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Huerta N, Stylli J, Mahar S, Chittal A, Grove D. Supraventricular Tachycardia Associated With Transdermal Scopolamine: A Case of Commonalities Leading to an Uncommon Toxicity. CJC Open 2024; 6:569-572. [PMID: 38559333 PMCID: PMC10980914 DOI: 10.1016/j.cjco.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/06/2023] [Indexed: 04/04/2024] Open
Affiliation(s)
- Nicholas Huerta
- Internal Medicine Residency Program, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Jack Stylli
- Georgetown University School of Medicine, Washington, DC, USA
| | - Samantha Mahar
- Department of Pulmonary and Critical Care Medicine, MedStar Union Memorial Hospital Baltimore, Maryland, USA
| | - Abhinandan Chittal
- Department of Pulmonary and Critical Care Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Daniel Grove
- Internal Medicine Residency Program, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
- Department of Pulmonary and Critical Care Medicine, MedStar Union Memorial Hospital Baltimore, Maryland, USA
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Muresan L, Cismaru G, Martins RP, Bataglia A, Rosu R, Puiu M, Gusetu G, Mada RO, Muresan C, Ispas DR, Le Bouar R, Diene LL, Rugina E, Levy J, Klein C, Sellal JM, Poull IM, Laurent G, de Chillou C. Recommendations for the use of electrophysiological study: Update 2018. Hellenic J Cardiol 2018; 60:82-100. [PMID: 30278230 DOI: 10.1016/j.hjc.2018.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/31/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
The field of cardiac electrophysiology has greatly developed during the past decades. Consequently, the use of electrophysiological studies (EPSs) in clinical practice has also significantly augmented, with a progressively increasing number of certified electrophysiology centers and specialists. Since Zipes et al published the Guidelines for Clinical Intracardiac Electrophysiology and Catheter Ablation Procedures in 1995, no official document summarizing current EPS indications has been published. The current paper focuses on summarizing all relevant data of the role of EPS in patients with different types of cardiac pathologies and provides up-to-date recommendations on this topic. For this purpose, the PubMed database was screened for relevant articles in English up to December 2018 and ESC and ACC/AHA Clinical Practice Guidelines, and EHRA/HRS/APHRS position statements related to the current topic were analyzed. Current recommendations for the use of EPS in clinical practice are discussed and presented in 17 distinct cardiac pathologies. A short rationale, evidence, and indications are provided for each cardiac disease/group of diseases. In conclusion, because of its capability to establish a diagnosis in patients with a variety of cardiac pathologies, the EPS remains a useful tool in the evaluation of patients with cardiac arrhythmias and conduction disorders and is capable of establishing indications for cardiac device implantation and guide catheter ablation procedures.
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Affiliation(s)
- Lucian Muresan
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France.
| | - Gabriel Cismaru
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Raphaël Pedro Martins
- Centre Hospitalier Universitaire de Rennes, Cardiology Department, 35000 Rennes, France
| | - Alberto Bataglia
- Institut Lorrain du Coeur et des Vaisseaux « Louis Mathieu », Cardiology Department, Electrophysiology Department, 54000 Vandoeuvre-les-Nancy, France
| | - Radu Rosu
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Mihai Puiu
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Gabriel Gusetu
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Razvan Olimpiu Mada
- "Niculae Stancioiu" Heart Institute, Cardiology Department, 400005 Cluj-Napoca, Romania
| | - Crina Muresan
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France
| | - Daniel Radu Ispas
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Ronan Le Bouar
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France
| | | | - Elena Rugina
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France
| | - Jacques Levy
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France
| | - Cedric Klein
- Centre Hospitalier Universitaire de Lille, Cardiology Department, 59000 Lille, France
| | - Jean Marc Sellal
- Institut Lorrain du Coeur et des Vaisseaux « Louis Mathieu », Cardiology Department, Electrophysiology Department, 54000 Vandoeuvre-les-Nancy, France
| | - Isabelle Magnin Poull
- Institut Lorrain du Coeur et des Vaisseaux « Louis Mathieu », Cardiology Department, Electrophysiology Department, 54000 Vandoeuvre-les-Nancy, France
| | - Gabriel Laurent
- Centre Hospitalier Universitaire de Dijon, Cardiology Department, 21000 Dijon, France
| | - Christian de Chillou
- Institut Lorrain du Coeur et des Vaisseaux « Louis Mathieu », Cardiology Department, Electrophysiology Department, 54000 Vandoeuvre-les-Nancy, France
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SVINARICH JOHNT, TAI DERYAN, SUNG RUEYJ. Clinical Indications and Results of Electrophysiologic Studies in Patients with Supraventricular Tachycardias. ACTA ACUST UNITED AC 2008. [DOI: 10.1111/j.1540-8167.1984.tb01656.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kantharia BK, Padder FA, Kutalek SP. Decremental Ramp Atrial Extrastimuli Pacing Protocol for the Induction of Atrioventricular Nodal Re-entrant Tachycardia and Other Supraventricular Tachycardias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:1096-104. [PMID: 17038142 DOI: 10.1111/j.1540-8159.2006.00503.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM The primary aim of this study was to evaluate the utility of decremental ramp atrial extrastimuli pacing protocol (PRTCL) for induction of atrioventricular nodal re-entrant tachycardia (AVNRT), and other supraventricular tachycardias (SVTs), compared to standard (STD) methods. METHODS The study cohort of 121 patients (age 57.51 +/- 14.02 years) who presented with documented SVTs and/or symptoms of palpitations and dizziness, and underwent invasive electrophysiological evaluation was divided into Group I (AVNRT, n = 42) and Group II (Control, n = 79). The PRTCL involved a train of six atrial extrastimuli, delivered in a decremental ramp fashion. The STD methods included continuous burst and rapid incremental pacing up to atrioventricular (AV) block cycle length, and single and occasionally double atrial extrastimuli. Prolongation in the Atrio-Hisian (Delta-AH) intervals achieved by both methods were compared, as were induction frequencies. RESULTS In Group I, three categories of responses--(1) induction of AVNRT, (2) induction of echo beats only, and (3) none--were observed in 29 (69%), 11 (26%), and 2 (5%) patients with the PRTCL, when compared with 14 (33%), 16 (38%), and 12 (29%) patients with STD methods in the baseline state without the use of pharmacological agents. The Delta-AH intervals for each of these three categories were larger using PRTCL versus STD methods; 293.3 +/- 95.2 ms versus 192.9 +/- 61.4 ms (P < 0.005), 308.6 +/- 68.5 ms versus 189. 9 +/- 64.9 ms (P < 0.0005), and 203.0 +/- 86.3 ms versus 145.8 +/- 58.9 ms (P = NS), respectively. In Group II, in one patient with dual AV nodal physiology but no clinical tachycardia, the PRTCL induced nonsustained (12 beats) AVNRT. Additionally, in this group, both PRTCL and STD methods induced atrial tachycardia in two patients and orthodromic AV re-entrant tachycardia in one patient. CONCLUSION Decremental ramp atrial extrastimuli pacing PRTCL demonstrates a superior response for induction of typical AVNRT as compared to STD techniques. Because of easy and reliable induction of AVNRT and echo beats by the PRTCL, we recommend it as a method to increase the likelihood of induction of AVNRT. For induction of other SVTs, the PRTCL and the STD methods are comparable.
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Affiliation(s)
- Bharat K Kantharia
- Department of Internal Medicine, Division of Cardiac Electrophysiology, Cardiac Electrophysiology Fellowship Training Program, Cardiac Electrophysiology Laboratories, Ohio State University Medical Center, Columbus, Ohio 43210, USA.
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Chiou CW, Chen SA, Kung MH, Chang MS, Prystowsky EN. Effects of continuous enhanced vagal tone on dual atrioventricular node and accessory pathways. Circulation 2003; 107:2583-8. [PMID: 12743004 DOI: 10.1161/01.cir.0000068339.04731.4d] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to test the electrophysiological effects of continuous enhanced vagal tone on dual atrioventricular (AV) nodal and accessory pathways. METHODS AND RESULTS This study included 10 patients with typical, slow-fast AV nodal reentrant tachycardia (AVNRT) and 10 patients with AV reciprocating tachycardia. Electrophysiological data were measured before and during continuous vagal enhancement by using phenylephrine infusion (0.6 to 1.5 microg/kg per min). For patients with AVNRT, during phenylephrine infusion, 1:1 conduction times over the anterograde fast and slow and retrograde fast pathways were prolonged (453+/-64 to 662+/-120 ms, P<0.001; 379+/-53 to 443+/-95 ms, P<0.05; 405+/-112 to 442+/-118 ms, P<0.05). The effective refractory period and functional refractory period of the anterograde fast pathway were prolonged with phenylephrine (394+/-73 to 544+/-128 ms, P<0.001; 454+/-60 to 596+/-118 ms, P<0.001). In contrast, the effective refractory period and functional refractory period of the anterograde slow and retrograde fast were not significantly changed. No significant change was observed in the conduction or refractoriness of the accessory pathways in patients with AV reciprocating tachycardia nor in atrial or ventricular refractoriness. CONCLUSIONS Enhanced vagal tone produces disparate effects on the refractoriness of the slow and fast AV nodal conduction pathways, with the anterograde fast pathway being the most sensitive. These changes are conducive to induction of AVNRT with a premature atrial complex and may explain in part the relatively common occurrence of AVNRT during sleep or other periods of presumed increased parasympathetic tone.
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Affiliation(s)
- Chuen-Wang Chiou
- Division of Cardiology, Veterans General Hospital-Taipei and Kaohsiung, National Yang-Ming University, School of Medicine, Taiwan
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6
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Lin LJ, Lin JL, Lai LP, Chen JH, Tseng YZ, Lien WP. Effects of pharmacological autonomic blockade on dual atrioventricular nodal pathways physiology in patients with slow-fast atrioventricular nodal reentrant tachycardia. Pacing Clin Electrophysiol 1998; 21:1375-9. [PMID: 9670180 DOI: 10.1111/j.1540-8159.1998.tb00207.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to investigate the atrioventricular AV nodal physiology and the inducibility of AV nodal reentrant tachycardia (AVNRT) under pharmacological autonomic blockade (AB). Seventeen consecutive patients (6 men and 11 women, mean age 39 +/- 17 years) with clinical recurrent slow-fast AVNRT received electrophysiological study before and after pharmacological AB with atropine (0.04 mg/kg) and propranolol (0.2 mg/kg). In baseline, all 17 patients could be induced with AVNRT, 5 were isoproterenol-dependent. After pharmacological AB, 12 (71%) of 17 patients still demonstrated AV nodal duality. AVNRT became noninducible in 7 of 12 nonisoproterenol dependent patients and remained noninducible in all 5 isoproterenol dependent patients. The sinus cycle length (801 +/- 105 ms vs 630 +/- 80 ms, P < 0.005) and AV blocking cycle length (365 +/- 64 ms vs 338 +/- 61 ms, P < 0.005) became shorter after AB. The antegrade effective refractory period and functional refractory period of the fast pathway (369 +/- 67 ms vs 305 +/- 73 ms, P < 0.005; 408 +/- 56 ms vs 350 +/- 62 ms, P < 0.005) and the slow pathway (271 +/- 30 ms vs 258 +/- 27 ms, P < 0.01; 344 +/- 60 ms vs 295 +/- 50 ms, P < 0.005) likewise became significantly shortened. However, the ventriculoatrial blocking cycle length (349 +/- 94 ms vs 326 +/- 89 ms, NS) and effective refractory period of retrograde fast pathway (228 +/- 38 ms vs 240 +/- 80 ms, NS) remained unchanged after autonomic blockade. Pharmacological AB unveiling the intrinsic AV nodal physiology could result in the masking of AV nodal duality and the decreased inducibility of clinical AVNRT.
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Affiliation(s)
- L J Lin
- Department of Internal Medicine, National Cheng-Kung University Hospital, Tainan, Republic of China
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7
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Hatzinikolaou H, Rodriguez LM, Smeets JL, Timmermans C, Vrouchos G, Grecas G, Wellens HJ. Isoprenaline and inducibility of atrioventricular nodal re-entrant tachycardia. Heart 1998; 79:165-8. [PMID: 9538310 PMCID: PMC1728591 DOI: 10.1136/hrt.79.2.165] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To examine the effect of isoprenaline on slow and fast pathway properties and tachycardia initiation. DESIGN Consecutive patients, prospective study. SETTING Referral centre for cardiology, academic hospital. PATIENTS 24 patients suffering from common type atrioventricular nodal reentrant tachycardia (AVNRT). INTERVENTIONS Programmed electrical stimulation and radiofrequency catheter ablation of the slow pathway. MEASUREMENTS AND MAIN RESULTS AVNRT was induced before and after the administration of isoprenaline in nine patients (group 1), before isoprenaline only in five (group 2), and after isoprenaline only in 10 (group 3). The anterograde effective refractory period of the fast pathway was prolonged significantly during isoprenaline administration in group 1 (405 (31) v 335 (34) ms, p < 0.001) and shortened in group 2 (308 (57) v 324 (52) ms, p = 0.005). There was also significant shortening in group 3 (346 (85) v 395 (76) ms, p < 0.001). Isoprenaline administration did not result in a significant change of the anterograde effective refractory period of the slow pathway in groups 1 and 3, but eliminated slow pathway conduction in group 2. Isoprenaline significantly shortened the minimal and maximal atrial to His bundle conduction interval recording in response to each extrastimulus of the slow pathway (210 (24) v 267 (25) ms, p < 0.001 and 275 (25) v 328 (25) ms, p < 0.001, respectively) in group 1 and significantly prolonged these intervals (331 (34) v 274 (34) ms and 407 (33) v 351 (33) ms, respectively) in group 3. In all groups only minimal changes in the refractory period of the atrium occurred after isoprenaline administration. The effect of isoprenaline was also measured on the ventricular effective refractory period and on the minimal and maximal length of the ventriculoatrial (V2-A2) interval during ventricular pacing. Isoprenaline did not result in a significant change of the ventricular effective refractory period in groups 1 and 2 nor of the shortest and longest V2-A2 interval. In group 3, however, the ventricular effective refractory period and the shortest and longest V2-A2 interval shortened significantly after isoprenaline administration. CONCLUSIONS In group 1 isoprenaline did not affect inducibility of AVNRT because it prolonged the fast pathway refractory period without affecting slow pathway conduction. In group 2 isoprenaline shortened the fast pathway refractory period and appeared to abolish slow pathway conduction. Consequently, isoprenaline prevented induction of AVNRT. In group 3 isoprenaline facilitated induction of AVNRT. This effect seemed primarily to be the result of shortening of retrograde refractoriness of the fast pathway with prolongation of slow pathway anterograde conduction and refractory period.
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Affiliation(s)
- H Hatzinikolaou
- Department of Cardiology, G Papanikolaou General Hospital, Exohi, Thessaloniki, Greece
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Lee SH, Chen SA, Chiang CE, Tai CT, Wen ZC, Ueng KC, Chiou CW, Chen YJ, Yu WC, Huang JL, Cheng JJ, Chang MS. Results of radiofrequency ablation in patients with clinically documented, but noninducible, atrioventricular node reentrant tachycardia and orthodromic atrioventricular reciprocating tachycardia. Am J Cardiol 1997; 79:974-8. [PMID: 9104917 DOI: 10.1016/s0002-9149(97)89270-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Among 1,281 patients with symptomatic supraventricular tachycardia, 34 patients (2.7%) with presumed diagnosis of atrioventricular node reentrant tachycardia and orthodromic atrioventricular reciprocating tachycardia did not have inducible tachycardia in the electrophysiologic laboratory. Application of radiofrequency energy to the presumed arrhythmogenic sites could achieve a high success rate, with a low recurrence rate in these patients.
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Affiliation(s)
- S H Lee
- Department of Medicine, National Yang-Ming University and Veterans General Hospital-Taipei, Taiwan, Republic of China
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Yu WC, Chen SA, Chiang CE, Tai CT, Lee SH, Chiou CW, Ueng KC, Wen ZC, Chen YJ, Huang JL, Chang MS. Effects of isoproterenol in facilitating induction of slow-fast atrioventricular nodal reentrant tachycardia. Am J Cardiol 1996; 78:1299-302. [PMID: 8960597 DOI: 10.1016/s0002-9149(96)00607-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study demonstrates that patients with poorer conduction properties of the anterograde slow and retrograde fast pathways usually need isoproterenol to facilitate induction of atrioventricular nodal reentrant tachycardia. Isoproterenol infusion usually facilitates induction of tachycardia by enhancing the retrograde ventriculoatrial conduction.
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Affiliation(s)
- W C Yu
- Division of Cardiology, Department of Medicine, National Yang-Ming University, School of Medicine, Taiwan, Republic of China
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Lo HM, Lin FY, Cheng JJ, Tseng YZ. Anatomic substrate of the experimentally-created atrioventricular node re-entrant tachycardia in the dog. Int J Cardiol 1995; 51:273-82; discussion 283-84. [PMID: 8586476 DOI: 10.1016/0167-5273(95)02419-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite major success in the treatment of atrioventricular (AV) node reentrant tachycardia using either catheter ablation or surgery, the morphologic basis underlying AV node reentry is not yet clear. A canine model of AV node reentrant tachycardia was used to examine the histologic features of the reentry circuit. AV node reentrant tachycardia was created in 4 of 8 dogs by a right atrial division which divided the right atrial free wall and the atrial septum into upper and lower portions on a plane between the mid-right atrial free wall and the fossa ovalis. The AV junctional area of all dogs were serially sectioned on a plane that was perpendicular to the AV annulus and the septum. The slices were stained with Masson's trichrome technique. The connections between atrial fibers and the compact AV node and the common AV bundle were examined, and comparison of the histologic features between dogs with and without AV nodal re-entry was made. The histologic examinations showed that, in all dogs, the operation scar was remote from the AV junctional area leaving the Koch's triangle intact. The compact node received its atrial inputs mainly from the anterosuperior and posterior aspects of the Koch's triangle. However, both atrial inputs gave off superficial (subendocardial) fibers that by-passed the compact node to terminate at the base of tricuspid valve. These superficial fibers might function as the proximal link between the dual AV nodal inputs by means of lateral connections. There was no bypass connection between atrial fibers and the common AV bundle. The histologic features of the AV junctional area was not different between dogs with and without AV nodal reentry. In conclusion, AV nodal reentry involves the anterior and posterior atrio-nodal inputs which function as dual AV nodal pathways, and the superficial bypass fibers form the proximal linkage between the two inputs. These structures, together with the compact node, complete the reentry circuit.
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Affiliation(s)
- H M Lo
- Department of Medicine, Taiwan Provincial Tao-Yuan General Hospital, Taipei, Republic of China
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Jordaens L, Vertongen P, Verstraeten T. Prolonged monitoring for detection of symptomatic arrhythmias after slow pathway ablation in AV-nodal tachycardia. Int J Cardiol 1994; 44:57-63. [PMID: 8021051 DOI: 10.1016/0167-5273(94)90067-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To study the incidence of symptoms and recurrences of AV-nodal re-entrant tachycardia (AVNT) after treatment with radio-frequency ablation of the slow pathway, event recording with transtelephonic transmission was performed for at least 3 weeks in 19 patients out of a series of 25. Follow-up with an implanted antitachycardia device was possible in two other patients, making the total number under continued surveillance 21/25. The period of monitoring was prolonged as complaints remained or became present after 1 month in eight patients. During a mean follow-up of 10 months, late recurrence of AVNT was observed in this way in 4/25 patients; they were submitted to a second procedure. Symptoms were present in many others and were explained by the recordings. Sinus tachycardia was recorded in three patients, intermittent AV-block of the first degree in another, and frequent atrial or ventricular premature beats in six patients. These minor arrhythmias tended to decrease over time. A coexistent atrial tachycardia was redetected in two patients. Thus, event recording is useful to distinguish recurrence of AVNT, sinus tachycardia, other types of supraventricular tachycardia, and atrial or ventricular premature beats, which all may be a reason of complaints during the first weeks after ablation. It provided a feeling of safety for symptomatic patients who often suffered from anxiety before the ablation.
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Affiliation(s)
- L Jordaens
- Department of Cardiology, University Hospital, Ghent, Belgium
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12
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Natale A, Klein G, Yee R, Thakur R. Shortening of fast pathway refractoriness after slow pathway ablation. Effects of autonomic blockade. Circulation 1994; 89:1103-8. [PMID: 8124796 DOI: 10.1161/01.cir.89.3.1103] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Shortening of the anterograde effective refractory period (ERP) of the fast pathway has been reported after radiofrequency ablation of the slow pathway. We hypothesized that ERP shortening may be related to autonomic changes, possibly catecholamine release, as a result of ablation. METHODS AND RESULTS To test this, 10 consecutive patients with atrioventricular node reentry undergoing slow pathway ablation were given autonomic blockade before the ablation procedure. This was achieved by atropine 0.03 mg/kg and propranolol 0.15 mg/kg IV supplemented by half the initial dose after ablation and before the final study. A control group of 10 patients underwent the protocol without autonomic blockade. Before ablation, autonomic blockade did not alter the ERP of either the fast pathway (295 +/- 22 versus 298 +/- 26 milliseconds) or the slow pathway (264 +/- 36 versus 269 +/- 38 milliseconds). Autonomic blockade obscured dual pathway physiology in 2 patients and brought it out in another 2 without dual pathway physiology initially. Slow pathway ablation shortened the ERP of the fast pathway for the group as a whole (331.5 +/- 54 versus 305.5 +/- 60 milliseconds, mean +/- SD, n = 20, P < .04). There was no difference in degree of ERP shortening in control patients (23.5 +/- 58 milliseconds) or autonomic blockade patients (25.5 +/- 52 milliseconds). CONCLUSIONS These data suggest that shortening of the ERP of the fast pathway after slow pathway ablation is not mediated by autonomic changes.
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Affiliation(s)
- A Natale
- Department of Medicine, University of Western Ontario, London, Canada
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13
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Mann DE, Marmont P, Shultz J, Reiter MJ. Atrioventricular nodal reentrant tachycardia initiated by catecholamine-induced ventricular tachycardia. A case report. J Electrocardiol 1991; 24:191-5. [PMID: 2037821 DOI: 10.1016/0022-0736(91)90011-a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The authors describe a patient who experienced recurrent wide-complex and narrow-complex tachycardias during exercise. Electrophysiologic testing in the resting state revealed dual atrioventricular (AV) nodal pathways. AV nodal reentrant tachycardia was inducible by ventricular premature stimulation but was always nonsustained, terminating with block in the anterograde slow pathway. During isoproterenol infusion, runs of ventricular tachycardia occurred frequently, and spontaneously initiated sustained AV nodal reentrant tachycardia. Exercise testing also provoked ventricular tachycardia and sustained AV nodal reentrant tachycardia. The patient was effectively treated with a combination of atenolol and verapamil. This case is an unusual example of a catecholamine-induced arrhythmia, possibly due to triggered activity (exercise-induced ventricular tachycardia), initiating an arrhythmia due to reentry (AV nodal reentrant tachycardia).
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Affiliation(s)
- D E Mann
- Cardiology Division, University of Colorado Health Sciences Center, Denver 80262
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Hashimoto T, Fukatani M, Mori M, Hashiba K. Effects of standing on the induction of paroxysmal supraventricular tachycardia. J Am Coll Cardiol 1991; 17:690-5. [PMID: 1993789 DOI: 10.1016/s0735-1097(10)80185-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To evaluate the effects of standing on induction of paroxysmal supraventricular tachycardia, electrophysiologic studies were performed in both the supine and standing positions in 22 patients with atrioventricular (AV) reciprocating tachycardia and in 11 with AV node reentrant tachycardia. AV reciprocating tachycardia was induced in 9 of the 22 patients with AV reciprocating tachycardia when they were in the supine position and in 17 when standing. The effective refractory period of the AV node markedly shortened, from 275 +/- 72 to 203 +/- 30 ms (n = 16, p less than 0.005) after standing. The effective refractory period of the accessory pathway shortened slightly, from 293 +/- 75 to 278 +/- 77 ms (n = 8, p less than 0.005), after standing. AV node reentrant tachycardia was induced in 3 of the 11 patients with AV node reentrant tachycardia when they were in the supine position and in 6 when standing. The effective refractory periods of the slow pathway and fast pathway shortened markedly, from 293 +/- 72 to 216 +/- 40 ms (n = 6, p less than 0.025) and from 416 +/- 85 to 277 +/- 50 ms (n = 10, p less than 0.005), respectively, after standing. Plasma norepinephrine levels increased during standing both in patients with AV reciprocating and in those with AV node reentrant tachycardia (n = 11, p less than 0.005, n = 8, p less than 0.005, respectively). In conclusion, standing, which is associated with increased sympathetic tone, changed the electrophysiologic properties of the reentrant circuits, facilitating induction of AV reciprocating tachycardia and AV node reentrant tachycardia.
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Affiliation(s)
- T Hashimoto
- Third Department of Internal Medicine, Nagasaki University School of Medicine, Japan
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Huycke EC, Lai WT, Nguyen NX, Keung EC, Sung RJ. Role of intravenous isoproterenol in the electrophysiologic induction of atrioventricular node reentrant tachycardia in patients with dual atrioventricular node pathways. Am J Cardiol 1989; 64:1131-7. [PMID: 2479251 DOI: 10.1016/0002-9149(89)90865-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
To assess the role of intravenous isoproterenol for the facilitation of electrophysiologic induction of atrioventricular (AV) node reentrant tachycardia, 20 patients with dual AV node pathways who lacked inducible AV node reentrant tachycardia at control study had a constant isoproterenol infusion administered and underwent repeat study. Six (30%) of 20 patients (group I) had inducible AV node reentrant tachycardia during isoproterenol infusion whereas the other 14 (70%) patients (group II) did not. Paroxysmal supraventricular tachycardia was clinically documented in all 6 group I patients compared to 3 (21%) of 14 group II patients (p = 0.002). The sensitivity and specificity of isoproterenol-facilitated induction of AV node reentrant tachycardia were 67 and 100%, respectively. The isoproterenol-facilitated induction of sustained AV node reentry was mediated by resolution of the weak link in anterograde slow pathway in 2 (33%) patients, in retrograde fast pathway in 3 (50%) and in both anterograde slow and retrograde fast pathways in 1 (17%) patient. Four group I patients were given intravenous propranolol, 0.2 mg/kg body weight, and had complete suppression of isoproterenol-facilitated induction of AV node reentry. Thus, intravenous isoproterenol is a rather sensitive and highly specific adjunct to electrophysiologic induction of AV node reentrant tachycardia in patients with dual AV node pathways but without inducible sustained AV node reentry.
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MESH Headings
- Adrenergic beta-Antagonists/pharmacology
- Adult
- Aged
- Aged, 80 and over
- Atrioventricular Node/drug effects
- Atrioventricular Node/physiopathology
- Cardiac Complexes, Premature/physiopathology
- Electric Stimulation
- Female
- Heart Conduction System
- Humans
- Infusions, Intravenous
- Isoproterenol/administration & dosage
- Isoproterenol/pharmacology
- Male
- Middle Aged
- Reaction Time
- Tachycardia, Atrioventricular Nodal Reentry/chemically induced
- Tachycardia, Atrioventricular Nodal Reentry/physiopathology
- Tachycardia, Paroxysmal/chemically induced
- Tachycardia, Paroxysmal/physiopathology
- Tachycardia, Sinus/chemically induced
- Tachycardia, Sinus/physiopathology
- Tachycardia, Supraventricular/chemically induced
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Affiliation(s)
- E C Huycke
- Department of Medicine, Letterman Army Medical Center, San Francisco, California
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16
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Niazi I, Naccarelli G, Dougherty A, Rinkenberger R, Tchou P, Akhtar M. Treatment of atrioventricular node reentrant tachycardia with encainide: reversal of drug effect with isoproterenol. J Am Coll Cardiol 1989; 13:904-10. [PMID: 2494243 DOI: 10.1016/0735-1097(89)90234-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
To determine the efficacy of encainide in the treatment of atrioventricular (AV) node reentrant tachycardia, Holter electrocardiographic (ECG) monitoring, exercise treadmill testing and programmed electrical stimulation were performed in 16 patients while they were taking no medication and after steady state levels were reached during treatment with encainide (75 to 200 mg/day; mean 117 +/- 47). In addition, to study the possible reversal of drug effects by sympathetic stimulation, AV node conduction and tachycardia induction were reassessed during isoproterenol infusion (1 to 3 micrograms/min), a dose calculated to increase the rest heart rate by 25 +/- 10%. Sustained AV node reentrant tachycardia could be initiated in all 16 patients in the control state, in 2 patients after encainide and in 10 patients during isoproterenol infusion. The shortest mean atrial paced cycle length sustaining 1:1 AV conduction was 358 +/- 57 ms during the control study, which increased to 409 +/- 59 ms with encainide (p less than 0.01 versus control) and decreased to 313 +/- 31 ms during isoproterenol infusion (p less than 0.01 versus control and encainide). The shortest mean ventricular paced cycle length with 1:1 ventriculoatrial conduction was 337 +/- 56 ms in the control study, 551 + 124 ms with encainide infusion (p less than 0.01 versus control) and 354 +/- 72 ms during isoproterenol infusion in the encainide-loaded state (p less than 0.01 versus both control and encainide). During a mean follow-up period of 19 +/- 10 months, significant clinical recurrences occurred in 4 of the 10 patients in whom tachycardia could still be initiated with encainide (with or without isoproterenol).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- I Niazi
- Natalie and Norman Soref and Family Electrophysiology Laboratory, University of Wisconsin-Milwaukee Clinical Campus, Sinai Samaritan Medical Center
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17
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Toda I, Kawahara T, Murakawa Y, Nozaki A, Kawakubo K, Inoue H, Sugimoto T. Electrophysiological study of young patients with exercise related paroxysms of palpitation: role of atropine and isoprenaline for initiation of supraventricular tachycardia. BRITISH HEART JOURNAL 1989; 61:268-73. [PMID: 2930664 PMCID: PMC1216656 DOI: 10.1136/hrt.61.3.268] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Electrophysiological studies were performed in eight patients (four men and four women, mean (SD) age 24 (5) years with paroxysmal attacks of palpitation during or immediately after exercise. Five patients were competitive athletes at college. In two patients spontaneous supraventricular tachycardia during exercise was recorded by ambulatory electrocardiographic monitoring and in another it was induced by treadmill exercise testing. Two had dual atrioventricular nodal pathways, three had manifest atrioventricular accessory pathways, and three had concealed atrioventricular pathways. Programmed stimulation induced sustained supraventricular tachycardia in six patients--in two after intravenous injection of atropine sulphate (1 mg) and in four during infusion of isoprenaline (0.01 microgram/kg/min). In one patient, non-sustained atrioventricular nodal reentrant tachycardia was induced during isoprenaline infusion. In the remaining patient, who had dual atrioventricular nodal pathways, tachycardia was not inducible. AH block prevented maintenance of reentry in five patients. In five patients shortening of the effective refractory period of the atrioventricular node with atropine (one patient) and isoprenaline (four patients) caused sustained supraventricular tachycardia. The present study indicates that treatment with atropine and isoprenaline may be an important factor in the initiation of supraventricular tachycardia in patients with exercise related paroxysms of palpitation.
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Affiliation(s)
- I Toda
- Second Department of Internal Medicine, University of Tokyo, Japan
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18
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Mann DE, Reiter MJ. Effects of upright posture on atrioventricular nodal reentry and dual atrioventricular nodal pathways. Am J Cardiol 1988; 62:408-12. [PMID: 2458027 DOI: 10.1016/0002-9149(88)90968-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The electrophysiologic effects of upright posture (45 degrees upright tilt) were studied in 17 patients with dual atrioventricular (AV) nodal pathways, AV nodal reentry or both. Discontinuous AV nodal conduction curves were observed in 16 patients while supine, but in only 11 patients while upright. Fast pathway refractoriness was shortened: the anterograde fast pathway effective refractory period decreased from 360 +/- 22 to 275 +/- 14 ms (mean +/- standard error of the mean), the anterograde fast pathway block cycle length shortened from 448 +/- 28 to 348 +/- 20 ms and the retrograde fast pathway block cycle length shortened from 425 +/- 29 to 338 +/- 24 ms (all p less than 0.01). The anterograde slow pathway block cycle length shortened from 378 +/- 29 to 316 +/- 17 ms (p less than 0.05). AV nodal reentrant tachycardia was induced in 5 patients while supine (2 sustained, 3 nonsustained) and in 6 patients while upright (4 sustained, 2 nonsustained). Tachycardia cycle length shortened during upright posture, from 413 +/- 30 to 345 +/- 22 ms (p less than 0.01), primarily due to shortened anterograde slow pathway conduction time, from 322 +/- 23 to 268 +/- 20 ms (p less than 0.05). Upright posture thus enhances conduction in patients with dual AV nodal pathways, facilitating AV nodal reentry. Electrophysiologic testing in the upright position may yield additional clinical important information in patients with dual AV nodal pathways.
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Affiliation(s)
- D E Mann
- Division of Cardiology, University of Colorado Health Sciences Center, Denver 80262
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19
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Brownstein SL, Hopson RC, Martins JB, Aschoff AM, Olshansky B, Constantin L, Kienzle MG. Usefulness of isoproterenol in facilitating atrioventricular nodal reentry tachycardia during electrophysiologic testing. Am J Cardiol 1988; 61:1037-41. [PMID: 2896452 DOI: 10.1016/0002-9149(88)90121-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In some patients with documented atrioventricular (AV) nodal supraventricular tachycardia (SVT), the arrhythmia is not inducible during a standard stimulation protocol. In these patients the level of sympathetic activity may be an important factor. This study evaluates the influence of isoproterenol on anterograde and retrograde pathway properties in patients with AV nodal SVT and the mechanism by which this SVT is facilitated. Group 1 consisted of 8 consecutive patients, ages 23 to 85 years (mean +/- standard error, 57 +/- 8) who had no inducible AV nodal SVT during electrophysiologic testing until isoproterenol (0.5 to 3.0 micrograms/min) was infused. These patients were compared with 6 patients in the same age range (45 to 78 years, mean +/- standard error, 64 +/- 5) who had inducible AV nodal SVT without isoproterenol and who comprised group 2. In comparing group 1 (before isoproterenol) with group 2, there was no significant difference in the refractory periods of the anterograde slow and fast pathways, although the anterograde block cycle length was longer in group 1 patients (421 +/- 18 vs 362 +/- 14 ms, p less than 0.05). The retrograde block cycle length was also longer in 7 of the 8 group 1 (before isoproterenol) patients in whom it could be measured versus those in group 2 (411 +/- 14 vs 318 +/- 27 ms, p less than 0.05). During isoproterenol, the anterograde and retrograde block cycle lengths in group 1 were not different from group 2. Therefore, AV nodal SVT may not be inducible in some patients during routine electrophysiologic testing.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S L Brownstein
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City 52242
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20
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Mann DE, Sensecqua JE, Easley AR, Reiter MJ. Effects of upright posture on anterograde and retrograde atrioventricular conduction in patients with coronary artery disease, mitral valve prolapse or no structural heart disease. Am J Cardiol 1987; 60:625-9. [PMID: 3630946 DOI: 10.1016/0002-9149(87)90317-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To assess the effects of posture on anterograde and retrograde atrioventricular conduction, electrophysiologic testing was performed in 25 patients in both the supine and 45 degrees upright positions on a tilt table. Retrograde conduction was present during ventricular pacing in 17 patients in the supine position; all 17 continued to manifest retrograde conduction in the upright position. In all patients with absent retrograde conduction while supine, retrograde conduction could not be demonstrated while upright. Upright posture significantly (p less than 0.05) shortened the sinus cycle length (from 808 +/- 34 to 678 +/- 26 ms, mean +/- standard error of the mean), AH interval during sinus rhythm (78 +/- 6 to 69 +/- 6 ms), and AH interval during atrial pacing at cycle length 500 ms (123 +/- 13 to 91 +/- 9 ms). Total atrioventricular conduction time during atrial pacing shortened significantly (from 169 +/- 13 to 136 +/- 10 ms), as did ventriculoatrial conduction time during ventricular pacing (from 192 +/- 9 to 178 +/- 7 ms). Upright posture also significantly shortened both anterograde block cycle length (390 +/- 20 to 328 +/- 17 ms) and retrograde block cycle length (466 +/- 27 to 354 +/- 18 ms). However, the effect of upright posture on retrograde block cycle length was significantly greater than on anterograde block cycle length: a 21% decrease retrograde vs a 14% decrease anterograde (p less than 0.05). These effects may produce clinically important changes in characteristics of arrhythmias that depend on the properties of anterograde and retrograde conduction.(ABSTRACT TRUNCATED AT 250 WORDS)
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21
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Fujiseki Y, Okuno M, Fujino H, Hattori M, Nonomura K, Shimada M. Transesophageal atrial pacing in paroxysmal supraventricular tachycardia in infants and children. ACTA PAEDIATRICA JAPONICA : OVERSEAS EDITION 1987; 29:605-13. [PMID: 3144899 DOI: 10.1111/j.1442-200x.1987.tb02248.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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22
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23
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Dougherty AH, Rinkenberger RL, Naccarelli GV. Effect of pharmacologic autonomic blockade on ventriculoatrial conduction. Am J Cardiol 1986; 57:1274-9. [PMID: 3717025 DOI: 10.1016/0002-9149(86)90204-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To determine the influence of autonomic tone on retrograde ventriculoatrial (VA) conduction, incremental atrial and ventricular pacing was performed before and after pharmacologic autonomic blockade in 28 patients. VA conduction during ventricular pacing was demonstrated, with highest frequency in patients capable of 1:1 atrioventricular (AV) conduction at atrial paced cycle lengths of 300 ms or less (7 of 7, 100%). In subjects with 1:1 AV conduction at minimum cycle lengths of 300 to 500 ms, 14 of 21 (67%) demonstrated VA conduction in the control state; however, only 12 of 21 (57%) did so after autonomic blockade. The lowest frequency was observed in those capable of 1:1 AV conduction at minimum cycle lengths of 505 ms or more before and after autonomic blockade (2 of 7, [29%], p less than or equal to 0.02 compared with values in the first group). No change in the mean minimum ventricular paced cycle length at which 1:1 VA conduction could be maintained was demonstrated after autonomic blockade. In individual subjects, incremental change in this cycle length after autonomic blockade correlated positively with the corresponding change in minimum atrial cycle length at which 1:1 AV conduction could be maintained (r = 0.62, p less than 0.005), and was concordant in direction in 18 of 21. In conclusion, the sympathetic and parasympathetic modulation of VA conduction is balanced and concordant in direction to the effect on AV nodal conduction.
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24
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Mahmud R, Denker ST, Lehmann MH, Addas A, Akhtar M. Unidirectional retrograde atrioventricular nodal block in man: determinants of reversibility by vagal antagonism. Am Heart J 1985; 110:568-74. [PMID: 4036782 DOI: 10.1016/0002-8703(85)90076-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The mechanism of unidirectional retrograde atrioventricular (AV) nodal block remains largely unknown. In this study, factors determining the reversal of the unidirectional block by atropine were evaluated in 12 patients who had no demonstrable ventriculoatrial (VA) conduction during ventricular pacing. Six patients demonstrated 1:1 VA conduction after atropine (group I), while the remaining six patients continued to show VA block (group II). During the control study there was no significant difference in the sinus cycle length and AH interval between the two groups. The percent decrease in sinus cycle length after atropine was also similar in groups I and II (i.e., 23 +/- 12 and 26 +/- 6, respectively). The effect on antegrade AV nodal conduction (i.e., the percent decrease in AH interval), however, was significantly greater in group I (24 +/- 9) as compared to group II (9 +/- 5) (p less than 0.004). The onset of VA conduction appeared to correlate with the improvement of antegrade conduction. The ratio of these two effects of atropine (i.e., percent decrease in AH interval to percent decrease in sinus cycle length) was higher when VA conduction was first demonstrated in group I (2.3 +/- 1.1) than at the maximal effect of atropine (1.2 +/- 0.3), reflecting a relatively greater decrease in sinus cycle length. Three of six group I patients redeveloped VA block at maximal effect of atropine. The results suggest a functional and dynamic nature of the unidirectional AV nodal block, possibly caused by vagal influence exaggerating the well-known directional asymmetry of AV nodal conduction in man.(ABSTRACT TRUNCATED AT 250 WORDS)
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25
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Hariman RJ, Pasquariello JL, Gomes JA, Holtzman R, el-Sherif N. Autonomic dependence of ventriculoatrial conduction. Am J Cardiol 1985; 56:285-91. [PMID: 4025167 DOI: 10.1016/0002-9149(85)90851-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To evaluate the effects of isoproterenol and atropine on patients with poor ventriculoatrial (VA) conduction, 17 patients were studied who did not have 1-to-1 VA conduction during ventricular pacing at a rate slightly faster than sinus rate (group I) and 11 patients were studied who had 1-to-1 VA conduction, but only at constant ventricular pacing cycle lengths longer than 600 ms (group II). Isoproterenol infusion at a rate causing a 20 to 30% increase in sinus rate or up to 4 micrograms/min shortened the ventricular pacing cycle lengths that induced VA block in all group II patients. Atropine administration at a dose causing a 20 to 30% increase in sinus rate or up to a total dose of 2 mg also shortened the ventricular pacing cycle lengths that induced VA block in all group II patients. At similar pacing cycle lengths, isoproterenol and atropine induced shorter VA intervals than control. Nine of 17 group I patients had demonstrable 1-to-1 VA conduction either during isoproterenol infusion or after atropine administration. Of these 9 patients, 1-to-1 VA conduction could be found only during isoproterenol infusion in 3 patients and only after atropine administration in 4 patients. The improvement of VA conduction by these drugs was related to their effects on the atrioventricular node. The change in VA conduction mediated by autonomic changes induced by these drugs may explain why some patients without demonstrable VA conduction during rest may have, under certain circumstances, "endless-loop" tachycardia or paroxysmal supraventricular tachycardia using atrioventricular nodal conduction as the retrograde limb.(ABSTRACT TRUNCATED AT 250 WORDS)
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26
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Brugada P, Heddle B, Green M, Wellens HJ. Initiation of atrioventricular nodal reentrant tachycardia in patients with discontinuous anterograde atrioventricular nodal conduction curves with and without documented supraventricular tachycardia: observations on the role of a discontinuous retrograde conduction curve. Am Heart J 1984; 107:685-97. [PMID: 6702563 DOI: 10.1016/0002-8703(84)90316-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
To evaluate factors playing a role in initiation of atrioventricular (AV) nodal reentrant tachycardia utilizing anterogradely a slow and retrogradely a fast conducting AV nodal pathway, 38 patients having no accessory pathways and showing discontinuous anterograde AV nodal conduction curves during atrial stimulation were studied. Twenty-two patients (group A) underwent an electrophysiologic investigation because of recurrent paroxysmal supraventricular tachycardia (SVT) that had been electrocardiographically documented before the study. Sixteen patients (group B) underwent the study because of a history of palpitations (15 patients) or recurrent ventricular tachycardia (one patient); in none of them had SVT ever been electrocardiographically documented before the investigation. Twenty-one of the 22 patients of group A demonstrated continuous retrograde conduction curves during ventricular stimulation. In 20 tachycardia was initiated by either a single atrial premature beat (18 patients) or by two atrial premature beats. Fifteen of the 16 patients of group B had discontinuous retrograde conduction curves during ventricular stimulation, with a long refractory period of their retrograde fast pathway. Tachycardia was initiated by multiple atrial premature beats in one patient. Thirteen out of the remaining 15 patients received atropine. Thereafter tachycardia could be initiated in three patients by a single atrial premature beat, by two atrial premature beats in one patient, and by incremental atrial pacing in another patient. In the remaining eight patients tachycardia could not be initiated. Our observations indicate that the pattern of ventriculoatrial conduction found during ventricular stimulation is a marker for ease of initiation of AV nodal tachycardia in patients with discontinuous anterograde AV nodal conduction curves.
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27
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28
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Abstract
An unusual case of atrioventricular nodal reentrant tachycardia precipitated by ethanol ingestion is presented. Programmed atrial and ventricular stimulation failed to induce the tachycardia during control conditions or after atropine administration. This failure to induce tachycardia was related to the absence of ventriculoatrial conduction. A low-dose isoproterenol infusion allowed induction of atrioventricular nodal reentrant tachycardia by the enhancement of ventriculoatrial conduction. This report suggests that programmed stimulation during isoproterenol infusion can be used to induce paroxysmal supraventricular tachycardia in suspected cases in whom induction during control conditions or after atropine administration is not possible.
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29
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Ward D, Valantine H. Spontaneous manifestation of dual AV nodal pathways resulting in complex patterns of AV conduction. Pacing Clin Electrophysiol 1983; 6:272-8. [PMID: 6189068 DOI: 10.1111/j.1540-8159.1983.tb04357.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Dual intranodal pathways are not uncommonly demonstrated at electophysiological study especially in patients with intranodal re-entrant tachycardias. This type of tachycardia is the most common spontaneous manifestation (albeit indirect) of dual AV nodal pathways. Other forms of spontaneous expression of dual atrio-His conduction are rare. In this report we describe a patient who exhibited complex atrioventricular conduction patterns over two intranodal pathways.
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30
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Wiener I, Rubin D, Pitchon R, Boccardo D. Rapid AV nodal re-entrant tachycardias presenting with syncope or pre-syncope: use of electrophysiological studies to select therapy. Pacing Clin Electrophysiol 1982; 5:173-9. [PMID: 6176954 DOI: 10.1111/j.1540-8159.1982.tb02210.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Five patients with recurrent syncope or pre-syncope due to rapid supraventricular tachycardias underwent electrophysiological study. In each patient, an AV nodal re-entrant tachycardia could be induced. By leaving a coronary sinus catheter in place, the effects of drugs on the ability to induce tachycardia could be tested on sequential days. Drug effects were highly variable, but in each patient it was possible to determine a drug which prevented induction of tachycardia. Patients treated with this drug have had no recurrent symptoms or tachycardias with a followup of 4-21 months. Although AV nodal re-entry is highly dependent on autonomic tone, electrophysiological study appears to be a useful means of selecting therapy in patients with severe, symptomatic tachycardias.
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31
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32
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Wu D, Hung JS, Kuo CT, Hsu KS, Shieh WB. Effects of quinidine on atrioventricular nodal reentrant paroxysmal tachycardia. Circulation 1981; 64:823-31. [PMID: 7273382 DOI: 10.1161/01.cir.64.4.823] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Electrophysiologic studies were performed in 14 patients with atrioventricular nodal reentrant paroxysmal tachycardia (PSVT) before and after oral administration of 1.2-1.6 g quinidine sulfate over a 24-hour period (0.3-0.4 g every 6 hours). Studies were performed after 0.5-1 mg i.v. atropine before and after quinidine. All 14 patients had induction of sustained PSVT before quinidine, with or without atropine. After quinidine, 11 patients lost the ability to induce echoes or sustain PSVT, reflecting depression of the retrograde pathway with either absence of atrial echoes (six patients) or induction of nonsustained PSVT, with termination of echoes or PSVT occurring after QRS (block in retrograde pathway) (five patients). In only one of these 11 patients was sustained PSVT inducible after addition of atropine. All 11 were discharged on the same dose of quinidine. In three patients, quinidine was discontinued because of side effects. Follow-up in the remaining eight patients for 8 +/- 2 months showed no recurrence of sustained PSVT. Three of the 14 patients had induction of sustained PSVT after quinidine. Ventricular paced cycle length producing ventriculoatrial block was 314 +/- 7 msec (mean +/- SEM) before and 392 +/- 13 msec after quinidine (p less than 0.01) in the 14 patients, suggesting depression of the retrograde pathway with quinidine. In summary, quinidine inhibited induction of sustained atrioventricular nodal reentrant tachycardia with depression of the retrograde pathway. It is very effective in preventing recurrence of PSVT in most patients.
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33
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Fisher JD. Role of electrophysiologic testing in the diagnosis and treatment of patients with known and suspected bradycardias and tachycardias. Prog Cardiovasc Dis 1981; 24:25-90. [PMID: 7019962 DOI: 10.1016/0033-0620(81)90026-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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34
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35
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Akhtar M, Gilbert CJ, Al-Nouri M, Schmidt DH. Electrophysiologic mechanisms for modification and abolition of atrioventricular junctional tachycardia with simultaneous and sequential atrial and ventricular pacing. Circulation 1979; 60:1443-54. [PMID: 498472 DOI: 10.1161/01.cir.60.7.1443] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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36
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Gomes JA, Dhatt MS, Damato AN, Akhtar M, Holder CA. Incidence, determinants and significance of fixed retrograde conduction in the region of the atrioventricular node. Evidence for retrograde atrioventricular nodal bypass tracts. Am J Cardiol 1979; 44:1089-98. [PMID: 495503 DOI: 10.1016/0002-9149(79)90174-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Of 104 consecutive patients studied in our laboratory with His bundle electrograms, atrial and ventricular pacing and the atrial and ventricular extrastimulus techniques, 18 patients in whom the existence and utilization of ventriculoatrial (V-A) bypass tracts were excluded demonstrated evidence for fixed and rapid retrograde conduction in the region of the atrioventricular node (A-V) as suggested by the following: (1) short (36 +/- 2 msec [mean +/- standard error of mean]) and constant retrograde H2-A2 intervals during retrograde refractory period studies; (2) significantly (P less than 0.025) better V-A than A-V conduction; (3) significantly (P less than 0.025) shorter retrograde functional refractory period of the V-A conducting system than of the A-V conduction system; and (4) the retrograde effective refractory period of the A=V nodal region was not attainable in any of the 18 patients. Fourteen of the 18 patients (77 percent) had a history of palpitations and 10 (51 percent) had documented paroxysmal supraventricular tachycardia; in 13 (72 percent) single echoes or sustained reentrant supraventricular tachycardia, or both, could be induced during atrial pacing or atrial premature stimulation studies, or both. During tachycardia all these 13 patients had a short (37 +/- 2.4 msec) and constant conduction time in the retrograde limb (H-Ae interval) of the reentrant circuit that was identical to the H2-A2 interval. In conclusion, fixed and rapid retrograde conduction in the region of the A-V node (1) is seen in approximately 17 percent of patients, (2) is associated with a large incidence of reentrant paroxysmal supraventricular tachycardia, and (3) suggests the presence of A-V nodal bypass tracts (intranodal or extranodal functioning in retrograde manner).
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37
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Wu D, Denes P, Bauernfeind R, Dhingra RC, Wyndham C, Rosen KM. Effects of atropine on induction and maintenance of atrioventricular nodal reentrant tachycardia. Circulation 1979; 59:779-88. [PMID: 421319 DOI: 10.1161/01.cir.59.4.779] [Citation(s) in RCA: 66] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The electrophysiologic effects of atropine were studied in 14 patients with dual atrioventricular (AV) nodal pathways and recurrent paroxysmal supraventricular tachycardia (PSVT). During PSVT, all patients used a slow pathway (SP) for antegrade and fast pathway (FP) for retrograde conduction. Atropine enhanced both SP antegrade and FP retrograde conduction, shown by a decrease in paced cycle lengths (atrial and ventricular) producing AV and ventriculoatrial block. Five patients had induction of sustained PSVT before and after atropine. Seven patients failed to induce or sustain PSVT before atropine, because of retrograde FP refractoriness. All seven had induction of sustained PSVT after atropine due to facilitation of FP retrograde conduction. Two patients had only single atrial echoes before atropine, reflecting SP antegrade refractoriness. After atropine, sustained PSVT was inducible in one, and nonsustained in the other, PSVT cycle length could be compared in seven patients before and after atropine and decreased from 383 +/- 25 to 336 +/- 17 (p less than 0.05). Thus, in patients with dual AV nodal pathways, atropine facilitated SP antegrade and FP retrograde conduction, shortened cycle length of PSVT and potentiated ability to sustain PSVT.
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Wu D, Denes P, Amat-Y-Leon F, Wyndham CR, Dhingra R, Rosen KM. An unusual variety of atrioventricular nodal re-entry due to retrograde dual atrioventricular nodal pathways. Circulation 1977; 56:50-9. [PMID: 862171 DOI: 10.1161/01.cir.56.1.50] [Citation(s) in RCA: 112] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Three patients with paroxysmal supraventricular tachycardia (PSVT) had discontinuous ventriculo-artrial conduction curves (V1-V2, A1-A2), suggesting dual A-V nodal pathways. Ventricular echoes occurred simultaneously with sudden increase of V-A interval. These echoes were characterized by retrograde P waves occurring in front of QRS, suggesting utilization of a slow pathway for retrograde conduction and a fast pathway for antegrade conduction. In case one, atropine improved retrograde slow pathway and antegrade fast pathway conduction and made A-V nodal re-entry sustained, resulting in PSVT (with retrograde P in front of the QRS). In cases 2 and 3, atropine markedly shortened retrograde fast pathway refractory period and slightly improved antegrade slow pathway conduction. The discontinuous V1-V2, A1-A2 curves and echoes were no longer demonstrable. However, with improvement of retrograde fast pathway and antegrade slow pathway conduction, A-V nodal re-entrant echoes and PSVT were observed, utilizing the slow pathway for antegrade conduction and the fast pathway for retrograde conduction (P simultaneous with QRS).
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Krikler D, Curry P, Attuel P, Coumel P. 'Incessant' tachycardias in Wolff-Parkinson-White syndrome. I: Initiation without antecedent extrasystoles or PR lengthening, with reference to reciprocation after shortening of cycle length. BRITISH HEART JOURNAL 1976; 38:885-96. [PMID: 61037 PMCID: PMC483102 DOI: 10.1136/hrt.38.9.885] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In 6 patients with the Wolff-Parkinson-White (WPW) syndrome, repetitive, almost continuous (incessant) reciprocating atrioventricular (AV) tachycardia has been shown to arise when the sinus cycle length was shortened to a critical point, at which unidirectional block occurred without the classical feature of PR prolongation. Though this phenomenon superficially resembles an aspect of chronic intranodal reciprocating tachycardia of children, basic differences can be identified. It was encountered more frequently in younger subjects; the only patient over 45 developed the arrhythmia as a complication of therapy. This incessant mechanism may explain some cases in which antiarrhythmic treatment does not control reciprocating tachycardia in the WPW syndrome, but such a mechanism can also occur spontaneously.
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