Cập nhật HƯỚNG dẫn cắt đốt QUA CATHETER các rối LOẠN NHỊP ở TRẺ EM

CẬP NHẬT HƯỚNG DẪN CẮT ĐỐT QUA CATHETER CÁC RỐI LOẠN NHỊP Ở TRẺ EM BS Bùi Thế Dũng BV Đại học Y Dược – TP HCM TÀI LIỆU THAM KHẢO Freidman RA (2002), "NASPE Expert Consensus Conference: Radiofrequency Catheter Ablation in Children with and without Congenital Heart Disease“ Cohen MI (2012), "PACES/HRS Expert Consensus Statement on Asymptomatic Young Patient With WPW Pattern" Saul JP (2016), "PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease“ main issues • • • • • • Safety - Efficacy Procedure: laboratory equipment personnel ablation energy catheter choice sedation/anesthesia pre- and post-ablation procedure management Arrhythmia type SAFETY - EFFICACY  The 2002 consensus: depended on patient age, typically expressed as “< or > years”  HRS 2014: groups: ≤ 12 years or 12 – 18 years  The 2016 consensus: patient weight was more important than age – chose cutoff “15 kg”  Succes rate of RFCA: 1991 – 1995 (Early Era, n=4193): 90.4% 1996 – 1999 (Late Era, n=3407): 95.2% SAFETY - EFFICACY  2000 – 2002 (n=2761, 41 centers): Succes rate of RFCA: 93% SVT, 78% VT Recurrence at 12 months: 24.6% right septal APs, 15.8% right freewall APs; 9.3% left free wall APs, 4.8% left septal APs; 4.8% AVNRT  Complications: 1991 – 1995: 4.2% 1996 – 1999: 3% Complications  Death and major complications:  congenital heart disease  lower patient weight  greater number of RF applications  left-sided procedures  Three most common serious complications:  AV block: 0.89 – 0.56%  Perforation or pericardial effusion: 0.69 – 0.53%  thrombi or emboli: 0.37 – 0.19% Fluoroscopy Exposure Deterministic effects (threshold level is Gy) Stochastic effects (dose independent) Skin erythema Malignancies: 0.02% – 0.03% Epilation Hereditary defects Cataracts Retarded bone growth Sterility Decreased white blood cell Organ atrophy Fibrosis Techniques to Reduce Procedure-Based Radiation As Low as Reasonably Achievable (ALARA) • Pulsed fluoroscopy • Lower frame rate • Adjusting collimators to decrease field view • Limiting the use of magnification • “store fluoro” function instead of cineangiography • Alternating between two views rather than a single imaging view to minimize site exposure Nonfluoroscopic systems • 3-D imaging systems + TEE or ICE Anesthesia and Sedation  Aims: improve patient comfort, reduce movement, and have minimal effect on the arrhythmia substrate  Personnel: • Pts > 12 years: nurse anesthetist • Pts ≤ 12 years: nurse anesthetist + anesthesiologist  General anesthesia with endotracheal intubation or laryngeal mask: age ≤ 12 years, significant CHD; ventricular dysfunction; pulmonary hypertension; hemodynamic instability; prolonged procedure; the need for complete immobility and patient or parent choice Safety Recommendations Class I  In-house pediatric cardiovascular surgical support for patients < 15 kg  A pediatric (or congenital) cardiovascular surgical program at the same institution where the ablation is performed for patients ≤ 12 years of ages  Age-appropriate cardiovascular surgical program and back-up at the same institution where the ablation is performed for patients from 12 to 18 years of ages Indications for SVT Ablation Class I  Documented SVT, recurrent or persistent associated with ventricular dysfunction in pts > 15 kg  Documented SVT, recurrent or persistent when medical therapy is either not effective or is intolerant  Documented SVT, recurrent or persistent when the family wishes to avoid chronic drugs in pts > 15 kg  Recurrent hemodynamic compromise (hypotension or syncope) from SVT in pts > 15 kg  Recurrent SVT requiring emergency medical care or electrical cardioversion for termination in pts > 15 kg Indications for SVT Ablation Class II a Recurrent symptoms clearly consistent with PSVT in pts > 15 kg, and one of the following: evidence of AP involvement; inducible SVT Slow pathway modification in pts > 15 kg with documented SVT, when SVT is not inducible at EP testing, but evidence for dual AV nodal physiology Cryotherapy should be considered Indications for SVT Ablation Class II b Recurrent symptoms clearly consistent with PSVT in pts < 15 kg, and one of the following: evidence of AP; inducible SVT Cryotherapy should be considered Recurrent hypotension or syncope from SVT in pts < 15 kg Intermittent symptomatic SVT which is nonsustained (less than 30s) in pts > 15kg Indications for SVT Ablation Class III SVT controlled with medical therapy without intolerable adverse effects in pts < 15 kg Clinical symptoms consistent with SVT, but no inducible SVT, and no evidence for dual AV nodal physiology during EP testing Slow pathway modification when dual AV node physiology is demonstrated after ablation of a different arrhythmia substrate (such as an AP when there is no inducible AVNRT Indications for WPW pattern Ablation Class I WPW pattern following cardiac arrest WPW pattern with syncope when there are predictors of high risk for cardiac arrest (The shortest preexcited RR interval during AF, or during incremental atrial pacing ≤ 250 ms; Multiple accessory pathways) Indications for WPW pattern Ablation Class II a  WPW pattern with ventricular dysfunction in pts > 15 kg, or when medical therapy is either not effective or intolerant in pts < 15 kg  WPW pattern with predictors of high risk for cardiac arrest in pts > 15 kg  WPW pattern with syncope, without predictors of high risk for cardiac arrest in pts > 15 kg  Asymtomatic WPW pattern in pts > 15 kg when the absence of WPW pattern is a prerequisite for participation in personal or professional activities Indications for WPW pattern Ablation Class II b Asymtomatic WPW pattern in pts > 15 kg without high risk for cardiac arrest because of a patient or family choice Class III WPW pattern caused by a fasciculoventricular accessory pathway WPW pattern without symptoms in pts < 15 kg Indications for ablation of ventricular arrhythmias without CHD Class I  VPCs or VT caused ventricular dysfunction, when medical therapy is either not effective or intolerant, or as an alternative to medical therapy in pts > 15 kg  Recurrent or persistent symptomatic verapamil – sensitive VT, idiopathic outflow tract VT, or VT with hemodynamic compromise, when medical therapy is either not effective or intolerant, or as an alternative to medical therapy in pts > 15 kg (LOVT-VT was a Class IIa indication in the prior pediatric guidelines) Indications for ablation of ventricular arrhythmias without CHD Class II a  VPCs with correlated symptoms in pts > 15 kg Class II b  Accelerated idioventricular rhythm with correlated symptoms in pts > 15 kg (Class IIa in the prior pediatric guidelines)  Recurrent/frequent polymorphic ventricular arrhythmia when there is a suspected triggering focus, arrhythmia, or substrate that can be targeted Indications for ablation of ventricular arrhythmias without CHD Class III VT in pts < 15 kg controlled medically, or is well tolerated without ventricular dysfunction Acc idioventricular rhythm in pts < 15kg Asymptomatic VPCs, VT, or accelerated idioventricular rhythm that is not suspected of causing or leading to ventricular dysfunction VPCs, VT due to transient reversible causes Indications for ablations in patients with CHD Class I  Recurrent or persistent AT, SVT related to AP or twin AV nodes in patients with CHD when medical therapy is either not effective or intolerant Ablation is also recommended as an alternative to medical therapy for pts > 15 kg  WPW pattern and high-risk, commonly in Ebstein’s anomaly, in pts > 15 kg  Ablation as adjunctive therapy to an ICD in pts with recurrent monomorphic VT, a VT storm, or multiple appropriate shocks that are not manageable by device reprogramming or drug Indications for ablations in patients with CHD Class II a • Sustained monomorphic VT causing symptoms or hypotension, when drug therapy is not effective or intolerant Ablation is an alternative to medical therapy in pts > 15 kg • AVNRT when medical therapy is either not effective or intolerant in pts > 15 kg with moderate or complex CHD Class I Indications for Ablation for Infants and Patients