Review
Transient proarrhythmic state following atrioventricular junction radiofrequency ablation: pathophysiologic mechanisms and recommendations for management

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Abstract

The induction of complete heart block by radiofrequency ablation of the atrioventricular junction combined with pacemaker implantation has become an established therapy for rate control in patients with atrial fibrillation who are unresponsive to drugs. Reports of ventricular arrhythmias and sudden death after ablation have, however, raised concerns about safety. Ventricular arrhythmias are usually polymorphic and related to a phase of electrical instability due to an initial prolongation and then slow adaptation of repolarization caused by the change in heart rate and activation sequence. Structural heart disease, and other factors that predispose for the acquired long QT syndrome, seem to add to the risk. Ventricular activation and repolarization stabilize during the first week after the procedure. Routine pacing at 80 beats per minute during this phase is recommended, as well as in hospital monitoring for at least 48 hours. Patients with high-risk features for arrhythmias, such as congestive heart failure or impaired left ventricular function, may require pacing at higher rates. Adjustment of the pacing rate—although rarely below 70 beats per minute—is usually undertaken after a week in most patients, preferably after an electrocardiographic evaluation for repolarization abnormalities at the lower rate.

Section snippets

Materials and methods

English-language clinical studies and case reports on AV junction or His ablation since 1982 were identified from MEDLINE via PubMed. Key references (published articles) rather than key words were used, and the reference lists created by the PubMed tool “Related articles” were reviewed. A personal database of relevant articles was also used.

In addition, we included our single-center experience involving 259 consecutive patients who underwent successful AV junction radiofrequency ablation from

Results

The English-language literature included five case reports on 7 patients 16, 17, 18, 19, 20. In addition, four cohort studies of 32 to more than 300 patients included 16 other patients with early life-threatening ventricular arrhythmias following AV junction radiofrequency ablation 13, 21, 22, 23, of whom at least 3 died (Table).

In addition, clinically important ventricular arrhythmias presumably related to the procedure were observed in 3 of our 259 patients. There were no deaths during the 30

Discussion

The induction of complete AV block by ablation of the AV junction using direct-current shock delivered through endocardially placed catheters was described in 1982 24, 25. In a subsequent report of 91 patients who underwent this treatment, 7 patients (8%; 95% CI: 3% to 15%) had ventricular arrhythmias up to 30 days after ablation, of whom 2 had a sustained ventricular arrhythmia (26). In another study of 136 patients, 8 died during hospitalization, of whom 6 (4%; 95% CI: 2% to 9%) suffered from

Acknowledgements

The authors are grateful to Marian Lettosunti for technical assistance.

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    This study was supported by grants from Karolinska Institutet, and the Swedish Heart-Lung Foundation for which Dr. Bergfeldt is a clinical investigator.

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