2248

AHA Medical/Scientific Statement

Special Report

Guidelines for Pediatric Therapeutic

Cardiac Catheterization
A Statement for Health Professionals From the Committee on
Congenital Cardiac Defects of the Council on Cardiovascular
Disease in the Young, the American Heart Association
Hugh D. Allen, MD, Chairman; David J. Driscoll, MD;
F. Jay Fricker, MD; Paul Herndon, MD; Charles E. Mullins, MD;
A. Rebecca Snider, MD, Members; Kathryn A. Taubert, PhD, AHA Staff
D uring the last few years, pediatric cardiologists
have witnessed a dramatic change in the
utilization of the cardiac catheterization laboratory.1-21 Improved noninvasive diagnostic techniques have narrowed indications for diagnostic cardiac
catheterizations while the laboratory is now increasingly being used for therapeutic procedures. Recently,
numerous catheter techniques, increased numbers of
persons and centers using these techniques, and the
increased number of lesion types thought to be amenable to catheter therapy have caused concern about the
appropriateness of some applications of pediatric therapeutic cardiac catheterization.
Compared with diagnostic cardiac catheterization,
therapeutic catheter procedures require more time
and resources, are costlier and riskier, and demand
more technical training and expertise. High levels of
skill and expertise are required of the operator who
performs the various therapeutic catheterization
techniques. These procedures should only be performed in institutions with appropriate facilities,
personnel, and programs.22 These considerations,
combined with the rapid increase in the number of
laboratories and cardiologists performing therapeutic catheterization procedures, cause concerns about
hospital and physician credentialing, hospital and
physician peer review, and human subjects investigational review. These concerns have prompted this
report on the current status of pediatric therapeutic
cardiac catheterization and its important new techniques as well as the development of guidelines for
specific credentialing and review.
"Guidelines for Pediatric Therapeutic Cardiac Catheterization"
was approved by the American Heart Association Steering Committee on May 16, 1991.
Requests for reprints should be sent to the Office of Scientific
Affairs, American Heart Association, 7272 Greenville Avenue,
Dallas, TX 75231.

Personnel Requirements
Performance of therapeutic catheterizations requires training, expertise, and experience, but therapeutic catheterization training programs vary in type,
extent, and quality. Because of the complexity and
potential risks of these procedures, specific credentialing criteria should be developed for those who
wish to perform, and for those who continue to
perform, each of these procedures.
Cardiologists who are trained in internal medicine
and who intend to perform percutaneous coronary
balloon dilation procedures are required to obtain an
extra (fourth) year of fellowship training in a program active in angioplasty. Minimum standards have
been set.23 Quality assurance review is expected to
demonstrate that complications are not excessive.
The physician is expected to maintain current knowledge by reading the literature and attending angioplasty postgraduate courses. However, attending
"how-to" seminars and observing experts does not
obviate the need for personal experience. The report
of an American College of Cardiology/American
Heart Association task force24 states that "in the
present climate it should be clear that not every
cardiologist desiring to perform angioplasty should
perform the procedure. Similarly, not every institution anxious to offer the procedure as part of its
health care program can be allowed to do so." The
emphasis of this report is on formal credentialing and
documentation of training, competence, and ongoing
maintenance of skills.
The pediatric cardiologist who intends to perform
therapeutic catheterization procedures should meet
training requirements similar to those discussed
above. Pediatric cardiology fellows should receive
therapeutic catheterization training in one or more
centers that carry out angioplasties, valvuloplasties,

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AHA Scientific Council Guidelines for Pediatric Therapeutic Cardiac Catheterization

vascular occlusion procedures, and/or interventional
electrophysiologic procedures. Before performing a
therapeutic catheterization as the primary operator,
the fellow or practicing pediatric cardiologist is required to receive procedure-specific training under
the supervision of a qualified individual. Credentialing should be procedure specific. To maintain his or
her credentials, the cardiologist must perform or
supervise an adequate number of cases annually to
maintain skills, and results must compare favorably
with national experiences. The cardiologist must be
aware of new trends and information through reading and attendance at meetings.
The facility, hospital, quality assurance programs,
and laboratory personnel associated with the pediatric therapeutic catheterization program must meet
applicable national standards of the American College of Cardiology/American Heart Association ad
hoc task force on cardiac catheterization.22

Facilities and Equipment

A catheterization laboratory in which therapeutic
catheterization procedures are performed should be
used regularly for all types of congenital cardiac
catheterization procedures. The radiographic equipment must be of the highest quality and be capable of
producing high resolution images. This equipment
must be constantly serviced and regularly replaced or
upgraded to maintain the high quality of imaging.
Tube angulation systems are necessary. Biplane fluoroscopy/cineangiography should be available in any
laboratory in which pediatric and congenital cardiac
catheterizations are performed. A large and complete inventory of specific equipment is needed. A
variety and complete stock of emergency devices such
as retrieval catheters is also required.
The institution in which the catheterization laboratory exists must be committed to therapeutic procedures and support of the laboratory requirements,
and there must be a cardiovascular surgical service at
that institution for immediate treatment of emergencies that may occur during therapeutic catheterization procedures. To maintain proficiency in techniques and to justify the cost of equipment, personnel
should regularly and frequently perform the specialized therapeutic procedures.
A sterile operating room environment must be
maintained for many of the procedures. The sites of
implanted devices are exceptionally susceptible to
infection.

Specific Procedures
The various therapeutic catheterization procedures are discussed in the following sections. Specific
cardiac conditions are designated Classes I, II, or III
for each procedure. Class I conditions are those for
which the procedure is usually appropriate, Class II
conditions are those for which the procedure may be
indicated, and Class III conditions are those for
which the procedure is usually thought at present to
be inappropriate.

2249

Balloon Atrial Septostomy

Balloon septostomy was introduced in 1964 as a
lifesaving procedure for infants with cyanosis due to
transposition of the great vessels.2 This technique creates an atrial septal defect and allows bidirectional
mixing of systemic and pulmonary venous blood at the
atrial level in patients with transposition of the great
arteries. The use of the technique has been extended to
young infants with conditions in which relatively unobstructed interatrial communication is advantageous.
The effectiveness of the balloon septostomy procedure
in infants less than 1 month old has been well documented.2 All trained and qualified pediatric cardiologists participating in the care of infants in the catheterization laboratory should be qualified to perform
balloon atrial septostomy.

Indications for Balloon Atrial Septostomy

Class I: Conditions in which balloon atrial septostomy is usually agreed to be appropriate: Infants
less than 4-6 weeks old with
1. Transposition of the great vessels, with or without associated cardiac anomalies
2. Total anomalous pulmonary venous connection
with restrictive atrial septal defect (balloon atrial
septostomy performed, if necessary, prior to surgery)
Class II: Conditions in which balloon atrial septostomy may be indicated
1. Mitral valve atresia
2. Pulmonary valve atresia with hypoplastic right
ventricle
3. Tricuspid valve atresia
Class III: Conditions in which balloon atrial septostomy alone is probably inappropriate
1. Interruption of inferior vena cava
2. Infants more than 6-8 weeks of age in whom
atrial septal thickness will not allow effective balloon septostomy
Blade/Balloon Atrial Septostomy
The blade atrial septostomy was developed to supplement the balloon atrial septostomy in patients in
whom the septum was too thick to be torn by balloon
septostomy alone.4 The indications for blade atrial
septostomy are virtually the same as those for balloon
atrial septostomy.25 Blade septostomy catheters are
available in three sizes for use in different-sized patients. A blade catheter is used to make several cuts at
different angles in the atrial septum before tearing it
further with a balloon catheter. Blade atrial septostomy
is seldom used as an acute emergency procedure. It can
be performed in patients of any age in whom the
septum is too thick for effective balloon atrial septostomy. Atrial septostomy is preferable to surgical
septostomy whenever possible.26
Indications for Blade/Balloon Atrial Septostomy
Class I: Conditions in which blade/balloon septostomy
is generally agreed to be appropriate: Patients usually
more than 4-6 weeks old with

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1. Transposition of the great vessels with or without associated cardiac anomalies

2. Pulmonary atresia with hypoplastic right ventricle
3. Tricuspid valve atresia
4. Total anomalous pulmonary venous connection
with restrictive atrial septal defect (blade/balloon
atrial septostomy performed, if necessary, prior to
surgery)
Class II: Conditions in which blade/balloon atrial
septostomy may be appropriate
1. Pulmonary vascular disease with intact ventricular septum and right ventricular decompensation
2. Mitral valve atresia
Class III: Conditions in which blade/balloon atrial
septostomy appears to be inappropriate or impossible
1. Interruption of inferior vena cava
Balloon Dilation of Cardiac Valves
Pulmonary Valve Stenosis
Since Semb and colleagues' initial description of
balloon valvulotomy in 19796 and Kan and coworkers'
description of balloon valvuloplasty in 1982,7 numerous investigators27-31 have reported successful initial
and midterm results of balloon dilation of stenotic
pulmonary valves. Percutaneous balloon dilation effectively reduces right ventricular systolic pressure
and transpulmonary gradients in most patients. Pulmonary regurgitation may occur in some patients
after balloon dilation, but it is usually mild and
inconsequential as an isolated lesion.32
Balloon dilation is the treatment of choice for pulmonary valve stenosis. Based on several reports of the
long-term results of surgical pulmonary valvotomy, the
indications for pulmonary valve balloon dilation should
be the same as those for surgical pulmonary valvotomy.
Specifically, these include a transpulmonary gradient of
more than 50 mm Hg for a patient with normal cardiac
output or, especially in neonates, the presence of
critical pulmonary stenosis, for which the transpulmonary gradient may be less than 50 mm Hg. Less stringent gradient criteria are appropriate in certain circumstances because of the lower morbidity and mortality of
the dilation technique.
The use of balloon valvuloplasty for the patient
with a severely dysplastic pulmonary valve has been
questioned. Nonetheless, many pediatric cardiologists will attempt balloon dilation of these valves,
recognizing that the result may be suboptimal.1213
Balloon dilation is not useful for treatment of infundibular pulmonary stenosis unassociated with pulmonary valve stenosis.

Aortic Valve Stenosis

Since the initial description by Lababidi et a133 of
balloon dilation of the aortic valve in children, several investigators have reported short-term and midterm results of balloon aortic valvuloplasty.34-41 The
transaortic pressure gradient and the left ventricular
peak systolic pressure can usually be reduced with

balloon valvuloplasty, and the improvement appears

to persist. In patients beyond infancy, the mortality
associated with balloon dilation is similar to that
associated with operation. As with surgical valvotomy, production of or worsening of aortic regurgitation can result from balloon dilation; whether the
prevalence of aortic regurgitation is greater or less
after balloon dilation than after surgical valvotomy is
unclear. Iliofemoral artery injury and occlusion can
occur after balloon dilation, especially in infants. The
frequency and long-term consequences of this complication are unknown. Because of these uncertainties, continued evaluation of the safety and long-term
efficacy of balloon dilation in cases of aortic valve
stenosis is necessary.
Fewer data about balloon dilation of subaortic
stenoses are available. Some evaluation of discrete
membranous subaortic stenosis is ongoing, and this
condition is currently designated as Class II. Fibromuscular subaortic stenosis and supravalvular aortic stenosis are not currently amenable to balloon
dilation. Therefore, these anomalies are in Class III
until further research demonstrates the need to
change classification.

Mitral Valve Stenosis

Investigators have reported successful reduction of
transmitral gradients with balloon dilation.'0,11,42-44
Experience with rheumatic mitral valve stenosis has
been more successful than that with dilation of congenitally stenotic mitral valves. Complications have included perforation of the left ventricle, transient complete atrioventricular (AV) block, tearing of the
anterior leaflet of the mitral valve, and severe mitral
regurgitation. Passage of the balloon catheter across
the atrial septum may necessitate dilation of a patent
foramen ovale or dilation of a transseptal needle puncture of the atrial septum. This can result in the production of a clinically significant residual atrial septal
defect. The risk of atrial septal defect is lessened with
use of a dual catheter technique.42-44 The intermediate
and long-term results of balloon dilation of the mitral
valve are unavailable, but the efficacy of this technique
for treatment of a congenital mitral valve stenosis is
being evaluated. Balloon dilation valvuloplasty is an
acceptable alternative to surgical treatment for rheumatic mitral valve stenosis. The procedure is very
technically demanding and requires a very high level of
technical expertise and experience.
Stenosis of Prosthetic Conduits and
Valves Within Conduits
Using balloon dilation, several investigators45,46
have successfully reduced the transconduit gradient
across stenotic areas of prosthetic conduits and
across valves contained within conduits. The success
of this procedure depends on the etiology of the
obstruction. Complications of this procedure can
include dislodgement of an intimal peel, embolization of valvar calcific deposits, and balloon rupture
with embolization of foreign material.

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AlA Scientific Council Guidelines for Pediatric Therapeutic Cardiac Catheterization

Indications for Balloon Dilation of Cardiac Valves

Class I: Conditions for which balloon dilation is
generally agreed to be appropriate
1. Pulmonary valve stenosis
2. Rheumatic mitral stenosis*
Class II: Conditions for which balloon dilation may
be indicated
1. Pulmonary valve stenosis associated with a dysplastic pulmonary valve
2. Congenital (noncalcific) aortic valve stenosis
3. Congenital mitral stenosis*
4. Stenosis of prosthetic conduits and valves within
conduits
5. Discrete membranous subaortic stenosis
Class III: Conditions for which balloon dilation is
probably inappropriate
1. Infundibular pulmonary stenosis unassociated
with pulmonary valve stenosis
2. Fibromuscular subaortic stenosis
3. Hypertrophic cardiomyopathy with subaortic
obstruction
4. Supravalvular aortic stenosis
Balloon Angioplasty
Balloon Dilation -of Coarctation of the Aorta
Surgery has been the standard therapy for coarctation of the aorta, but the operation is associated
with a certain risk of morbidity and mortality. The
feasibility of coarctation angioplasty was first demonstrated by Sos et a147 in 1979 when they showed that
excised segments of coarctation of the aorta could be
dilated. The technique was brought to the clinical
arena by Lock and others.8,16,48-53
The indications for balloon dilation of the aorta
are essentially the same as those for operation:
evidence of systemic hypertension in the upper extremity, a resting systolic pressure gradient across the
coarcted segment of more than 20 mm Hg, or an
angiographically severe coarctation with extensive
collaterals. The mechanism of improvement by balloon dilation is through vascular injury resulting from
intimal and medial tear. The controversy about balloon dilation of the coarctation relates both to the
risk of aneurysm formation following angioplasty and
to whether angioplasty should be performed only on
restenosed coarctation or on both restenosed and
native coarctation.
Native Coarctation
Data on balloon angioplasty of native coarctation
of the aorta are accumulating.8,50,54-60 Balloon dilation has been effective in patients from 3 days to 29
years of age. The pressure gradient across the
coarctation site can be significantly decreased with
an angiographically apparent increase in the diameter of the coarctation segment, and the systolic
pressure gradient across the coarctation segment
*Procedure requires high degree of operator skill.

2251

can be reduced to less than 10 mm Hg in about 50%

of patients. A complication rate of 17% was reported in this group of patients.56 Most complications are related to arterial injury in the smaller
patient. Aneurysms, both acute and late, have been
reported in approximately 6% of these children.56
Although effective palliation with balloon angioplasty can be accomplished in most patients, the
risk of aortic aneurysm formation suggests that
surgery may remain the best recommendation for
patients with native coarctation. Further evaluation
of the safety and efficacy of most balloon dilation
angioplasties for native coarctation is necessary.

Recoarctation of the Aorta

A number of patients, especially infants, who have
had surgical repair of coarctation of the aorta develop
persistent or recurrent obstruction at the repair
site.61-69 Reoperation may carry a significant risk of
morbidity and mortality.61,70-73 In a large multicenter
study of 200 patients with recoarctation,74 an effective
reduction in pressure gradient across the coarctation
segment was demonstrated in those who had balloon
angioplasty. The multicenter study demonstrated relief
of residual or recurrent coarctation in approximately
78% of patients undergoing the procedure. Five patients (2.5%) died; three deaths were associated with
the underlying condition of the patient, and two were
related to the procedure itself. Complications of this
procedure occurred in 25% of patients and included
artery damage and occlusion (8.5%), postcoartectomy
syndrome (2%), neurological events (1.5%), and intimal dissection (1.5%). However, when the five deaths
were considered separately, and when balloon rupture
was not included as a complication, the complication
rate was 13.5%. Late aneurysm development has been
reported in only three patients.75 Based on this study,
balloon angioplasty offers a preferable alternative to
surgery for treatment of residual or recurrent coarctation of the aorta.
Branch Pulmonary Artery Stenosis
Hypoplastic and stenotic branch pulmonary arteries may be associated with a variety of cardiac
malformations. Many of these are present in postoperative patients. Intracardiac operation results are
adversely affected by unrelieved branch pulmonary
artery stenosis. The acute success rate for pulmonary
artery branch dilation is 60%, as judged by an
increase of at least 50% of the predilation diameter
of the pulmonary artery or a 20% decrease in the
systolic right ventricular: aortic pressure ratio.76,77
The morbidity associated with this procedure relates
to technical difficulty, vascular rupture, unilateral
pulmonary edema, hemoptysis, and thrombosis. Mortality, although low, has been associated with this
procedure and relates to pulmonary artery rupture.78
Aneurysm formation is estimated to occur in approximately 3% of patients. Because an operative treatment of branch pulmonary artery stenosis is often not

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Circulation Vol 84, No 5 November 1991

possible, attempting balloon angioplasty for branch

pulmonary arteries is justified.
Long-term results of this procedure are not yet
available, although sporadic reports of significant
restenosis raise concern about the long-term patency
of some vessels. A modification of the technique,
using an intravascular stent, may be necessary for
interventional balloon dilation to be successful in
some patients with this lesion. Studies are being
conducted to address this possibility.
Systemic Venous and Pulmonary Venous Stenosis
Scattered reports of attempts to dilate systemic
venous obstruction after a Mustard or Senning procedure indicate that the procedure has been generally quite successful, with little morbidity.79 Operation for these residual lesions is technically difficult
and associated with high morbidity and some mortality. Balloon dilation of these lesions is thus recommended as a preferred alternative to operation. In
contrast to the success with postoperative systemic
venous obstruction, the limited experience with balloon dilation for pulmonary vein stenosis has shown
reoccurrence of the stenosis in each instance.

Systemic-to-Pulmonary Artery Shunts

Successful dilation of systemic-to-pulmonary artery shunts has been reported.80,81 The success rate
may be better in patients with tissue anastomoses,
such as standard Blalock-Taussig shunts, than in
those without tissue-to-tissue anastomoses. Even
modified Blalock-Taussig Goretex shunts with discrete stenosis at the anastomotic site can occasionally be successfully dilated. Backup surgical support
must be available when tubular prosthetic shunts
are dilated because of the danger of dislodging
prosthetic intimal linings. Dilation of systemic-topulmonary artery shunts is reasonable and should
be attempted before repetition of a surgical shunting procedure is considered.

Indications for Balloon Angioplasty

Class I: Conditions for which balloon angioplasty is
generally agreed to be appropriate
1. Recoarctation of the aorta
2. Systemic vein stenosis
Class II: Conditions for which balloon angioplasty
may be indicated
1. Pulmonary artery stenosis
2. Native coarctation
3. Blalock-Taussig shunts
Class III: Conditions for which balloon angioplasty
is probably inappropriate
1. Pulmonary vein stenosis (so far, universally
unsuccessful)

Implantation of Devices
Implantable devices are predominantly used for
occlusion (coils, miniballoons, or umbrellas) or for
maintaining the patency of vessels or previously

stenotic areas that have been dilated (stents). Implanting these devices is more difficult and requires
greater skill and better equipment than other therapeutic catheterization procedures. The components
of the implantable devices are small, hard to see, and
require more precise positioning with the aid of
fewer fixed landmarks than those of other procedures. This is especially so in patients with secundum
atrial septal defects, in whom simultaneous transesophageal echocardiography is required for implantation of atrial septal occlusion devices. Failure results from incorrect placement or migration of the
device from the implant site, which then may even
occlude a vital structure. This complication may
require catheter retrieval or emergency operation.
The implant procedures are best performed by two
trained physicians or a physician and a specially
trained nurse/technician who regularly work as a
team. The other laboratory technicians/nurses should
be very familiar with the implant procedures and
should perform them regularly enough to maintain
their proficiency.

Indications for Transcatheter Implantation *

Class I: Conditions for which transcatheter implantation is generally agreed to be appropriate
1. Coil, balloon, or umbrella occlusion of undesirable vascular structure
2. Patent ductus arteriosus umbrella closure
Class II: Conditions for which transcatheter implantation may be appropriate
1. Secundum atrial septal defect
2. Ventricular septal defect remote from cardiac
valves
3. Postsurgical baffle defects
4. Stents for vascular patency
5. Patent foramen ovale in thromboembolic cerebrovascular accident with no proven source of embolus
Class III: Conditions for which transcatheter implantation is probably inappropriate
1. Ostium primum atrial septal defect
2. Sinus venosus atrial septal defect
3. Ventricular septal defect close to valves
4. Defects too large to accept device

Foreign Body Retrieval

Nonsurgical removal of foreign bodies from the
heart or peripheral vessels has become a frequent
function of therapeutic cardiac catheterization.82 Foreign bodies successfully retrieved using catheterization techniques include dislodged indwelling catheters, ventriculojugular shunts, pacemaker electrodes,
and catheter-delivered therapeutic devices.83-86 Full
nonoperative retrieval of an intracardiac foreign body
has been performed successfully in small preterm and
term infants.87,88
A variety of catheter devices are available for the
nonoperative removal of a foreign body during cardiac
*Procedure requires high degree of operator skill.

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AlA Scientific Council Guidelines for Pediatric Therapeutic Cardiac Catheterization

catheterization. Four commonly used devices include
the spring guide wire snare or loop, the Cotter type
basket, the forceps grabber with three or four grasping
prongs, and the bioptome forceps.82'89'90 These devices
can be placed into the circulation from most vascular
approaches.91,92
Foreign body retrieval is an accepted therapeutic
catheterization procedure. This procedure should be
performed by a pediatric cardiologist skilled in the
techniques of complex intracardiac catheter manipulations and the use of biplane fluoroscopy.82 Most
foreign bodies in the circulation can be removed by a
catheter technique, but catheter retrieval of expanded intravascular stents or umbrellas embedded
within AV valves is not possible.

Indications for Foreign Body Retrieval

Class I: Conditions for which foreign body retrieval
is generally agreed to be appropriate
1. Dislodged indwelling catheters
2. Dislodged ventriculojugular shunts
3. Dislodged pacemaker electrodes
4. Dislodged catheter-delivered therapeutic devices
5. Intracardiac foreign body in small preterm and
term infants
Class II: Conditions for which foreign body retrieval
may be indicated
1. Nonfunctional transvenous pacemaker leads
Class III: Conditions for which foreign body retrieval is probably inappropriate
1. Expanded intravascular stents
2. Umbrellas imbedded in cardiac valves
Electrophysiologic Applications of
Catheter Ablation
The success of surgery to abolish or modify
tachycardia depends on intraoperative identification of the cardiac tissue responsible for the maintenance of tachycardia and on the success and
safety with which that tissue can be ablated or
modified by operation.93 96 Similar requirements
exist for the performance of electrode catheter
ablative techniques (direct current transcatheter
ablation97) and for that of other forms of catheter
treatment such as radiofrequency energy ablation,98-105 chemical ablation,106 and laser photocoagulation.107 Whichever form of ablation is considered, detailed electrophysiologic evaluation must
be performed to define the origin of the tachycardia
and the integral parts of the tachycardia circuit. All
treatment options, including pharmacological and
surgical, should be considered. Although direct
current catheter ablation as a treatment for tachycardia has been reported since the early 1980s,97"108
knowledge of its efficacy, safety, and long-term
results is limited, particularly in young patients. In
addition, the spectrum of structural cardiac diseases that may be associated with tachycardias is
much more varied in children than in adults. Therefore, pediatric catheter ablation procedures should

2253

only be performed in centers with active clinical and

surgical pediatric electrophysiology programs.
Availability of facilities for intraoperative mapping
and standard operative treatment of tachycardias is
essential. As more experience is gained in these
catheter ablation procedures, they are becoming
treatment options for young patients with tachycardias. Most published studies of catheter treatment
of tachycardia have, to date, used direct current
ablation techniques. Radiofrequency catheter ablation may have similar indications and in certain
situations may be safer. Recent preliminary studies
provide information about its short-term efficacy
and safety,109-112 but long-term results of radiofrequency catheter ablation for different types of
tachycardias are presently unknown.
Catheter Ablation of the Atrioventricular Junction
Catheter ablation of the AV junction is an appropriate treatment for patients with primary atrial
tachycardias (e.g., atrial flutter, atrial fibrillation,
multifocal atrial tachycardia, and automatic atrial
tachycardia) only after medical treatment is ineffective or has not been possible. The procedure results
in complete AV block. The purpose of this procedure
is to control the ventricular rate but requires implantation of a permanent pacemaker.97113"114 Results of
direct current catheter ablation of the AV junction
suggest that this procedure is 90% effective in producing AV block but may be associated with a small,
late risk of sudden death.97 Experience with radiofrequency catheter ablation of the AV node is limited; some reports suggest that this procedure has a
lower success rate (65%) than direct current catheter
ablation,98 but refinements in this technique may
improve results.99
Catheter ablation may be indicated in patients with
His bundle automatic tachycardia in whom medication fails to control the tachycardia or in patients in
whom medication results in undesirable side effects.
A recent case report indicates that radiofrequency
ablation can also be used.115 Catheter ablation of the
AV junction may be indicated in some patients with
severe ventricular dysfunction when the AV node is
part of the tachycardia circuit (i.e., when surgical
treatment is too risky).
For most patients with an AV reciprocating tachycardia, direct current catheter ablation of the AV
junction is not indicated, because the accessory pathway can be eliminated directly with the radiofrequency
ablation technique12 or surgery.93-95 In patients with
ventricular preexcitation (Wolff-Parkinson-White syndrome), creation of AV block prevents orthodromic
reciprocating tachycardia but does not diminish the risk
of sudden death from a rapid ventricular response from
the accessory AV connection if atrial fibrillation occurs.
Catheter Ablation of Ventricular Tachycardia
Catheter ablation of the right bundle branch in
adult patients has been used in the treatment of
macrobundle (bundle branch) reentry tachycardia, a

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Circulation Vol 84, No 5 November 1991

specific type of ventricular tachycardia that involves

the specialized conduction system.116117 Catheter ablation may also be indicated for patients with symptomatic monomorphic ventricular tachycardia that
can be mapped during electrophysiologic study if
antiarrhythmic drugs are ineffective or not tolerated.
In certain rare cases in which an asymptomatic
patient is thought to be at high risk for sudden death
(e.g., inoperable postoperative tetralogy of Fallot),
catheter ablation may be indicated.
Catheter ablation is not indicated for most patients
with ventricular tachycardia controlled by antiarrhythmic drugs, patients who require surgical treatment of a structural cardiac abnormality, patients
with ventricular extrasystoles or polymorphic ventricular tachycardia, or patients in whom ventricular
mapping during tachycardia cannot be performed.

Catheter Ablation of Accessory

Atrioventricular Connections
In the early 1980s, attempts to abolish conduction
through an accessory AV connection using direct
current catheter ablation were reported.118 Although
posteroseptal accessory AV connections seem to be
the most amenable to direct current catheter ablation,119-121 the success rate for this procedure is
approximately 70% and has significant morbidity.122
Radiofrequency catheter ablation of accessory AV
connections has been performed at some centers.
There has been a high rate of success in the shortterm follow-up of these patients, with few complications.109"12 More information about safety and both
short- and long-term efficacy of this procedure is
needed. Operative treatment is more than 95% successful, and morbidity and mortality are low.93,95,96
Catheter ablation may be indicated for accessory
AV connections. These should be performed in
selected centers at which active clinical electrophysiologic research into catheter ablative techniques is
carried out. Because cardiac perforation and tamponade may occur, especially if the direct current
technique is used, emergency operating room facilities with intraoperative mapping and electrophysiologic surgical capabilities must be available. This
procedure may also be indicated in patients who have
had unsuccessful operative procedures for accessory
AV connections, because pericardial scarring may
decrease the risk of cardiac perforation.
Catheter Ablation of Tachycardia Due to Reentry in
the Atrioventricular Node or Adjacent Tissues
As an improved understanding of the anatomy of
tachycardia due to reentry has developed, direct
operative treatment of the tachycardia circuit has
been shown to be effective.94 Reports of direct current catheter ablation of part of the tachycardia
circuit have shown success rates of 65-75%.123,124
Some patients require permanent pacemaker implantation for postoperative treatment of tachycardia
due to reentry in the AV node because of procedurerelated complete AV block. Recent reports of radio-

frequency catheter ablation of part of the tachycardia

circuit in the AV node or adjacent tissues suggest
that this procedure may be an effective treatment for
tachycardia due to reentry in the AV node.'04105 The
risk of causing complete AV block is not known. In
young patients, the long-term effects of AV nodal
modification, whether by surgical methods or by
catheter ablation, are unknown.
Catheter ablation may be indicated in some patients with AV nodal reentry tachycardia. It should
be performed only at an electrophysiology center
with experience in this procedure and performed as a
clinical investigation. Availability of operating room
back-up is mandatory.
Indications for Catheter Ablative Procedures
for Tachycardias

Catheter ablation of the AVjunction

Class I: Conditions for which catheter ablation of
the AV junction is generally agreed to be appropriate
1. Primary atrial tachycardias when medical or
surgical therapy is not a possibility
Class II: Conditions for which catheter ablation of
the AV junction may be indicated
1. His' bundle automatic tachycardia unresponsive
to medication or when drug side effects prohibit the
use of medication
Class III: Conditions for which catheter ablation of
the AV junction is inappropriate
1. Most AV reciprocating tachycardias
2. Ventricular preexcitation
Catheter ablation for treatment ofventrcular tachycardia
Class I: Conditions for which catheter ablation for
treatment of ventricular tachycardia is generally
agreed to be appropriate
None
Class II: Conditions for which catheter ablation for
treatment of ventricular tachycardia may be indicated
1. Macrobundle reentry tachycardia
2. Symptomatic monomorphic ventricular tachycardia unresponsive to antiarrhythmic drugs or when
drugs are ineffective or not tolerated (see text)
Class III: Conditions for which catheter ablation for
treatment of ventricular tachycardia is inappropriate
1. Most ventricular tachycardias controlled with
antiarrhythmic drugs
2. When surgery is also required to treat a structural cardiac problem
3. Polymorphic ventricular tachycardia

Catheter ablation of accessory A V connections

Class I: Conditions for which catheter ablation of
accessory AV connections is generally agreed to be
appropriate
None

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AH4 Scientific Council Guidelines for Pediatric Therapeutic Cardiac Catheterization

Class II: Conditions for which catheter ablation of

accessory AV connections may be indicated
1. Accessory AV connections
Class III: Conditions for which catheter ablation of
accessory AV connections is inappropriate
None
Catheter ablation of tachycardia due to reentry in the
AV node or adjacent tissues
Class I: Conditions for which catheter ablation of
tachycardia due to reentry in the AV node is generally agreed to be indicated
None
Class II: Conditions for which catheter ablation of
tachycardia due to reentry in the AV node may be
indicated
1. Some AV node reentry tachycardias
Class III: Conditions for which catheter ablation of
tachycardia due to reentry in the AV node is inappropriate
None
Degrees of Difficulty of Procedures
The procedures discussed in this report have differing degrees of difficulty for the operator. These
are listed below. The difficulty of some will change
for example, from 1 to 2 or from 3 to 2 -with time.
Some can be performed by most cardiologists skilled
in catheterization procedures and others are presently performed in a very few centers and have a high
degree of difficulty.
-

1. Available in all centers and by all individuals

doing acute care pediatric cardiology
* Balloon atrial septostomy
2. Procedures available in centers committed to
therapeutic catheterizations (requires large inventory of equipment and skilled designated
personnel)*
* Blade/balloon atrial septostomy
* Balloon dilation of pulmonary valve
* Balloon dilation of recoarctation
* Embolization of collaterals
* Branch pulmonary artery dilation (acquired and
congenital)
* Tricuspid valve (acquired and congenital) dilation
* Systemic vein/baffle dilation
* AV fistula occlusion
* Systemic arterial stenosis dilation
* Dilation of systemic-pulmonary shunt stenosis
* Foreign body removal
* Balloon dilation of aortic valve
* Balloon dilation of rheumatic mitral valve stenosis

2255

3. Procedures to be done at present only in active

therapeutic catheterization centers by cardiologists who have undergone specific training for
these procedures and follow ongoing investigational protocols for same.*
* Patent ductus arteriosus umbrella occlusion
* Secundum atrial septal defect umbrella occlusion
* Balloon dilation of congenital mitral valve stenosis
* Balloon dilation of native coarctation
* Transcatheter ablation of undesired electrical
pathways
4. Purely investigational procedures to be performed at present only in designated centers with
specific investigational protocols.*
* Umbrella occlusion of muscular or atypical ventricular septal defects
* Implant of intravascular stents
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Guidelines for pediatric therapeutic cardiac catheterization. A statement for health

professionals from the Committee on Congenital Cardiac Defects of the Council on
Cardiovascular Disease in the Young, the American Heart Association.
H D Allen, D J Driscoll, F J Fricker, P Herndon, C E Mullins, A R Snider and K A Taubert
Circulation. 1991;84:2248-2258
doi: 10.1161/01.CIR.84.5.2248
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 1991 American Heart Association, Inc. All rights reserved.
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