eMedicine Specialties > Cardiology > Electrophysiology Procedures
Catheter Ablation
Updated: Oct 14, 2008
Introduction and History
Background
Radiofrequency catheter ablation (RFCA) has revolutionized treatment for tachyarrhythmias and has become first-line therapy for some tachycardias. Although developed in the 1980s and widely applied in the 1990s, formalized guidelines for its use in clinical practice were not developed until recently.
History
Catheters were first used for intracardiac recording and stimulation in the late 1960s, but surgical treatment for refractory tachyarrhythmias was the mainstay of nonpharmacologic therapy until it was superseded by catheter ablation. The initial energy source used was direct current (DC) from a standard external defibrillator. A shock was delivered between the distal catheter electrode and a cutaneous surface electrode; however, this high-voltage discharge was difficult to control and could cause extensive tissue damage.
Radiofrequency (RF) energy, a low-voltage, high-frequency form of electrical energy familiar to physicians from its use in surgery (eg, electrocautery), quickly supplanted DC ablation. RF energy produces small, homogeneous, necrotic lesions by heating tissue. Lesion size is influenced, in part, by the length of the distal ablation electrode and the type of catheter (standard vs saline-cooled). With typical power settings and good catheter contact pressure with cardiac tissue, lesions are minimally about 5-7 mm in diameter and 3-5 mm in depth. The relative safety of this energy source contributed to the widespread adoption of catheter ablation as a therapeutic modality.
Frequency
A study of catheter ablation in elderly patients documented more than 16,000 RF ablations in Medicare fee-for-service beneficiaries in 1998.1 Fee-for-service, as opposed to managed care, covered 80% of the Medicare population in 1998.
Patient education
For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education articles Atrial Flutter, Atrial Fibrillation, and Supraventricular Tachycardia.
Etiology
Radiofrequency catheter ablation (RFCA) has been applied to most clinical tachycardias, even to polymorphic ventricular tachycardia and ventricular fibrillation in preliminary studies. Success rates are highest in patients with common forms of supraventricular tachycardia (SVT), namely atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic reciprocating tachycardia (ORT). The most commonly performed ablation procedures based on rhythm diagnosis are described in this section.
For related information, see Medscape's Cardiac Rhythm Management Resource Center.
Generic supraventricular tachycardia
Paroxysmal supraventricular tachycardia has 3 main mechanisms.
The most common type of generic SVT is AVNRT, accounting for more than half of all cases (see Media files 1-3). In the common form of AVNRT, the inferior atrionodal input to the atrioventricular (AV) node serves as the anterograde limb (ie, the slow pathway) of the reentry circuit, and the superior atrionodal input serves as the retrograde limb (ie, the fast pathway). Typically, AVNRT can be cured by targeting the slow pathway near the inferior tricuspid valve annulus at the level of the coronary sinus os or somewhat higher. The risk of iatrogenic heart block by ablating in this region is quite low (1-2%), and targeting the slow pathway is safer than targeting the fast pathway, which is located closer to the compact AV node.
The second most common type of generic SVT is ORT, a reentrant rhythm using the AV node as the anterograde limb and an accessory AV connection (ie, the accessory pathway) as the retrograde limb (see Media files 4-5). This tachycardia mechanism accounts for approximately 30% of paroxysmal SVTs. Typically, this rhythm disturbance can be cured by targeting the accessory pathway as it crosses the mitral or tricuspid valve annulus.
The least common type of SVT (10% of cases) is a unifocal atrial tachycardia, which can arise from either atrium. These tachycardias are somewhat more challenging to ablate than the more common forms of generic SVT. For those tachycardias originating from the left atrium, transseptal catheterization via a patent foramen ovale or transseptal puncture is usually required.
Wolff-Parkinson-White syndrome
Wolff-Parkinson-White (WPW) syndrome is the most common of the preexcitation syndromes. In this syndrome, rapid antegrade conduction over an accessory AV connection (accessory pathway or bypass tract are older terms) may lead to ventricular fibrillation and sudden death in a minority of patients. Typically, a transition from ORT to atrial fibrillation can be the cause of rapid preexcited tachycardia. RFCA of the accessory pathway cures WPW syndrome, eliminating ORT and atrial fibrillation in most instances.
Atrial flutter
Atrial flutter is most commonly due to a large reentrant circuit in the right atrium, involving an isthmus of tissue between the tricuspid valve annulus and the inferior vena cava. Most commonly, reentry proceeds counterclockwise up the atrial septum and down the lateral wall of the right atrium, inscribing inverted (ie, "sawtooth") flutter waves in the inferior leads and upright P waves in V1 (see Media files 6-7). Clockwise reentry using this same circuit can also occur, giving upright P waves inferiorly and inverted P waves in V1. Linear ablation of the cavotricuspid isthmus cures these common forms of atrial flutter.
Non–isthmus-dependent flutters can occur elsewhere in the right atrium as well as in the left atrium. Left atrial flutters are uncommon, may be difficult to ablate, and generally require a 3-dimensional mapping system to facilitate the procedure.
For related information, see Medscape's Atrial Flutter Resource Center.
Atrial fibrillation
Atrial fibrillation is the most common of all sustained tachyarrhythmias. The simplest catheter ablation procedure performed in patients with atrial fibrillation is RFCA of the AV junction. This procedure is indicated for patients with high ventricular rates not amenable to drug therapy. RFCA of the AV junction results in excellent rate control, relieves palpitations, and improves functional capacity; however, it requires permanent pacemaker implantation to manage the resulting AV block and requires warfarin to prevent stroke because the atrial fibrillation itself is not affected.
RF AV nodal modification is a method of slowing AV nodal conduction without causing heart block. This type of ablation is not commonly performed because it is less therapeutic than AV junction ablation and may result in late heart block.
Catheter ablation of atrial tissue to cure atrial fibrillation is still evolving. The procedure is technically demanding, more risky, and less successful than the other ablation procedures described above. Nevertheless, the observation of Haissaguerre2 and others that pulmonary vein foci can trigger atrial fibrillation has stimulated much additional research, and there is considerable scientific excitement that this common tachyarrhythmia may be amenable to a curative catheter procedure. The most commonly used techniques involve ablation of the muscular connections between the pulmonary veins and the left atrium (pulmonary vein isolation), or a wide circumferential ablation around the pulmonary veins (see Media file 8). The goal is to electrically isolate foci arising from inside the veins, or adjacent to the pulmonary vein ostia, from the rest of the left atrium.
The complete surgical Maze procedure (incisions in both atria +/- transmural radiofrequency lesions) is still the most effective technique for potentially curing atrial fibrillation in all comers, regardless of chronicity or whether structural heart disease is present. The best success rates with left atrial catheter ablation are in patients with paroxysmal atrial fibrillation and hearts that are not too structurally abnormal.
No consensus exists on the optimal left atrial ablation technique or what constitutes a clinically successful procedure. Nevertheless, evidence is accruing that catheter ablation for atrial fibrillation is more effective than antiarrhythmic drug therapy, especially in patients who have already failed an antiarrhythmic drug. The 2006 ACC/AHA/ESC guidelines for the management of atrial fibrillation now list catheter ablation as a reasonable strategy for patients with life-style impairing symptoms who have failed at least one antiarrhythmic agent.3
Ventricular tachycardia
Idiopathic ventricular tachycardia (VT) most commonly arises from the right ventricular outflow tract and less commonly originates in the inferoseptal left ventricle near the apex. These forms of VT are amenable to catheter ablation, although success rates are somewhat lower than those for the common forms of SVT. In patients with VT due to structural heart disease, catheter ablation is used as adjunctive therapy to the implantable cardioverter-defibrillator (ICD), eg, in patients with frequent ICD discharges.
Pathophysiology
Radiofrequency catheter ablation (RFCA)
The current used in RFCA is a sinusoidal high-frequency (eg, 500 kilohertz [kHz]) form of electrical current that causes small lesions within the heart. The primary mechanism of tissue destruction is by thermal injury (ie, desiccation necrosis).
The delivery of RF energy causes resistive heating of a narrow rim of tissue in direct contact with the electrode at the tip of the catheter. Deeper tissues are heated by conduction of heat from this perielectrode region. Lesion size is determined by the balance between conduction of heat through the tissue and convective heat loss to the blood pool. The temperature at the electrode-tissue interface must be approximately 50°C or higher to cause tissue necrosis. As the temperature approaches the boiling point of 100°C, the delivery of current is impeded by coagulum (eg, denatured proteins) on the tip of the catheter. This coagulum may predispose the patient to thromboembolic complications. In addition to electrode-tissue interface temperature, lesion size is proportional to the delivered power, the diameter of the distal electrode, and the contact pressure of this electrode with cardiac tissue.
Current ablation systems allow for temperature-controlled energy delivery and rapidly curtail energy delivery for an impedance rise. Newer technical modifications, such as a larger distal electrode and saline-cooling of this electrode, have helped to minimize impedance rises and to allow creation of larger and deeper lesions.
The acute lesion of RFCA consists of a central zone of coagulation necrosis surrounded by a border zone of hemorrhage and inflammation. The presence of this border region may explain the recurrence of tachyarrhythmias days to weeks after the procedure because this region may contain viable arrhythmogenic tissue.
Catheter-based cryoablation has been commercially available for several years. Pressurized liquid nitrous oxide is injected into the closed catheter tip, where its rapid evaporation leads to cooling of the underlying tissue to about -75ºC. A hemispherical block of frozen tissue (ice ball) is formed at the catheter tip, and thawing results in tissue injury (including hemorrhage and inflammation) that eventually results in a fibrotic lesion.
Cryoablation has a number of potential advantages over RFCA: (1) minimal risk of permanent heart block with ablation near the AV node (due to good reversibility of the electrophysiologic effect with rapid rewarming), (2) excellent catheter stability during ablation due to the ice ball, (3) no pain during energy delivery, and (4) less risk of damaging vascular structures such as the coronary arteries and pulmonary veins. However, cryoablation is somewhat less effective clinically than RFCA, and the cryoablation catheter is less maneuverable. Though cryoablation is useful in specific clinical circumstances, especially with ablation close to the compact AV node, RFCA remains the dominant and most useful energy source in clinical practice.
Catheter-based ablation systems using ultrasound, laser, and microwaves are in development and are not yet FDA-approved for routine clinical use.
- High-intensity focused ultrasound (HIFU) creates a pressure wave that is converted to heat by the absorbing tissue, resulting in thermal injury. It can be applied through a fluid-filled balloon to ablate tissue near the pulmonary vein orifices (pulmonary vein isolation), where ectopic foci can arise that initiate atrial fibrillation. One potential advantage of the HIFU balloon catheter over RFCA is that contact with tissue is not required for ablation. Phrenic nerve palsy has been a complication of HIFU near the pulmonary veins.
- Catheter-based laser ablation causes thermal injury in tissue by photon absorption. At lower tissue temperatures (eg, 42-65ºC, the lesion is caused by protein denaturation. At temperatures more than 100ºC, tissue vaporization occurs. An endoscopic diode laser balloon ablation system has been developed for pulmonary vein isolation. It allows direct visualization of endocardial-balloon contact and has an adjustable aiming beam to tailor the lesion to the desired location. Unlike RFCA, laser ablation is not impeded by fibrotic tissue, which may be advantageous in ablating VT in ischemic cardiomyopathy.
- Microwave ablation uses an antenna to heat tissue by radiative energy (electromagnetic waves). Potential advantages over RFCA include larger lesions, less dependence on direct endocardial contact, and less risk of endocardial thrombus.
Indications for Catheter Ablation
Class I indications for catheter ablation
- Symptomatic supraventricular tachycardia (SVT) due to atrioventricular nodal reentrant tachycardia (AVNRT), Wolff-Parkinson-White syndrome, unifocal atrial tachycardia, and atrial flutter (especially common right atrial forms); first-line therapy if patient preference
- Atrial fibrillation with lifestyle-impairing symptoms, after inefficacy or intolerance of at least 1 antiarrhythmic agent (Both left atrial ablation for restoration of sinus rhythm and AV junction ablation for rate control are Class I indications, depending on the circumstance.)
- Symptomatic ventricular tachycardia (first-line therapy in idiopathic VT [if patient preference]; in structural heart disease, generally performed for drug inefficacy or intolerance, or in implantable cardioverter-defibrillator shocks)
Uncommon indications for catheter ablation
- Symptomatic drug-refractory (inefficacy or intolerance) idiopathic sinus tachycardia
- Lifestyle-impairing ectopic beats
- Symptomatic junctional ectopic tachycardia
Few absolute contraindications to RFCA exist. Left atrial ablation and ablation for persistent atrial flutter should not be performed in the presence of known atrial thrombus. Similarly, mobile left ventricular thrombus would be a contraindication to left ventricular ablation. Mechanical prosthetic heart valves are generally not crossed with ablation catheters.
Procedural Considerations
Preprocedural considerations
The preprocedural evaluation always includes a thorough history and physical examination, review of ECG findings of the tachycardia (12 leads if available), and ECGs performed in sinus rhythm.
At a minimum, preprocedure laboratory work typically includes a complete blood cell count and an assessment of renal function and electrolyte levels.
An echocardiogram is frequently obtained to exclude structural heart disease. Other tests that are indicated in specific situations include exercise testing with or without cardiac imaging (especially for exercise-induced tachyarrhythmias), and cardiac catheterization.
The patient should report for the procedure after overnight fasting. Cardiac medications with electrophysiologic effects, such as beta-blockers, calcium channel blockers, digoxin, and class I and III antiarrhythmic drugs, are often tapered and/or discontinued prior to the procedure. Warfarin is typically discontinued for at least a few doses prior to the procedure.
Reproductive-aged women should not be exposed to fluoroscopy if any possibility exists that they are pregnant.
Intraprocedural considerations
The procedure is typically performed under conscious sedation with intravenous tranquilizers and narcotics. General anesthesia is used in children and selected adults.
Typically, 2-5 electrode catheters are percutaneously inserted via the femoral or internal jugular veins and are positioned within the left heart, right heart, or both. Multiple catheters are needed to induce and map various tachyarrhythmias prior to catheter ablation. Cannulation of the coronary sinus is helpful to exclude left-sided accessory pathways or other left-sided tachyarrhythmia substrates. For left heart catheterization, 1 of 2 approaches may be taken, ie, (1) transseptal catheterization via the interatrial septum or (2) retrograde catheterization across the aortic valve. Anticoagulation with intravenous heparin is used to reduce the risk of periprocedural thromboembolism.
Postprocedural considerations
Some physicians empirically treat patients with 4-12 weeks of aspirin therapy to possibly reduce the risk of thromboembolic sequelae.
Echocardiography is not routinely performed unless a complication may have occurred (eg, pericardial effusion). Postprocedure electrophysiologic testing is not performed routinely unless recurrent tachyarrhythmias are suspected.
Complications
Radiation risk in catheter ablation is low, but it may exceed the risk from common radiologic procedures. The average risk for genetic defects has been computed at 1 case per million births. The average risk for fatal malignancies ranges from 0.3-2.3 deaths per 1000 cases for every 60 minutes of fluoroscopy. Many ablation procedures require less than 60 minutes of fluoroscopy.
Major complications occur in approximately 3% of patients who have ablation procedures, including thromboembolism in less than 1% (higher in some atrial fibrillation ablation series) and death in less than 0.3%. The list below is noninclusive but includes the most reported complications, most of which are rare or uncommon.
- Death (0.1-0.2% of all procedures)
- Cardiac complications (incidence varies based on site and type of ablation)
- High-grade AV block
- Cardiac tamponade (highest in atrial fibrillation ablation, up to 6%)
- Coronary artery spasm/thrombosis
- Pericarditis
- Valve trauma
- Vascular complications (~2-4%)
- Retroperitoneal bleeding
- Hematoma
- Vascular Injury
- Transient ischemic attack/stroke
- Hypotension
- Thromboembolism or air embolism
- Pulmonary complications
- Pulmonary hypertension with and without hemoptysis (secondary to pulmonary vein stenosis)
- Pneumothorax
- Miscellaneous
- Left atrial-esophageal fistula
- Acute pyloric spasm/gastric hypomotility
- Phrenic nerve paralysis
- Radiation or electrically induced skin damage
- Infection at access site
- Inappropriate sinus tachycardia
- Proarrhythmia
Outcomes
Supraventricular tachyarrhythmias
The common forms of supraventricular tachycardia (SVT) (eg, atrioventricular nodal reentrant tachycardia [AVNRT], SVT associated with Wolff-Parkinson-White syndrome) are usually curable with a single procedure; the success rate is typically 90-95%. Cure rates for unifocal atrial tachycardia and common right atrial flutter are somewhat lower but still approach 90%. Recurrent tachyarrhythmias typically occur in the first few months after ablation and may be amenable to cure with a second procedure.
AVNRT is usually amenable to cure with a slow pathway ablation near the inferior atrial septum, where the risk of heart block is 1-2%. In the uncommon circumstances in which ablation near the compact AV node is required (eg, fast pathway for AVNRT, or an accessory pathway in a para-Hisian location), the risk of heart block may approach 5% or a little higher.
In a number of centers, catheter-based cryoablation is used rather than radiofrequency catheter ablation (RFCA) near the compact AV node to minimize the risk of heart block. With cryoablation, heart block is generally reversible with prompt rewarming. However, cryoablation appears to be a little less effective than radiofrequency as an energy source, especially for deep accessory pathways.
Success rates for curing atrial fibrillation with RFCA are highest (up to 87% in the 5 randomized trials reported through 2006) for paroxysmal atrial fibrillation in the absence of structural heart disease and lowest (50% or less) with persistent atrial fibrillation in the presence of structural heart disease and left atrial enlargement. Repeat procedures are typically needed in 25% or more of patients. Success rates have historically been based on patient symptoms and periodic electrocardiographic monitoring. Success rates are lower if intensive ambulatory monitoring to detect asymptomatic atrial fibrillation recurrences is used, such as daily monitoring for a month with an auto-triggering event monitor. Some patients require the use of previously ineffective antiarrhythmic drugs to maintain success.
Ventricular tachyarrhythmias
Idiopathic ventricular tachycardia (VT) is curable (success rate approximately 80%), assuming it is readily inducible during electrophysiology studies. The most common location for these VTs is the right ventricular outflow tract. Because these VTs are usually not reentrant in nature, a significant percentage are not inducible. Some cannot be ablated because of their deep septal or epicardial location. Some left ventricular VTs originate near a coronary cusp, which may preclude a successful ablation because of concern regarding coronary artery damage.
Approximately half the cases of VTs associated with structural heart disease can be palliated by catheter ablation. Extensive scarring in these ventricles may limit the efficacy of the relatively small lesions made by RFCA, and multiple VT circuits may also contribute to this moderate success rate. Some form of 3-dimensional mapping is helpful for these complex ablations. In practice, many of these patients have ICDs, and catheter ablation is used as adjunctive therapy for frequent device activations.
Future Advances
A curative procedure for atrial fibrillation is a major goal in clinical cardiac electrophysiology. Success has been achieved in patients with paroxysmal lone atrial fibrillation by eliminating conduction from the pulmonary veins to the left atrium, as many of these episodes begin in the pulmonary veins. Other forms of atrial fibrillation may require some degree of substrate ablation (eg, linear transmural lesions in the left atrium).
Techniques are still evolving to address the challenge of a catheter-based cure for all forms of atrial fibrillation. Three-dimensional electroanatomic mapping systems, overlayed on MRI or CT images of the left atrium, can facilitate navigation of the ablation catheter, mapping of ectopic foci and atrial scars, and the assessment of the transmurality of ablation lines. Intracardiac echocardiography may also be helpful to avoid collateral damage to the pulmonary veins or esophagus, ensure adequate endocardial contact, and to avoid complications from thrombus development. Alternative energy sources are being investigated in the ablation of atrial fibrillation (eg, balloon-based technologies using cryoablation, ultrasound, and laser). In addition, robotic catheter navigation is now available to deliver radiofrequency catheter ablation (RFCA).
Research is also focused on developing better methods and tools for catheter ablation of ventricular tachycardia (VT), and even ventricular fibrillation (VF), in patients with structural heart disease. Epicardial electrophysiology via subxiphoid pericardial puncture is a relatively new frontier, as some tachyarrhythmia substrates (especially VT in nonischemic cardiomyopathy) cannot be reached from the endocardium.
Multimedia
 | Media file 1: Diagrammatic schema of the typical type of atrioventricular nodal reentrant tachycardia (AVNRT). The slow pathway (dashed arrow) is the usual antegrade limb of the reentry circuit and the usual ablation target area (shaded). The fast pathway (solid arrow) is the usual retrograde limb of the reentry circuit and commonly activates the atria simultaneously with ventricular activation, producing the typical ECG finding of AVNRT shown below. The P wave is not visible because it is buried in the QRS complex. Infrequently, the reentry circuit is reversed, with antegrade conduction over the fast pathway and retrograde conduction over the slow pathway, producing the atypical ECG finding of AVNRT shown below (ie, long R-P tachycardia, in which the interval between the QRS complex and retrograde P wave is longer than the subsequent P-R interval, and the P wave is in the second half of the R-R interval). The fast pathway is close to the compact atrioventricular node, and ablation in this area is avoided if possible because of the risk of iatrogenic heart block. |
 | Media file 2: The pseudo S waves inferiorly (compare this to the sinus rhythm ECG in Image 3) are retrograde P waves. This short interval between the QRS complex and the retrograde P wave is highly specific for atrioventricular nodal reentrant tachycardia (AVNRT). A pseudo R wave in V1 may also be observed, but this is not shown here. In many instances, the retrograde P wave occurs during QRS activation and is not observed; this "no-P-wave" tachycardia (see Media file 1) also suggests AVNRT. |
 | Media file 3: Sinus rhythm in a patient with atrioventricular nodal reentrant tachycardia. |
 | Media file 4: Schema of orthodromic reciprocating tachycardia (ORT). The atrioventricular node serves as the antegrade limb, whereas an accessory pathway (atrioventricular connection) serves as the retrograde limb. For ECG features of ORT, see Media file 5. |
 | Media file 5: Supraventricular tachycardia (SVT) in a patient with orthodromic reciprocating tachycardia (ORT) due to a concealed pathway. Note the retrograde P wave, seen best in lead V2, separated from the QRS complex by an isoelectric baseline. (Compare to Media file 2, in which the P wave is fused to the QRS.) This pattern of "short R-P tachycardia" (in which the interval between the QRS complex and retrograde P wave is shorter than the subsequent P-R interval and the P wave is in the first half of the R-R interval) suggests an SVT incorporating an accessory pathway. |
 | Media file 6: Schema of the common variety of atrial flutter. The reentry circuit is confined to the right atrium and circulates as a counterclockwise macroreentrant circuit proceeding superiorly over the atrial septum and inferiorly over the lateral atrial wall. The wave front circulates through a narrow isthmus of tissue between the tricuspid valve annulus and the inferior vena cava. Linear ablation across this isthmus cures this common form of atrial flutter. For ECG features, see Media file 7. |
 | Media file 7: An example of a typical counterclockwise atrial flutter, the most common form of atrial flutter. The cardinal features are a perfectly regular atrial rhythm with inverted P waves inferiorly that have a positive overshoot, upright P waves in V1, and inverted P waves in V6. |
 | Media file 8: Electroanatomic map of the posterior left atrium, illustrating the pulmonary veins: right superior pulmonary vein (RSPV), right inferior pulmonary vein (RIPV), left superior pulmonary vein (LSPV), and left inferior pulmonary vein (LIPV). The red circles represent actual discrete radiofrequency applications, predominantly delivered in a circumferential pattern around the pulmonary veins. This ablation strategy can isolate pulmonary vein foci that initiate atrial fibrillation, and/or alter the substrate of the left atrium to inhibit fibrillatory activity due to reentry. Image courtesy of American College of Cardiology Foundation. |
Keywords
RFCA, radiofrequency ablation, catheter ablation, tachyarrhythmias, tachycardias, supraventricular tachycardia, SVT, orthodromic reciprocating tachycardia, ORT, unifocal atrial tachycardia, ventricular tachycardia, VT, Wolff-Parkinson-White syndrome, WPW syndrome, atrial flutter, atrial fibrillation, atrioventricular nodal reentrant tachycardia, AVNRT, polymorphic ventricular tachycardia, ventricular fibrillation, paroxysmal atrial fibrillation, idiopathic ventricular tachycardia
More on Catheter Ablation |
| References |
References
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Further Reading
Keywords
RFCA, radiofrequency ablation, catheter ablation, tachyarrhythmias, tachycardias, supraventricular tachycardia, SVT, orthodromic reciprocating tachycardia, ORT, unifocal atrial tachycardia, ventricular tachycardia, VT, Wolff-Parkinson-White syndrome, WPW syndrome, atrial flutter, atrial fibrillation, atrioventricular nodal reentrant tachycardia, AVNRT, polymorphic ventricular tachycardia, ventricular fibrillation, paroxysmal atrial fibrillation, idiopathic ventricular tachycardia
