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Catheter ablation for cardiac arrhythmias

Article in The BMJ · October 2000

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We must be clear about the aims of inquiries. Are they appoint members of the inquiry, confident that
they to work out what happened, make recommenda- their processes will be adequate, and sure that they will
tions to improve practice, consider the “scandal” in a be value for money. Inquries should publish their
broader context, or allocate blame? Or are they materials and methods, check oral allegations against
supposed to be like South Africa’s truth and reconcili- documentary evidence, and send drafts of evidence
ation commission and try and create harmony from accusing individuals to those individuals so that errors
discord? The aims of these inquiries often seems to be of fact can be corrected. Inquiries should also surely be
confused—and perhaps their real purpose is to divert held in public—otherwise, there will always be
the heat from politicians. They are not usually about suspicions of bias, corruption, or incompetence.
blaming individuals. Nevertheless, those being ques- Finally, ministers should think hard before setting up
tioned often feel as if they are being accused and an inquiry. They can easily make things worse rather
denied the safeguards they would have in a court of than better.
law.
The quality of the process is vital in these inquiries, Richard Smith editor, BMJ
and the Griffiths inquiry seems to have fallen short of
best practice. One problem may have been the absence
of a lawyer on the inquiry. Much as doctors and others 1 Hey E, Chalmers I. Investigating allegations of research misconduct: the
may resent the fact, it is lawyers who know how to con- vital need for due process. BMJ 2000;321:752-6.
2 NHS Executive. West Midlands regional office report of a review of the research
duct inquiries justly, although they may create the framework in North Staffordshire Hospital NHS Trust. www.doh.gov.uk/
intimidating atmosphere of a court when something wmro/northstaffs.htm (updated 8 May 2000, accessed 9 May 2000).
3 Legge A. Hospital criticised for not obtaining proper consent. BMJ
more agreeable is needed. The process by which 2000;320:1291.
people are appointed to inquiries appears wholly 4 Smith R. Babies and consent: yet another NHS scandal. BMJ
2000;320:1285-6.
opaque, raising the suspicion that politicians appoint 5 www.doh.gov.uk/research/announcements/researchgovernanceconsult.
people who will give them the result they want. The htm
Bristol inquiry has suffered from these suspicions.9 6 Mayor S. New governance framework for NHS research aims to stop
fraud. BMJ 2000;321:725.
It would be paradoxical to advocate an inquiry into 7 Dyer C. “Unprecedented” row delays second phase of BSE inquiry. BMJ
inquiries, but we can begin to see criteria that will make 1999;318:558.
8 Gunn J. Ashworth revisited. BMJ 1999;318:271.
them more likely to succeed. Those who set them up 9 Barnes N. Bristol again: (Very) short service on the Bristol inquiry. BMJ
should be clear about their purpose, open about how 1998;317:1577-9.

Catheter ablation for cardiac arrhythmias

T
he first diagnostic electrocardiography on a techniques, and availability of this procedure are not
person was carried out by Augustus Waller over widely known.
a century ago at St Mary’s Hospital, London. It The technique involves the percutaneous introduc-
was not until the 1980s that therapeutic cardiac tion of electrode catheters (insulated wires with
electrophysiology emerged; this procedure, carried out electrodes at their tip, much like temporary pacing
while patients are conscious, uses wires passed wires) into the heart under fluoroscopic guidance to
percutaneously to the heart to ablate the cause of record electrical signals from relevant parts of the
arrhythmias. Cardiac electrophysiology is now an heart.2–4 Once the mechanism of the arrhythmia is
established specialty within cardiology.1 2 Although the established, one of the electrode catheters is navigated
word “cure” is not widely applicable in medicine, it can to a critical site at which ablative energy (radiofre-
now justifiably be used for the treatment of cardiac quency current, which is predictable, effective, and well
arrhythmias. Catheter ablation is a safe and curative tolerated) is delivered to create a localised scar that will
option for most arrhythmias, with 85-98% cure rates disrupt the cause of the arrhythmia.
among the arrhythmias treated most frequently.3 4 The mechanism of the arrhythmias is described as
These results have been borne out by a recent large either focal or re-entrant. Re-entry is a simple concept,
prospective multicentre study of 1050 patients which and is the mechanism of most clinically important
provides further evidence of the benefit of catheter arrhythmias. It describes the progression of a wave
ablation; the study found an overall cure rate of 95% front of electrical activation through cardiac muscle
and that a second procedure was required in 4% of over a pathway that leads back to its point of origin.
patients. The rate of important complications related This completes one cycle of a re-entrant circuit, and
to the procedure was < 3%.3 The only randomised trial providing that certain critical conditions exist, conduc-
comparing catheter ablation with drugs in the tion will continue around the circuit again and again to
treatment of recurrent atrial flutter showed that produce a regular arrhythmia. The Wolff-Parkinson-
ablation had a better success rate, a greater impact on White syndrome is well recognised as causing a tachy-
improving quality of life, and a lower incidence of atrial cardia through a re-entry circuit of conduction from
fibrillation and rehospitalisation.5 It would seem, atria to ventricles via the atrioventricular node and
however, that many eligible patients may not be then from ventricles to atria via an accessory pathway
referred for definitive treatment because the principles, that is congenitally anomalous. BMJ 2000;321:716–7

716 BMJ VOLUME 321 23 SEPTEMBER 2000 bmj.com

In any condition in which there is a structural variant contrast, younger patients with documented
providing a similar circular conduction pathway—be it arrhythmias—or even those suspected of having
congenital (such as accessory pathway mediated arrhythmias as a result of a good clinical history—that
tachycardia, atrioventricular nodal re-entrant tachycar- are sufficiently troublesome to require any form of
dia, and possibly atrial flutter) or acquired (such as ven- treatment should be referred for consideration of cath-
tricular tachycardia after myocardial infarction)—there is eter ablation. As a general rule, indefinite drug
the potential for re-entrant arrhythmias. By contrast, treatment of arrhythmias, particularly in younger
when there is severe, generalised disruption of the elec- patients, should be avoided if possible. Any patient with
trical properties of the myocardium, as occurs in many potentially life threatening arrhythmias—such as
forms of structural heart disease, re-entrant wave fronts ventricular tachycardia or the Wolff-Parkinson-White
can meander aimlessly through the myocardium syndrome—or those who have survived cardiac arrest
without following a fixed path and lead to fibrillation. should be referred.
The mechanism underlying focal arrhythmias is abnor- As a safe treatment, performed under local
mal, rapid, spontaneous electrical activity of a group of anaesthesia, which is usually effective as a single proce-
cells spreading to the rest of the myocardium. dure, catheter ablation is the first choice treatment for
The aim of catheter ablation is to eliminate the most cardiac arrhythmias. Patients who would other-
arrhythmia by locating and ablating the safest and wise have to be committed to long term drug treatment
most accessible point that will either transect and and follow up should be offered a cure. The number of
interrupt a re-entrant circuit or eliminate a focus. hospital cardiac departments with the expertise and
At the beginning of the 21st century, ventricular facilities for catheter ablation is expanding, and this
fibrillation is the only arrhythmia for which ablative service is now widely available in all parts of the devel-
therapy is not an option, although in patients who sur- oped world. There is a great need to demystify cardiac
vive cardiac arrest, the implantable cardiac defibrilla- arrhythmias and help practitioners understand what
tor, also often underused, has proved beneficial in treatment is available for the best management of our
improving prognosis. patients: a cure that is safe, efficacious, and cost
There are well developed techniques using catheter effective.
ablation that can reliably cure arrhythmias such as Nicholas S Peters professor of cardiac electrophysiology
atrioventricular junctional re-entrant tachycardias,
Department of Cardiology, St Mary’s Hospital and Imperial College
atrial flutter, atrial tachycardias and some ventricular School of Medicine, London W2 1NY ([email protected])
tachycardias. But there are other arrhythmias that
catheter ablation is less likely to cure, although it is
likely to reduce the frequency and duration of 1 Scheinman MM, Morady F, Hess DS, Gonzales R. Catheter-induced abla-
tion of the atrioventricular junction to control refractory supraventricular
episodes. Atrial fibrillation, the most common arrhyth- arrhythmias. JAMA. 1982;248:851-5.
mia, can be ablated in selected patients, and 2 Jackman WM, Xunzhang W, Friday KJ, Roman CA, Moulton KP,
considerable effort is being made to refine the Beckman KJ, et al. Catheter ablation of accessory atrioventricular
pathways (Wolff-Parkinson-White syndrome) by radiofrequency current.
procedure. The most promising approach is that of N Engl J Med. 1991;324:1605-11.
electrically isolating the focal sources of rapid activity 3 Calkins H, Yong P, Miller JM, Olshansky B, Carlson M, Saul JP, et al. Cath-
eter ablation of accessory pathways, atrioventricular nodal reentrant
that are recognised as the underlying cause of atrial tachycardia, and the atrioventricular junction: final results of a
fibrillation in a growing proportion of patients.6 Rapid prospective, multicenter clinical trial. Circulation 1999;99:262-70.
4 Paydak H, Kall JG, Burke MC, Rubenstein D, Kopp DE, Verdino RJ, et al.
technological advances are providing better tools for Atrial fibrillation after radiofrequency ablation of type I atrial flutter: time
electrical mapping and ablation of more demanding to onset, determinants, and clinical course. Circulation 1998;98: 315-22.
5 Natale A, Newby KH, Pisano E, Leonelli F, Fanelli R, Potenza D, et al. Pro-
arrhythmias.7 spective randomized comparison of antiarrhythmic therapy versus
So, who should be considered for referral to an first-line radiofrequency ablation in patients with atrial flutter. J Am Coll
Cardiol 2000;35:1898-904.
arrhythmia specialist? Clearly, the older patient with 6 Haïssaguerre M, Jaïs P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al.
longstanding atrial fibrillation can be managed by con- Spontaneous initiation of atrial fibrillation by ectopic beats originating in
the pulmonary veins. N Engl J Med 1998;339:659-66.
trolling the ventricular rate and with anticoagulation 7 Schilling RJ, Davies DW, Peters NS. Clinical developments in cardiac acti-
treatment without need for input from a specialist. By vation mapping. Eur Heart J 2000;21:801-7.

Infection in xenotransplantation
Studies with cell free virus are needed to define infection—there is no proof yet of
safety or danger

X
enotransplantation is the transfer of viable that these infections could spread from the xenograft
cells, tissues, or organs between species. It has recipient to the general population. At present, few
been proposed as a solution to the shortage of data address the degree of risk for such interspecies
human organs (allografts) to treat people with organ infections in humans.
failure. There are still serious immunological barriers Infectious diseases are common after organ
to the broad clinical application of this technology. transplantation, largely due to the immunosupressive
Concern has centered on the risk of introducing novel agents given to prevent graft rejection.1 The risk of
pathogens derived from animals into human recipi- infection may be greater in xenograft recipients
BMJ 2000;321:717–8 ents of xenografts. In addition, there is the possibility because of the possible need for greater levels of

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