A new insight into the different approaches for the ablation of para-Hisian accessory pathways: safety, effectiveness, and mechanism

BACKGROUND: To compare the safety, effectiveness, electrophysiological characteristics, and mechanisms of different approaches for the ablation of para-Hisian accessory pathways (APs). METHOD: Eighteen consecutive patients with para-Hisian APs were enrolled in this study. Detailed mapping of retrograde conduction as well as antegrade conduction (if possible) in both the right sided His bundle region and non-coronary cusp (NCC) region was performed before ablation. Ten patients underwent initial ablation in the right septal (RS) region while the remaining 8 patients were ablated in NCC region. Repeat ablation was attempted in an alternative region if ablation at the first site failed. RESULTS: Among the patients whose procedures were successful, 7 cases were successfully ablated with a NCC approach while 10 were conventionally ablated in RS region. For successful procedures targeting the NCC region, the earliest atrial activation (EAA) in NCC region preceded that at RS region by 4–13 ms. The distance between NCC targets and near-field His potential (NFH) points was longer than that between RS targets and NFH points. Additionally, the risk of complication after ablation in NCC region was lower compared with that following RS-targeted procedure. CONCLUSION: NCC approach provided a high success rate and low risk of complication for the ablation of para-Hisian APs as long as EAA was observed in NCC region. Sites of successful para-Hisian AP ablation in NCC region had different retrograde mapping patterns in comparison with successful ablation sites in the RS region.