Endocavitary electrophysiological study by percutaneous antecubital vein and without X-ray for risk stratification of asymptomatic ventricular pre-excitation in young athletes

Abstract

Athletes with asymptomatic ventricular pre-excitation (VP) should undergo electrophysiological study for risk stratification. We aimed to evaluate the feasibility, efficacy, safety and tolerability of an electrophysiological study using a percutaneous antecubital vein access and without the use of X-ray (ESnoXr). Methods: We collected data from all young athletes < 18 year-old with AVP, who underwent ESnoXr from January 2000 to September 2020 for evaluation of accessory pathway refractoriness and arrhythmia inducibility using an antecubital percutaneous venous access. Endocavitary signals were used to advance the catheter in the right atrium and ventricle. Results: We included 63 consecutive young athletes (mean age 14.6 ± 1.9 years, 46% male). Feasibility of the ESnoXr technique was 87% while in 13% fluoroscopy and/or a femoral approach were needed. Specifically, fluoroscopy was used in 7 cases to position the catheter inside the heart cavities with an average exposure of 43 ± 38 s while in 2 femoral venous access was needed. The mean procedural time was 35 ± 11 min. The exam was diagnostic in all patients, there were no procedural complications and tolerability was excellent. 53% of the patients had an accessory pathway with high refractoriness and no inducible atrio-ventricular reentry tachycardia: this subgroup was considered eligible to competitive sports and no event was observed during long-term follow-up (13.6 ± 5.2 years) without drug use. The others underwent catheter ablation. Conclusion. ESnoXr has been shown to be a feasible, effective, safe and well-tolerated procedure for the assessment of arrhythmic risk in a population of young athletes with asymptomatic VP.

Keywords: Electrophysiology; Pediatrics; Sports cardiology; Wolff-parkinson-white; Zero x-ray.

Fig. 1

Materials needed for ESnoXr. A) syringe with physiological solution, 4 French pediatric Cordis introducer, needle for brachial puncture, 0.21 in. guide, local anesthesia in insulin syringe; B) 4 fr Bard tetrapolar catheter which is introduced percutaneously in the antecubital vein.

Fig. 2

A) catheter positioned in the atrium, records the atrial signal; B) catheter positioned in the right ventricle guided by the recording of the endocavitary signal.

Fig. 3

A) programmed pacing from the right ventricle with induction of orthodromic atrioventricular reentry tachycardia; B) catheter withdrawn into the atrium and degeneration of the tachycardia into pre-excited atrial fibrillation; C) minimum RR during pre-excited atrial fibrillation 212 ms, indicative of high-risk accessory pathway; D) spontaneous restoration of sinus rhythm.

Fig. 4

A) four-pole catheter positioned in the atrium; B) incremental pacing to increase the degree of ventricular pre-excitation.

Fig. 5

Venous access used to perform ESnoXr. pt = patient, pts = patients, Xr = radiological exposure.

Fig. 6

ESnoXr results. AVRT = atrioventricular reciprocating tachycardia; F.U. = follow-up; ESnoXr. endocavitary electrophysiological study by percutaneous antecubital approach without use of fluoroscopy and with the aid of endocavitary recording; sRRP = the shortest RR interval between two pre-excited QRS.

Fig. 7

locations of the anomalous pathways found at EsnoXr. AS = antero-septal; LAL = left anterolateral; LL = left lateral; LP = left posterior LPL = left posterolateral; LPS = left postero-septal; MS = mid-septal; RPS = right postero-septal.