Catheter ablation of left posteroseptal accessory pathways and of long RP′ tachycardias with a right endocardial approach

Fifty-four patients with a posteroseptal accessory connection and symptomatic tachycardias underwent catheter ablation of the anomalous pathway. Eight had the permanent form of reciprocating tachycardias (long RP' tachycardia) and 46 had a left posteroseptal preexcitation marked by a prominent R wave in lead VI. In 14 of 19 patients, ventriculoatrial conduction time during tachycardia lengthened in conjunction with functional left bundle branch block; this behaviour was significantly different from a series of patients with right posteroseptal preexcitation in which functional left bundle branch block lengthened the ventriculoatrial time in only one of 12 patients. A quadripolar electrode catheter was left within the proximal coronary sinus in order to locate the earliest atrial or ventricular activation site. The appropriate bipole was used as the radiographic and electrophysiological reference of the insertion of the accessory pathway. A catheter was then positioned on the septal side of the right atrium, outside the coronary sinus, so that atrial activity during reciprocating tachycardia and ventricular activity during preexcitation were synchronous with or earlier than that recorded within the proximal coronary sinus. Accessory pathway potential was not recorded in any patient. Early ventricular potential occurring --1.5 +/- 8 ms relative to delta wave onset was present at that site. In 38 patients, including 5 with permanent junctional tachycardia, high current (14 mA) pacing yielded direct ventricular paced QRS complexes (no delay spike-QRS) with a morphology similar to left posteroseptal maximal preexcitation. Slight movements of catheter position yielded significantly different pace-maps. One to eight 160 J cathodal shocks (510 +/- 213 J cumulative per patient) were delivered at this site in 61 sessions. Following fulguration, tachycardia recurred without drugs in only one patient over a follow-up period of 20 +/- 13 months. Asymptomatic intermittent preexcitation recurred in two patients. In all patients with long RP' tachycardia, the ablation procedure was successful without the need for drugs or permanent cardiac pacing. A long-term follow-up electrophysiological study in 18 patients demonstrated that conduction through the anomalous pathway was absent in 16 and deeply altered in the two patients with intermittent preexcitation; no tachycardia was inducible in any patient. In conclusion, catheter ablation of left posteroseptal accessory pathways is a feasible procedure using a right atrial approach outside the coronary sinus. This technique is also effective for the treatment of the permanent form of reciprocating tachycardia.