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Sumario Vol. 42 - Nº 3 Julio - Septiembre 2013

National Registry of Catheter Ablation 2010

  • Coordinator of the Committee of Arrhythmias of the
    Federación Argentina de Cardiología (FAC) Dr. Roberto Keegan.
  • Coordinator of the Committee of Electrophysiology, Electrocardiography, Arrhythmias and Pacemaker of the Sociedad Argentina de Cardiología (SAC) Dr. José Gant López.

Gustavo Fava (Policlínico Neuquén), José Gant López (Hospital Alemán, CABA), Alejandro Ventura, Lisandro Soriano (Instituto Cordis, Resistencia, Chaco), Gustavo Maid (Hospital Italiano, CABA), Roberto Keegan, Nicolás Valera (Hospital Privado del Sur, Bahía Blanca), Fernando Scazzuso (Instituto Cardiovascular de Buenos Aires), Luis Aguinaga (Hemodinamia y Electrofisiología Parque, Tucumán), Roberto Rivero Paz (Sanatorio Quintar, Jujuy), Rodolfo Sansalone (Sanatorio San Cayetano, CABA / Sanatorio Güemes, CABA / Clínica Olivos, Buenos Aires / Casa Hospital San Juan de Dios, Ramos Mejía, Bs. As. / Clínica Pueyrredón, Mar del Plata, Bs. As. / Sanatorio Central EMHSA, Mar del Plata, Bs. As. / Hospital Privado de Comunidad, Mar del Plata, Bs. As.), Mauricio Abello (Instituto FLENI, CABA), Luis Medesani, Federico Zabala (Instituto de Diagnóstico Cardiovascular La Plata, Bs. As.) Luis González Sabathie, Mariana Valentino (Instituto de Cardiología de Rosario, Santa Fe), Mariana Valentino (Clínica La Pequeña Familia, Junín, Bs. As.), Néstor Galizio, José Luis González (Instituto de Cardiología y Cirugía Cardiovascular (ICYCC) Fundación Favaloro, CABA), Karina Alonso (Sanatorio Franchin, CABA), Jorge Secchi (Sanatorio El Carmen, Salta), Andrés Bochoeyer, Rafael Rabinovich (Hospital de Alta Complejidad, Formosa), Andrés Bochoeyer, Rafael Rabinovich (Sanatorio Mitre, CABA).

Investigadores del Primer Registro Nacional de Ablación por Catéter FAC-SAC 2010.
Av. Amancay 70. (B8002GRN) Bahía Blanca, Buenos Aires, Argentina.
E mail

Recibido 14-JUL-2013 – ACEPTADO 28-JULIO-2013.

The authors declare not having a conflict of interest.

Rev Fed Arg Cardiol. 2013; 42(3): 200-204


Print version Imprimir sólo la columna central

 

RESUMEN

La ablación por catéter es un procedimiento de probada eficacia y seguridad para la curación de muchas arritmias cardíacas, aunque probablemente subutulizado en la práctica diaria. El Registro Nacional de Ablación 2010, coordinado por representantes de la Sociedad Argentina de Cardiología y de la Federación Argentina de Cardiología, tuvo por objetivo conocer los resultados de la ablación por catéter en Argentina mediante la recolección de los datos de los procedimientos realizados entre el 1 de Enero y 31 de Diciembre de 2010. El total de centros participantes fue 24 y se analizaron los datos de 1.500 procedimientos realizados en 1.460 pacientes. El éxito global durante el procedimiento fue de 93,8% y se presentaron complicaciones en el 2.2%. Los sustratos más frecuentemente tratados  fueron la taquicardia por reentrada nodal AV (25%), los haces accesorios (25%), el aleteo auricular (18%) y la fibrilación auricular (16%). La ablación por catéter en Argentina es un procedimiento efectivo y seguro para la curación de muchas arritmias cardíacas, con resultados similares a los de otros registros.

Palabras clave: Registro. Electrofisiología. Ablación por catéter.
SUMMARY

Catheter ablation is a safe and effective procedure to treat many cardiac arrhythmias. However it could be used in less patients than necessary. National Ablation 2010 Registry was coordinated by members of Argentine Society of Cardiology and Argentine Federation of Cardiology and its goal was to know the results of this procedure in Argentina carried out from January 1st to December 31st, 2010. Twenty four centers sent data about  1.500 procedures carried out in 1.460 patients. The global success was 93,8% and complications occured in 2.2%. The more frequent arrhythmias  were AV nodal reentran tachycardia (25%), accesory pathways (25%), atrial flutter (18%) and atrial fibrillation. Catheter ablation in Argentina is a safe and effective procedure to cure many cardiac arrhythmias with similar results to the ones coming from other registries.

Key words: Registry. Electrophysiology. Catheter Ablation.

 

 

 

INTRODUCTION
Catheter ablation (ABL) is a procedure that has been proven efficient and safe to heal many cardiac arrhythmias [1-12]. However, it is still underused in daily practice [13]. There are recent data about the efficacy and safety of this technique in our country, from registries made independently from the Federación Argentina de Cardiología (FAC) and the Sociedad Argentina de Cardiología (SAC) [14-15]. To obtain representative data about the results of this procedure in our country, the first joint registry was carried out, coordinated by the Committee of Arrhythmias of the FAC and the Committee on Electrophysiology, Electrocardiography, Arrhythmias and Pacemaking of the SAC.

 

MATERIAL AND METHODS
The Committee of Arrhythmias of FAC and the Committee of Electrophysiology, Electrocardiography, Arrhythmias and Pacemaking of SAC invited centers from all Argentina to participate willingly. By an off-line database (Microsoft Access®), every center added in a retrospective manner the data of ABL procedures conducted from January 1st to December 31st 2010.

The substrates included atrial flutter (typical and atypical), premature ventricular contractions (of the RV and the LV), atrial fibrillation, accessory bundles (manifest and concealed, anteroseptal, mid-septal, posteroseptal, of the left free wall and of the right free wall), atrioventricular node, tachycardia by atrioventricular node reentry (typical or atypical), focal atrial tachycardia and ventricular tachycardia (right ventricular idiopathic, left ventricular idiopathic, post-myocardial infarction, by reentry between branches and other heart diseases). The success of the procedure was considered when the substrate was removed and/or post-ablation arrhythmia was not inducible.

The complications included AV block (with and without permanent pacemaker requirement), vascular ones related to access (bruising, fistula, thrombosis, thrombophlebitis, pseudoaneurysm, and vascular complication that required treatment), pericardial effusion, cardiac tamponade, acute pericarditis, pleural effusion, pneumothorax, ischemia/myocardial infarction, heart failure/acute pulmonary edema, stroke (transient and installed), peripheral embolism, death and other complications.

Data related to the infrastructure of the center and the technical and human resources used in the procedures were also included.

The databases, once completed, were sent in an attachment by e-mail to the Coordination of the registry, that finally added the data in a single database, giving a code to each center to preserve anonymity during the analysis. These were expressed as percentage for the categorical variables and as mean or median for continuous variables.

 

RESULTS
Twenty four centers participated in the registry, representing 9 provinces (attachment). Thirty eight percent (9 centers) were located in the city of Buenos Aires (CABA), 8% (2 centers) in cities from the province of Buenos Aires very near CABA (Gran Buenos Aires) and the remaining 54% in locations from the interior of the country. All centers were private institutions. From the 19 providing information, 3 (16%) had less than 50 hospitalization beds, 8 (42%) between 50 and 100, 3 (16%) between 100 and 200, and 4 (26%) more than 200. Only 1 from the 21 centers (5%) did not have a cardiovascular surgery service. 62% (13/21) had a residency in cardiology. The total sum of inhabitants of the cities where the 24 centers were located, was 8,279,445 (21% of the total population of Argentina). The cities had a minimum of 90,305 inhabitants and a maximum of 2,891,082, with the average of inhabitants per center being 344,977.

Twenty one percent of the centers (5/24) had a 3-D navigator and only 1 had intracardiac echo. None had a system for cryoablation. Twenty nine percent (7/24) had programs for professional training (fellows). From the 17 centers that provided the information, 5 (29%) had a room of electrophysiology, 10 (59%) made the procedures in hemodynamic labs, and 2 (12%) in the OR.

All the procedures were 1,500, with an average per center of 65, a median of 25, a minimum of 2 and a maximum of 312. However, because many centers have the same human resources (electrophysiologists), when the number of procedures are analyzed in relation to them, and not the center, it is observed that the average was 115, the median 74, the minimum 25 and the maximum 312 procedures per year. Ninety seven percent (1460) corresponded to single procedures in the same patient, while in 40 patients more than one procedure was carried out (3% of the total), whether by anterior failure and/or by recurrence. The energy used was radiofrequency in all cases.

The most frequent substrates approached (Figure 1) were tachycardia by AV nodal reentry (25%) and accessory bundles (25%), followed by atrial flutter (18%) and atrial fibrillation (16%). Figure 2 shows the distribution of the location of the accessory bundles.

AVNR: Typical and atypical tachycardia by atrioventricular node reentry. AF: Atrial fibrillation. AFl: Typical and atypical atrial flutter. AV node: Atrioventricular node. Accessory bundle: Concealed and manifest accessory bundles, of the left and right free walls, anteroseptal, mid-septal, and postero-septal. Idiopathic ventricular: Premature ventricular contractions of the right and left ventricles and idiopathic ventricular tachycardia of the right and left ventricles. AT: Focal atrial tachycardia. VT in heart diseases: Ventricular tachycardias in patients with CAD, by reentry between branches and in other heart diseases.

Figure 1. Distribution of the most frequently ablated substrates.

 

Figure 2. Location of accessory bundles.

Overall success at the end of the procedure was 93.8% (Table 1). Figure 3 shows the success of the different substrates grouped by type of clinical arrhythmia.

Table 1
SUBSTRATES

Procedures

Success
⧣ - %

Complications
⧣  - %

Atypical AFl

27

22

81.5

0

 

Typical AFl

247

245

99.2

7

2.8

RV PVC

39

36

92.3

0

 

LV PVC

10

8

80

1

10

AF

235

230

97.9

13

5.5

Anteroseptal AB

0

 

 

 

 

Right AB

10

9

90

0

 

Left AB

82

81

98.8

1

1.2

Mid-septal AB

3

3

100

0

 

Posteroseptal AB

16

15

93.8

0

 

AV node

32

31

96.9

0

 

Atypical AVNR

23

21

91.3

0

 

Typical AVNR

352

347

98.6

3

0.9

AT

67

54

80.6

1

1.5

VTwith heart disease

20

13

65

0

 

RV idiopathic VT

37

28

75.7

0

 

LV idiopathic VT

13

12

92.3

2

15.4

Post-AMI VT

25

20

80

2

8

Branch-branch VT

1

1

100

0

 

Anteroseptal WPW

26

19

73.1

0

 

Right WPW

36

29

80.6

0

 

Left WPW

117

110

94

2

1.7

Mid-septal WPW

17

12

70.6

0

 

Posteroseptal WPW

65

61

93.8

1

1.5

TOTAL

1500

1407

93.8

33

2.2

AFl: Atrial flutter; PVC: Premature ventricular contractions; RV: Right ventricle; LV: Left ventricle; AF: Atrial fibrillation; AB: Accessory bundle; AV: AV node; AVNR: Atrioventricular nodal reentry; AT: Atrial tachycardia; VT: Ventricular tachycardia; WPW: Wolf Parkinson White.

 

AVNR: Typical and atypical tachycardia by atrioventricular nodal reentry. AF: Atrial fibrillation. AFl: Typical and atypical atrial flutter. AV Node: atrioventricular node. Accessory bundle: Concealed and manifest accessory bundles, of the left and right free walls, anteroseptal, mid-septal and postero-septal. Idiopathic ventricular: Premature ventricular contractions of the right and left ventricles and idiopathic ventricular tachycardia of the right and left ventricles. AT: Focal atrial tachycardia. VT in heart diseases: Ventricular tachycardias in patients with CAD, by reentry between branches and other heart diseases.

Figure 3. Success of the procedure in the different substrates.

 

Complications presented in 2.2% of the procedures (Table 1). The substrate with a greater rate of complications was idiopathic VT of the left ventricle (15.4%), followed by premature ventricular contractions with origin in the left ventricle (10%), VT in patients with CAD (8%), atrial fibrillation (5.5%), manifest left accessory bundles (1.7%), manifest accessory postero-septal bundles (1.5%), focal atrial tachycardia (1.5%), concealed left accessory bundles (1.2%) and tachycardia by typical AV nodal reentry (0.9%). Complications did not appear in the rest of the substrates. The most frequent complication was the vascular one, related to access (0.7%), followed by cardiac tamponade (0.4%), TIA (0.3%), AVB with no requirement of pacemaker (0.13%), heart failure (0.13%), pericardial effusion (0.07), pleural effusion (0.07%), stroke installed (0.07%) and peripheral embolism (0.07%). There was no pericarditis, pneumothorax or AMI/myocardial ischemia. A single death was recorded, related to ABL of typical atrial flutter due to massive pulmonary thromboembolism in a patient with congenital heart disease (tetralogy of Fallot).

 

DISCUSSION
The data coming from registries made in other countries for more than 10 years, and recent data from our country, show that ABL is an effective and safe procedure [14-27]. Although the number of centers participating in this registry was greater than in the previous ones, the number of procedures was similar and the number of provinces representedwas lower. Just as with previous registries, only private centers participated. Data about this practice in the public system of health care are unknown.

The number of procedures by center shows a great heterogeneity, with centers that make very few procedures of ABL per year. However, and as it was observed in this registry, it is frequent for the same electrophysiologist or group of electrophysiologists to make procedures in different centers. This could explain the observation of similar results when centers of low and high volumes of procedures per year are compared.

In regard to the substrates, it is observed that the distribution remains similar to the previous registries and similar to that observed in other registries. The four more frequently ablated substrates are still tachycardia by AV nodal reentry, accessory bundles, atrial flutter and atrial fibrillation.

The success of the procedure is still very high, with rates similar to those observed previously.

In regard to the complications, it is worth to highlight a significant reduction in the overall rate, very likely associated to the reduction observed in the fourth substrate most frequently treated, such as atrial fibrillation. However, a high rate was observed in the ABL procedures of idiopathic ventricular arrhythmias. This high prevalence could be related to the small number of procedures included in this substrate. The prevalence of mortality observed in this registry (0.06%) is similar to that of the last 11 Spanish registries (0.05%)[16-27]. In the latter, 35 deaths were reported, related to 72,379 procedures made between years 2001 and 2011, with the yearly prevalence being lower than 0.02% (year 2006) and the highest 0.11% (year 2003). The substrates in which mortality was observed, included both the most complex as atrial fibrillation and ventricular tachycardia in patients with heart disease, and tachycardia by nodal reentry, accessory bundles, atrial flutter, focal atrial tachycardia, and atrioventricular node tachycardia. Thrombotic phenomena (pulmonary thromboembolism, stroke, coronary artery occlusion) and cardiac tamponade were some of the complications that preceded it.

 

CONCLUSIONS
In Argentina, the ABL procedure of the most frequently treated arrhythmias (tachycardia by intranodal reentry, accessory bundles and atrial flutter) maintains a high efficacy and safety, similar to that of other registries, while ABL of atrial fibrillation, compared to previous data, showed a notorious improvement of results, namely a lower rate of complications.

 

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Publication: September 2013

 

 
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