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Transcatheter Ablation of Cardiac Arrhythmias in the Young
Macdonald Dick II, Peter S. Fischbach and Ian H. Law
Transcatheter ablation of cardiac arrhythmias emerged in the early 1990s as definitive treat- ment for many forms of tachyarrhythmias in adults; the technique was rapidly adapted for treatment of arrhythmias in children. A con- ference a decade later (2001) sponsored by the North American Society for Pacing and Elec- trophysiology (NASPE, later renamed the Heart Rhythm Society, HRS) led a discussion of current knowledge and experience regard- ing ablation of cardiac arrhythmias in chil- dren. From these presentations, indications for ablation for cardiac arrhythmias in chil- dren were distilled that were based on a con- sensus expert opinion among a selected num- ber of the participants.
Class I indication is present when there is broad agreement among experts for ablation, where supportive data exist, and where the outcome is likely to be beneficial.
Class II indication is present when opinion regarding benefit is divergent.
Class IIA is present when evidence/
opinion favor benefit.
Class IIB is present when evidence/
opinion do not favor benefit.
Class III indication is present when there is agreement that radiofrequency ablation is not med- ically indicated.
Using these three classes, different clin- ical scenarios were devised as examples for suggested indications for radiofrequency ab- lation of arrhythmias in children.
Class I: RFCA
WPW syndrome following aborted SCD
WPW, syncope, AFib w/preexcited RR
<250 msec or APERP <250 msec
Chronic or recurrent SVT w/ventricular dysfunction
Recurrent VT, Hemodynamic compro- mise, amenable to RFCA
Class IIA: RFCA
Recurrent/symptomatic SVT, refractory to medical management, >4 yrs age
CHD Surgery, chamber inaccessible
Chronic (6–12 months) or incessant SVT w/normal ventricular function
Recurrent, chronic IART
Palpitations, w/SVT at EPS
Class IIB: RFCA
Asymptomatic preexcitation (WPW),
>5 years; risks/benefits of arrhythmia &
ablation explained
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SVT, >5 yrs; replace effective AAD
SVT, <5 yrs; ineffective AAD (Sol &
Amio) or intolerable side effects
IART—1–3/year
AVN ablation for recurrent or intractable IART
VT—one episode, hemodynamic com- promise, amenable to RFCA
Class III: RFCA
Asymptomatic preexcitation (WPW),
<5 years
SVT, <5 years; effective AAD
NS-VT (not incessant – hours) no hemo- dynamic compromise