW in children compared with fluoroscopy

Ceresnak et al. 3-D Mapping Improves Success Rates for WPW Ablation

alone. We hypothesized that use of 3-D mapping systems improve success rates with ablation of WPW in children.

Methods The study was a multicenter, retrospective study of pediatric patients with WPW who underwent invasive electrophysiology (EP) testing between 2008 and 2012. Institutional Review Board (IRB) approval was obtained at each center. This study was a post hoc analysis of a multicenter project that investigated the demographics of symptomatic and asymptomatic patients with WPW undergoing EP study.12 All patients ࣘ21 years of age with WPW who underwent invasive EP testing and ablation between 2008 and 2012 were included in this analysis. Patients were excluded if they underwent invasive EP testing for risk stratification alone but did not undergo an ablation attempt. Seven geographically and programmatically diverse American pediatric arrhythmia centers participated in this study including: The Children’s Hospital at Montefiore—Albert Einstein College of Medicine, Lucile Packard Children’s Hospital—Stanford University, Texas Children’s Hospital—Baylor College of Medicine, Miami Children’s Hospital, Benioff Children’s Hospital—The University of California San Francisco, Advocate Children’s Hospital, and Maine Medical Center. All centers had a least one 3-D mapping system available for use during the entire study period. For procedures performed with Carto, a fast anatomical map with a limited geometrical shell of the heart was created in each case. For NavX cases, standard EP diagnostic catheters were utilized at each center and there was no change in the type of catheter with or without the use of a 3-D mapping system. Activation mapping was performed in all cases and ablation lesion locations were marked during each case. During 3-D cases, while mapping was performed locations of all mapped areas were recorded by either the Carto or NavX system. Intracardiac echocardiography was not routinely used at each center. The majority of the cases were performed with Biosense Webster (NaviStar, Diamond Bar, CA, USA) or Boston Scientific (Blazer, Marlborough, MA, USA) 7 French 4 mm tip catheters. Data Collection Data collected at each center are listed below and included patient specific demographic and clinical information, EP study and ablation data, and follow-up data. The following data were collected on each patient: demographic and clinical information (age at the time of EP study, weight, height, gender, echocardiographic findings, presence of congenital or other heart disease), EP study and ablation findings (including location of the AP, AP EP properties, type of ablation performed, and complications during or after testing), and follow-up data (time to last follow-up, recurrence of AP conduction on ECG or documented SVT). Success at ablation was defined as no further evidence of AP conduction with no further inducible tachycardia in patients with inducible SVT. For this analysis, complications were defined as cardiac perforation, vascular injury, stroke, permanent AV nodal injury requiring a pacemaker, or other serious complication requiring intervention.

413

Data and Statistical Analysis Statistical analysis was performed using STATA version 12 (StataCorp LP, College Station, TX, USA). Categorical and dichotomous variables were expressed as numbers and percentages and continuous variables were expressed as mean ± standard deviation. Demographic, EP study, and ablation data were compared between patients undergoing ablation with the use of 3-D systems (3-D) and those undergoing ablation with fluoroscopy alone (FLUORO) via chisquare and t-tests. A forward stepwise multivariable logistic regression model was then performed with acute success as the primary outcome variable of interest. A priori all variables with a P value

Success rates in pediatric WPW ablation are improved with 3-dimensional mapping systems compared with fluoroscopy alone: a multicenter study.

Three-dimensional mapping (3-D) systems are frequently used for ablation of supraventricular tachycardia. Prior studies have demonstrated radiation do...
236KB Sizes 1 Downloads 5 Views