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Catheter ablation in paediatric arrhythmias
  1. CHRISTOPHER WREN, Consultant Paediatric Cardiologist
  1. Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK

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    The introduction of catheter ablation in the early 1990s was a major step forward in the management of arrhythmias. Before that most children were controlled with long term drug treatment, while a few underwent open heart surgery. Radiofrequency ablation now offers a non-surgical cure and has rapidly been adopted for the treatment of a wide variety of tachycardias. It has also redefined theories about the substrates and mechanisms of several tachycardias (so called “learning while burning”).

    What is radiofrequency ablation?

    Catheter ablation is usually performed in conjunction with an invasive diagnostic electrophysiology study, which will identify the critical site in the tachycardia circuit or the origin of abnormal impulse formation. Radiofrequency ablation involves delivery of a high frequency (500 kHz), low energy electric current to the critical area via an intracardiac catheter. The current induces a rise in tissue temperature at the point of contact with the heart and is similar, in a way, to low energy diathermy although the energy, frequency, and waveform are different. If the burn is precisely targeted it will produce a localised lesion to destroy the arrhythmia substrate. Energy delivery can be precisely controlled with catheter tip temperature feedback.

    Diagnosis and natural history of tachycardia

    The key to management of all tachycardias is a precise diagnosis. “Supraventricular tachycardia” is an inadequate term for a group of up to 12 different tachycardia mechanisms. Knowledge of the age of onset and analysis of 12 lead electrocardiograms recorded in tachycardia and in sinus rhythm will lead to a precise diagnosis in most cases. Knowing the diagnosis, one can define the natural history and plan treatment.

    Most tachycardias in infancy are due to atrioventricular re-entry via an accessory pathway. In some the pathway functions anterogradely in sinus rhythm producing ventricular pre-excitation (Wolff-Parkinson-White syndrome) whereas in most the pathway conducts in a retrograde direction only and is known as “concealed”. …

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