A prospective randomised evaluation of voltage propagation vs anatomical atrioventricular nodal re-entry tachycardia mapping in paediatric patients

BACKGROUND: There is currently no consensus on the optimal mapping technique for atrioventricular nodal re-entry tachycardia ablation. OBJECTIVE: This, the first of its kind, prospective randomised trial compared procedural characteristics and ablation outcomes between an anatomic approach for atrioventricular nodal re-entry tachycardia ablation and an approach guided by low voltage signals, local activation time, and the propagation wave collision. METHODS: A randomised, prospective, multi-centre clinical trial was performed at 5 paediatric cardiac centres. 3D mapping was used on all patients. After atrioventricular nodal re-entry tachycardia confirmation, patients were randomly assigned to either an anatomic-based approach or to a 3D mapping technique that assessed for low voltage, activation time, and propagation wave collision to select the initial ablation site. Patient and procedural characteristics were collected with up to a 2-year post-procedure follow-up. RESULTS: In all, 70 patients were randomised: 37 within the voltage-propagation wave approach and 33 in the anatomic approach group. There was no significant difference between patient demographics or follow-up duration between groups. No significant difference was seen between duration of procedure, success rate, complications, or recurrences between techniques. There was a trend toward fewer ablation applications to initial success with the voltage-propagation technique (median of 2 vs 5). Conversely, there were significantly more total lesions placed for the voltage-propagation group. Typical atrioventricular nodal re-entry tachycardia trended towards fewer lesions to success and fewer recurrences than ablations for atypical atrioventricular nodal re-entry tachycardia or jump/echo. CONCLUSION: Both techniques demonstrated an excellent acute success rate and a low recurrence rate. Voltage-propagation mapping trended toward fewer ablations to initial success and did not prolong the procedure time. This paediatric study suggests that both a traditional anatomical technique and a voltage-propagation technique can provide excellent clinical outcomes, especially for typical atrioventricular nodal re-entry tachycardia.