Ablation of the heart – one of the methods of arrhythmia treatment

Author Ольга Кияница

2018-05-14

With some types of cardiac arrhythmia, the use of pharmacological drugs and other treatments does not give a positive result and does not allow the removal of clinical manifestations. Cardiac ablation is a medical manipulation that involves the destruction or replacement of certain parts of the myocardium on the connective tissue that cause and maintain abnormal electrophysiological activity.

History

The catheters were first used for intracardiac stimulation and recording of electrical activity back in the late 60s of the last century.At that time, surgical manipulations were used to treat persistent forms of rhythm disturbance, for example, removal of the arrhythmogenic focus in atrial tachycardia or cryo-surgery of the AV node with resistant ventricular tachycardia. In 1967, two famous doctors, Durer and Kumel, described the possibility of inducing tachyarrhythmia using programmed electrical stimulation. At that time, thanks to intracardiac catheterization, it was possible to evaluate the features of the electrical processes taking place in the myocardium, which allowed performing a procedure such as epicardial mapping.
In 1981, the concept was first used in practice, but it happened in a random way. Dr. Gonzales described the clinical case in which the patient was subjected to an electrophysiological examination after defibrillation, but a contact appeared between the defibrillator electrode and the catheter electrode, which triggered the appearance of a high-voltage discharge directed into the bundle of Guiss. The released energy caused damage to the underlying tissue and triggered a full heart block. Later this case was studied in detail and based on it, modern techniques of cardiac ablation were developed that saved the lives of hundreds of thousands of people.

The essence of the method

This procedure is able to cure certain types of rhythm disturbances and other structural diseases of the heart.Arrhythmia develops when electrical impulses of the conducting system become inconsistent, which provokes an accelerated, delayed or unstable rhythm.
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Cardioablation can prevent inconsistency of contractions, interrupting electrical pathways and restoring normal heartbeat. Before carrying out the manipulation, it is necessary to undergo a catheter physiological study evaluating the electrical activity of the heart and determining the ablation region.

Indications for ablation of the heart

There are three classes of indications for ablation of the heart.

First grade
  • Supraventricular tachycardia due to atrivercular nodal reentrant tachycardia.
  • Wolff-Parkinsan-White syndrome;
  • Unifocal atrial tachycardia or atrial flutter (especially common right-hearted forms).

For the abnormalities listed above, ablation is the first-line therapy.

Second class Atrial flutter, accompanied by a decrease in the quality of life, as well as ineffectiveness or intolerance of at least one antiarrhythmic drug. In this case, if ablation of the left atrium and AB ablation are used to control the rate of heartbeat, then this is an indication of Class I.
Third class This symptomatic group includes symptomatic ventricular tachycardia. Catheter ablation is the method of choice in the treatment of idiopathic VT. In structural heart diseases, catheter ablation is usually performed in the absence of a positive effect on the intake of drugs. The method is also used as an additional therapy in patients experiencing too frequent discharges from an implanted cardioverter defibrillator.

Rarer indications include the following conditions:

  • Symptomatic drug-refractory idiopathic sinus tachycardia;
  • Abnormal quality of life ectopic contractions;
  • Symptomatic nodal ectopic tachycardia.

Radio-frequency catheter ablation is used in clinically expressed tachycardias, including polymorphic VT and AF. The greatest effectiveness of treatment is observed in patients suffering from general forms of SVT, namely from nodal reciprocal tachycardia and from orthodromal recurrent tachycardia.

Contraindications of the procedure

There are several factors that completely prohibit radiofrequency ablation. Left atrial ablation and ablation with persistent atrial flutter should not be given if there is a diagnosed thrombus in the atrium. Similarly, the presence of a mobile thrombus is a contraindication to conducting left ventricular ablation.
Mechanical heart valve prostheses, as a rule, do not intersect and do not interact with ablation catheters. If pregnancy is suspected, women of reproductive age are not allowed to carry out fluoroscopy.

Preparing for the operation

Before the procedure, the patient must undergo a series of diagnostic tests to assess the overall health of his patients.Then the doctor discusses with the patient the possible risks and benefits of cardiac ablation. The night before the manipulation is forbidden to drink and eat. If the patient is taking any pharmacological drugs, then it is required to inform the treating doctor about it. In some cases, patients are asked to stop taking antiarrhythmic drugs a few days before ablation.
If the patient has an implanted cardiac device, such as a pacemaker or a cardioverter defibrillator, the doctor takes special measures to avoid intra-operative complications.

Method of conducting

Since ablation is not accompanied by severe pain, then, as a rule, the procedure is performed under local anesthesia.Long flexible tubes (catheters) are inserted into the vein or artery (depends on the disturbing parts) and are guided through the circulatory system to the heart. Once they can be installed in the correct position, a high-frequency energy pulse is applied through the wire, heating and destroying the heart tissues that contribute to the development of arrhythmia. The procedure usually lasts from 2 to 4 hours, but may take longer.

Radiofrequency catheter ablation of the heart

This is a microsurgical procedure that uses thin, flexible tubes called catheters that penetrate the heart. Manipulation is convenient because it does not require general anesthesia or cardiac arrest. The method is used in special cardiology centers that have the necessary equipment.

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For the procedure, one or more catheters are inserted into the blood vessels and, using fluoroscopy (the method of obtaining a dynamic X-ray image), they are brought to the heart chambers. Catheters are divided into diagnostic and ablative. The first type allows you to determine the area of the source of abnormal heart rhythm, and the second is necessary to eliminate it.

Advantages of RFA

Thanks to catheter ablation, patients can be completely relieved of the symptoms of arrhythmia.
Video: Catheter ablation

After manipulation in patients who previously suffered from a permanent form of tachycardia, breathing improves, dyspnea disappears, fatigue disappears and general weakness disappears. In statistical studies, it was noted that the procedure increases life expectancy, and also reduces cardiovascular risk by 60%.
In comparison with other manipulations, for example, with surgical ablation, the cutter has several advantages:

  • Less traumatic;
  • Does not require general anesthesia;
  • Does not require intraoperative cardiac arrest;
  • Has a shorter rehabilitation period;
  • Less risk of bleeding and adhesions.

Thoracoscopic ablation

The essence of this method of treatment is not much different from the previous one. The key difference is in the way of access to the heart muscle. The procedure itself is performed in the operating room under general anesthesia. To perform torascopic ablation, small incisions are made on each side of the chest through which a special tube with a video camera at the end will be inserted. Then the radio-frequency electrodes are brought to the sites of pathological activity, and through them a powerful electric pulse is sent, replacing the pathological focus on the scar tissue.

Laser ablation

This is an innovative minimally invasive surgical intervention, which involves the use of a special medical laser, with which it is possible to achieve scarring of pathological parts of the myocardium. When carrying out manipulation, a directed flow is created that provokes thermal changes in the muscles of the heart and replaces it on the connective tissue. In order for the procedure to have a positive effect, it may take several repetitions. 2-3 "course" of laser ablation can achieve the necessary volume of scar tissue and completely replace the area of abnormal electrophysiological activity.

How is the postoperative period?

At the end of the procedure, all tubes, conductors and catheters will be removed from the patient's body. Sometimes there may be a slight bleeding from the inguinal, wrist, or any other area through which rapid access is provided. It, as a rule, quickly stops with the help of simple manipulations and a pressing dressing.
Within a few hours, the patient needs to maintain a reclining position. Reduced motor activity prevents the development of bleeding in the area of the operating wound. At least one night after the procedure is required to be carried out in a hospital department under the supervision of a specialist. Many patients in the first few days feel general fatigue after ablation, but after about a week life returns to the usual course.

Complications

The greatest threat to the patient is not the procedure itself, but radiological control, which can exceed the allowable dose of radiation. Statistical analysis showed that the probability of a child with genetic defects after fluoroscopy is 1 per million births. The average risk of developing malignant neoplasms during irradiation lasting more than 60 minutes varies from 0.3 to 2.3 deaths per 1000. In most cases, the duration of irradiation does not exceed an hour.
The main complications that can be observed directly from ablation are found in about 3% of patients.Thromboembolism develops in about 1% of cases. At the same time, 0.1-0.2% of all procedures result in fatalities. The frequency of heart complications varies depending on the location and type of ablation. Cardiac complications include the following:

  • AV-blockade of high gradation;
  • Cardiac tamponade;
  • Coronary artery spasm / thrombosis;
  • Pericarditis;
  • Damage to the valve.

Vascular complications that can be observed at 2-4% of the total number of procedures include the following:

  • Retroperitoneal bleeding;
  • Hematoma;
  • Vascular trauma;
  • Transient ischemic attack / stroke;
  • Hypotension;
  • Air or thromboembolism.

Complications from the respiratory system:

  • Pulmonary hypertension with the presence or absence of hemoptysis (can develop with stenosis of the pulmonary artery);
  • Pneumothorax.

Other, less common complications:

  • Left atrial-esophageal fistula;
  • Acute pyloric spasm;
  • Paralysis of the diaphragmatic nerve;
  • Radiation or electrical damage to the skin;
  • Infection at the access site;
  • Pathological sinus tachycardia;
  • Proarhythmy.

Lifestyle and prognosis after surgery

In most cases, rhythm normalization can be achieved after the first manipulation, but some patients need a repetition of the procedure. Sometimes, even after ablation, it may be necessary to continue taking medications. There are a number of changes that can be made to your lifestyle and help the heart not to experience any rhythm problems in the future:

  • Avoid taking stimulants that can cause heart rhythm disturbances, such as caffeine, alcohol and nicotine;
  • Regularly examine blood pressure and cholesterol level in the blood, and keep these rates within normal limits;
  • It is necessary to keep the motor activity. It is recommended to discuss with the doctor the optimal level of physical activity and on the basis of this make an exercise program;
  • Avoid stress and psycho-emotional stress;
  • Have healthy food and fight excess weight;
  • Regularly undergo a screening examination.

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Conclusion

Ablation of the heart is a highly effective and mini-traumatic method of restoring the heart rhythm. The procedure favorably affects the general condition of patients, removes clinical manifestations of arrhythmia, increases life expectancy and reduces the risk of premature death. The technique has become a new round in the development of cardiology and allowed to put aside more dangerous surgical procedures on the open heart.


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