Heart Vessels (2005) 20:142–146
DOI 10.1007/s00380-005-0819-7
ORIGINAL ARTICLE
Sedat Kose · Basri Amasyali · Kudret Aytemir
Ilknur Can · Ayhan Kilic · Hurkan Kursaklioglu
Atila Iyisoy · Ersoy Isik
Radiofrequency catheter ablation of accessory pathways during pre-excited
atrial fibrillation: acute success rate and long-term clinical follow-up results
as compared to those patients undergoing successful catheter ablation
during sinus rhythm
Received: July 5, 2004 / Accepted: November 27, 2004
Abstract The onset of recurrent or sustained atrial fibrilla-
tion (AF) is common during electrophysiological (EP) stud-
ies of accessory pathways (AP). We report our experience
in patients with Wolff-Parkinson-White (WPW) syndrome
in whom AF with rapid antegrade conduction over the AP
occurred during an EP study and mapping and ablation
were done during sustained AF, as compared to patients
ablated during sinus rhythm. The study group consisted of
18 patients (group 1) with WPW syndrome who underwent
catheter ablation during pre-excited AF. Two hundred and
sixty-three patients, comparable for clinical characteristics,
whose manifest APs were ablated under sinus rhythm
formed the control group (group 2). Bipolar electrogram
criteria recorded from the ablation catheter showing early
ventricular activation relative to the delta wave on the
surface ECG and AP potentials preceding the onset of
ventricular activation were used as targets for ablation.
Clinically documented atrial fibrillation was significantly
more frequent and antegrade ERP of AP was significantly
shorter in group 1 than in group 2 (39% vs 14%, P ⫽ 0.014
and 268 ⫾ 37 vs 283 ⫾ 16, P ⬍ 0.001, respectively). Proce-
dure-related variables, acute success rates (17/18 [94%] in
group 1, 251/263 [95%] in group 2; P ⬎ 0.05) and late
recurrence rates (0/18 [0%] in group 1 vs 5/263 [2%] in
group 2; P ⬎ 0.05) during a mean follow-up of 25 ⫾ 9
months (range 8–52 months) did not differ significantly.
Our results show that both right- and left-sided accessory
pathways can be mapped and ablated safely during pre-
S. Kose · B. Amasyali (*) · A. Kilic · H. Kursaklioglu · A. Iyisoy ·
E. Isik
Department of Cardiology, Gulhane Military Medical Academy,
06018 Etlik, Ankara, Turkey
Tel. ⫹90-312-304-2390; Fax ⫹90-312-304-4250
e-mail: dramasyali@yahoo.com
K. Aytemir · I. Can
Department of Cardiology, Faculty of Medicine, Hacettepe
University, Ankara, Turkey
© Springer-Verlag 2005
excited AF without delay, and that acute success and recur-
rence rates and long-term follow-up results are similar to
those of pathways ablated during sinus rhythm.
Key words Wolff-Parkinson-White syndrome · Radio-
frequency catheter ablation · Atrial fibrillation
Introduction
Radiofrequency catheter ablation of accessory atrioven-
tricular (AV) pathways has evolved as a first-line treatment
for patients with symptomatic arrhythmias due to accessory
pathway (AP) conduction, with several groups reporting
primary success rates around 90% with a low incidence of
complications.1–4 Localization and subsequent catheter ab-
lation of APs is usually performed during sinus rhythm in
patients with an overt AP or during orthodromic tachycar-
dia or ventricular pacing in those with a concealed AP.1,2,5,6
However, the onset of atrial fibrillation during ablation sig-
nificantly complicates and prolongs the procedure in many
cases. Drugs given to restore sinus rhythm may have addi-
tional effects on the AP conduction characteristics or may
cause block, obscuring the target for ablation. Direct cur-
rent (DC) cardioversion, though almost always effective,
requires deep sedation and carries the risk of compromising
patient compliance in the electrophysiology (EP) labora-
tory. Additionally, atrial fibrillation may recur after
restoring sinus rhythm either pharmacologically or by DC
cardioversion, thus requiring a second intervention. Pro-
ceeding with RF catheter ablation of APs during pre-
excited AF with considerable success has been previously
reported by us and others. However, there are no system-
atic analyses of this approach assessing its acute success
rates and long-term clinical follow-up results, and whether
these differ from ablation under sinus rhythm.7–11
In this study, we report our experience with 18 consecu-
tive patients with Wolff-Parkinson-White syndrome in
whom atrial fibrillation with antegrade conduction over the
AP occurred during an EP study and the entire mapping
 143

Fig. 1. Successful
radiofrequency (RF) ablation of
a left posterolateral accessory
pathway during pre-excited
atrial fibrillation. Note the
disappearance of pre-excitation
within 2 s after the onset of RF
application. The arrow shows
the accessory pathway potential
preceding the ventricular
electrogram. ABL, proximal
(px) and distal (d) electrode of
the ablation catheter; HRAd,
distal high right atrial
electrogram; CS, coronary sinus

and ablation were done during sustained AF; we also com-
pare the acute success rates, late recurrence rates, and long-
term clinical follow-up results of these patients with those in
patients ablated during sinus rhythm.
Patients and methods
Patients
Eighteen of 281 (6.4%) consecutive patients taken to the
laboratory for ablation of manifest accessory pathways
developed sustained atrial fibrillation during the initial
workup and formed the study group (group 1). The remain-
ing 263 patients with manifest accessory pathway conduc-
tion who were ablated under sinus rhythm formed the
control group (group 2). There were 111 women and 170
men with a mean age of 31 ⫾ 12 years (range 17–85). The
indications for catheter ablation were ineffective medical
therapy of symptomatic tachyarrhythmia, adverse effects of
antiarrhythmic drugs, or risk of sudden cardiac death in the
setting of fast ventricular response to atrial fibrillation or
flutter due to accessory pathways. Written informed con-
sent was obtained from all patients before the EP study and
ablation.
Electrophysiology study and radiofrequency
catheter ablation
Patients underwent the EP study in a nonsedated and fast-
ing state with conventional techniques of intracardiac
recording and stimulation as described previously.6
Multipolar electrode catheters were introduced percutane-
ously from peripheral veins and were positioned in the high
right atrium, the His area, and the right ventricular apex. A
7-F deflectable catheter with a 4-mm tip electrode (Marinr,
Medtronic, Minneapolis, MN, USA) was used for precise
localization of the accessory pathway and delivery of the RF
current. Left-sided accessory pathways were mapped and
ablated with the retrograde transaortic approach. In pa-
tients with right-sided pathways, the ablation catheter was
inserted into the femoral vein and positioned in the ven-
tricular aspect of the tricuspid annulus. Intravenous heparin
(5000–10000 U) was administered before mapping of the
left-sided pathways.
Sites were sought where the ventricular activation was
early (by at least 10 ms for the right-sided pathways and 0 ms
for the left-sided pathways) relative to the delta wave on the
surface electrogram and/or a small, sharp, and rapid
deflection preceding the ventricular component of the local
electrogram, consistent with an accessory pathway poten-
tial, was inscribed (Fig. 1).
In all patients, a temperature-controlled RF current was
applied to the ventricular or atrial insertion of the accessory
pathways. RF current delivery, set at 70°C and 50 W, was
discontinued after 15 s if accessory pathway conduction
failed to block and continued for up to 60 s at successful sites
of ablation.
Follow-up after radiofrequency catheter ablation
All patients were discharged within 2 days postoperatively.
All patients were scheduled for a follow-up visit 4–6 weeks
after discharge and every 6 months thereafter. Long-term
efficacy was assessed clinically on the basis of the resting 12-
lead ECG recording, 24-h Holter monitoring, and clinical
symptoms.
Statistical analysis
Data were expressed as percentage for discrete variables
and as mean ⫾ standard deviation for continuous variables.
144

Groups were compared by means of chi-square analysis or
Fisher’s exact test when needed for discrete variables, and
with Student’s t-test or the Mann–Whitney U-test for con-
tinuous variables where appropriate. Statistical compari-
sons were performed using the statistical software package,
SPSS 10.01 (SPSS, Chicago, IL, USA). In all statistical tests,
calculated P values of less than 0.05 were considered
significant.
Results
There were 6 women and 12 men in the study group, aged
29 ⫾ 11 years (range 20–63), whose clinical and electro-
physiological characteristics are presented in Table 1. Seven
of these 18 patients had clinically documented pre-excited
atrial fibrillation with rapid conduction over the accessory
pathway. Four patients (22%) in the study group had struc-
tural heart disease; 1 had coronary artery disease, 2 had
mitral valve disease, and 1 had aortic valve disease. All
patients in the study group were on sinus rhythm at the
beginning of the EP study. Atrial fibrillation developed dur-
ing catheter positioning in 4 patients and during mapping in
14, as summarized in Table 1. The mean ventricular rate
was 167 ⫾ 12 beats/min (range 145–186). None of the pa-
tients in the study group had any evidence of multiple acces-
sory pathways (Table 1).
Except for the antegrade accessory pathway effective
refractory period (ERP), which was shorter in the study
group, there were no significant differences regarding basic
clinical and electrophysiological data and follow-up results
among the study and control groups (Table 2). Antegrade
accessory pathway conduction was successfully abolished
during pre-excited atrial fibrillation in 17 patients. One pa-
tient could not tolerate ablation during atrial fibrillation
after a total of 12 unsuccessful RF pulses and underwent
successful catheter ablation with five more attempts after
DC cardioversion. Sinus rhythm was restored with DC
cardioversion in all 17 patients after successful ablation dur-
ing pre-excited atrial fibrillation. Then, the EP testing was
repeated, in the same session, to confirm antegrade block
and to test for the presence of possible retrograde accessory
pathway conduction or multiple accessory pathways, which
proved negative in all patients.
In the control group, accessory pathway conduction was
successfully ablated in 251 of 263 patients (95%), 198 during
sinus rhythm and 53 during orthodromic tachycardia or

Table 1. Characteristics of 18 patients, clinically documented arrhythmias, onset of atrial fibrillation, electrophysiological data, and outcome of
the ablation procedure
Patient Age AF AP location AF onset Heart rate ERP Duration No. of Success
no. (years) during during AF of AP of study RF
(beats/min) (ms) (min) pulses

1 28 Yes Left lateral Catheter 178 250 60 1 Yes

placement
2 20 Yes Right Catheter 173 290 90 4 Yes
posteroseptal placement
3 35 No Left anterior Mapping 156 275 83 8 Yes
4 24 No Left posterior Catheter 145 260 78 7 Yes
placement
5 22 Yes Right Mapping 155 265 79 5 Yes
posteroseptal
6 45 No Left lateral Mapping 177 240 77 4 Yes
7 20 No Left Mapping 145 260 80 3 Yes
posteroseptal
8 36 No Left lateral Catheter 176 310 85 3 Yes
placement
9 32 Yes Right Catheter 186 190 160 17 No
posteroseptal placement
10 24 Yes Left posterior Mapping 165 290 138 11 Yes
11 21 No Left Mapping 176 310 50 6 Yes
posterolateral
12 23 Yes Right Mapping 165 300 112 7 Yes
anterior
13 24 No Right Mapping 176 325 80 5 Yes
posterior
14 63 No Left lateral Catheter 155 270 83 4 Yes
placement
15 20 Yes Right Mapping 176 230 90 9 Yes
posterior
16 27 No Right Mapping 156 210 90 6 Yes
posteroseptal
17 34 No Left lateral Catheter 178 240 55 5 Yes
placement
18 28 No Right Mapping 159 300 115 14 Yes
posteroseptal
AF, clinically documented atrial fibrillation; ERP, antegrade effective refractory period of the accessory pathway; AP, accessory pathway
 145

Table 2. Comparison of basic characteristics of groups sustained atrial fibrillation, drugs or electrical cardioversion
Group 1 Group 2 P used to terminate sustained atrial fibrillation often results
(n ⫽ 18) (n ⫽ 263) in delay and in some patients, atrial fibrillation cannot be
terminated by drugs or restarts soon after electrical
Age (years) 29 ⫾ 11 31 ⫾ 12 n.s.
Sex [Male n (%)] 12 (67%) 158 (60%) n.s.
cardioversion. Thus, on the basis of our previous experience
Structural heart disease, n (%) 4 (22%) 36 (14%) n.s. of successful RF ablation of accessory pathways during
Frequency of PSVT (attacks/year) 23 ⫾ 7 21 ⫾ 5 n.s. atrial fibrillation, we have proceeded with RF catheter abla-
Antiarrhythmic therapy, n (%) 14 (78%) 185 (70%) n.s. tion during atrial fibrillation in 8 patients with right-sided
AF, n (%) 7 (39%) 38 (14%) 0.014
and 10 patients with left-sided accessory pathways.7 Only in
AF, clinically documented atrial fibrillation; PSVT, paroxysmal 1 of the 18 patients was the attempt unsuccessful, and the
supraventricular tachycardia; n.s., not significant patient underwent successful ablation after restoration of
sinus rhythm with DC cardioversion. The results of our
study show that localization and catheter ablation of both
Table 3. Comparison of electrophysiological variables, ablation data, left- and right-sided pathways during pre-excited atrial fi-
and long-term recurrence rates of groups brillation is as feasible, safe, and effective as ablation during
Group 1 Group 2 P background sinus rhythm and also does not result in signifi-
(n ⫽ 18) (n ⫽ 263) cant delay.
Hindricks et al. reported successful localization and RF
Left-sided AP, n (%) 10 (56%) 149 (57%) n.s.
Antegrade ERP of AP (ms) 268 ⫾ 37 283 ⫾ 16 ⬍0.001 ablation of APs during atrial fibrillation in 18 of 19 patients
AP potentials recorded at 13 (72%) 202 (77%) n.s. with left-sided APs and in two patients with right-sided
endocardial target sides, APs, of which one was right posterolateral and one was
n (%)
right lateral.8,9 We have also previously reported successful
Vo-QRSo (ms) ⫺19 ⫾ 4 ⫺21 ⫾ 6 n.s.
Duration of procedure (min) 92 ⫾ 26 87 ⫾ 31 n.s. mapping and ablation of APs in two patients during atrial
Radiation exposure time (min) 20 ⫾ 5 18 ⫾ 7 n.s. fibrillation; one with a left lateral and one with a right
No. of RF pulses 7⫾4 6⫾5 n.s. posteroseptal location.7 In our present study, we report
Acute success rate, n (%) 17 (94%) 251 (95%) n.s.
eight cases of successful right-sided accessory pathway abla-
Recurrence, n (%) 0 5 (2%) n.s.
Follow-up (months) 23 ⫾ 8 25 ⫾ 9 n.s. tion during atrial fibrillation, two of which were located at
the right posterior and the right anterior positions, which
Vo-QRSo, onset of local ventricular activation in relation to the onset of
pre-excitation in the surface electrocardiogram; AP, accessory path- have not been reported previously. Iturraide et al. reported
way; ERP, antegrade effective refractory period of the accessory successful RF catheter ablation of accessory pathways in
pathway; n.s., not significant four patients during atrial fibrillation, one of whom had a
Mahaim type atriofascicular fiber.10 Siller Rodriguez et al.
reported successful RF ablation of a left lateral accessory
ventricular pacing. There were no significant differences pathway in a patient during atrial fibrillation.11
between the study and control groups regarding acces- Several groups have reported criteria for the identifi-
sory pathway potentials and endocardial activation times cation of successful target sites for catheter ablation of
recorded at successful endocardial target sites, and accessory pathways with mapping under sinus rhythm or
procedure-related variables such as number of RF pulses orthodromic tachycardia.3,6 In these studies, the presence of
and duration of fluoroscopy or the total procedure (Table an accessory pathway potential and the timing of the local
3). ventricular electrogram relative to the QRS complex of pre-
During a mean follow-up period of 25 ⫾ 9 months (range excited beats were identified as the most powerful predic-
8–52 months), there was recurrence of antegrade accessory tors for successful ablation. Hindricks et al. used unipolar
pathway conduction in only 5 patients (2%) in the control recordings in the first step to identify the approximate loca-
group and all these patients underwent successful repeat tion of the ventricular insertion of the accessory pathways
ablation (Table 3). Two of the recurrences occurred within 3 during atrial fibrillation, then applied criteria using bipolar
months after the ablation. Three patients in the study group electrograms for more precise localization.8,9 When the uni-
and 5 patients in the control group had documented paroxys- polar electrograms indicated a close proximity of the abla-
mal atrial fibrillation without pre-excitation during follow- tion catheter to the accessory pathway, as evidenced by a
up after successful ablation, and were treated medically. QS configuration, mapping was continued with the bipolar
electrograms. They sought sites with an early ventricular
activation relative to the delta wave on the surface electro-
cardiogram and a small high-frequency deflection con-
Discussion sistent with an accessory pathway potential, present in
pre-excited beats and absent in normally conducted beats.
The occurrence of atrial fibrillation during an EP study or However, a QS complex detected on the unipolar electro-
catheter ablation in patients with accessory pathways is a gram was recorded at almost all successful and unsuccessful
common problem. In our series, sustained atrial fibrillation sites, making this a useful but nonspecific marker of path-
during an EP study occurred in 18 of 281 patients (6.4%) way location.9 In their multivariate analysis, the strongest
during the enrollment period of the study. In patients with independent predictors of the outcome of ablation were the
146
presence of an accessory pathway potential (recorded from
94% of successful sites) and early ventricular activation in
relation to the onset of the pre-excited QRS complex. In
our study, we did not use unipolar electrograms; instead, we
applied bipolar electrogram criteria in all patients both in
the study and the control groups and proceeded with abla-
tion and thus, we completed the procedure in a relatively
shorter time as compared to the study conducted by
Hindricks et al. (mean 89 ⫾ 27 min, range 50–160 vs 145 ⫾
49 min, range 60–240).9
It is well known that atrial fibrillation with rapid conduc-
tion over the accessory pathway can compromise patient
compliance severely and may on rare occasions induce
ventricular fibrillation. Thus, it is necessary to proceed cau-
tiously and be aware of this complication. No complications
were observed in this study or reported previously.7–11 In our
study, we had to stop the ablation procedure during AF
only in one patient after 12 attempts of RF pulses because
of compromised patient compliance.
In our study group, there were no cases of midseptal or
anteroseptal accessory pathways. Since close observation of
atrioventricular conduction during ablation in patients with
pre-excited atrial fibrillation is difficult and unreliable, and
also not yet reported in the literature, we do not suggest
utilization of this approach in patients with midseptal or
anteroseptal accessory pathways.
Conclusion
Our results show that the onset of atrial fibrillation during
an EP study should not be a cause of frustration for electro-
physiologists. Successful ablation of both right-sided and
left-sided accessory pathways can be performed safely dur-
ing pre-excited atrial fibrillation without delay, and acute
success rates, recurrence of AP conduction, and long-term
follow-up results are comparable with those in patients ab-
lated during sinus rhythm.
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